D

izziness and balance problems A guide for patients and carers

A Brain and Spine Disorders Booklet

Brain & Spine Foundation

Dizziness and balance problems

A guide for patients and carers Published by the Brain and Spine Foundation British Brain and Spine Foundation 1998 Reprinted (3) 2002 ISBN 1 901893 022 British Library of Cataloguing in Publication Data A catalogue record for this book is available from the British Library Editor, Brain and Spine Booklet Series: M Alexander CBiol MIBiol Medical illustrations: Philip Wilson FMAA RMIP Cover design: Image International Print: Clifford Martin Press

Brain and Spine Foundation

The Brain and Spine Foundation aims to improve the quality of life for people with neurological disorders and to reduce neurological disability by providing a national focus for research, education and information. Brain and Spine Foundation 7 Winchester House Kennington Park Cranmer Road, London SW9 6EJ Tel: 020 7793 5900 Fax: 020 7793 5939

Email: info@brainandspine.org.uk Website: www.brainandspine.org.uk Registered charity no.1010067

Contents
Acknowledgements

Page

Introduction

What is dizziness?

How does the balance system work?

What other symptoms could I have?

What tests might I have?

What diseases can cause dizziness?

What treatments are available?

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Some dos and donts

18

Conclusion

19

Glossary

20

Other organisations that may be able to help

23

Acknowledgements
The British Brain and Spine Foundation would like to thank Adolfo M Bronstein MD, PhD, Hon. Consultant Neurologist, National Hospital for Neurology and Neurosurgery, London and Consultant Clinical Scientist, MRC Human Movement and Balance Unit, who has written this booklet, and Dr Rosalyn Davies, Consultant in Audiological Medicine, National Hospital for Neurology and Neurosurgery, London for her invaluable assistance with this project. Brain and Spine Foundation, 2002

Introduction
This booklet is intended to provide some general information on dizziness and balance problems. It has been written to answer some of the questions often asked by people who are experiencing these problems, as well as their families and carers. The medical information in this booklet is evidence-based and draws on current best practice guidelines. However, because dizziness affects each person differently and because it can have so many different causes, it is important that you speak to your own GP or to the doctor or physiotherapist who is looking after you, since they are in a position to offer advice and information to meet your own specific needs. Words that are printed in bold are explained in the glossary.

What is dizziness?
Dizziness is a broad term used to explain how we feel when our sense of balance is not quite right. Most people who experience dizziness actually find it quite difficult to explain exactly how it makes them feel. If you have this problem your doctor may find it helpful if you try to describe your dizziness by comparing what you feel with something that everyone may have had direct experience of. For example, some people who complain of feeling dizzy, giddy or offbalance say they feel as if everything is spinning around, or as if they are spinning around. Doctors use the term vertigo to describe this condition. Others feel as though they were walking on cotton wool or on a mattress, or as if they were drunk. Or they may feel wobbly, or as if they were on a merry-go-round or a boat. It is important to realise that dizziness and vertigo are not diseases as such. They are symptoms - that is, sensations which indicate that something is wrong - like a cough, which as we know can have a number of different causes. Dizziness is a common symptom, and by the time we are old most of us will have experienced it. Just like a cough, it can be caused by lots of different things. Fortunately it is very rarely the symptom of a serious or life-threatening illness. To understand why you feel dizzy you need to know a bit about how the balance system works.

How does the balance system work?

It is often said that the sense of balance comes from the balance organs located in the inner ear. This is largely true and indeed most cases of dizziness and vertigo are due to problems in these balance organs. The ear has three main components: the external, or outer ear, which is the only part that can be seen from the outside; the middle ear, whose main function is to transmit the sound from the outer to the inner ear; and the labyrinth, or inner ear. The labyrinth is

located deep inside some of the hardest bones in our skull. It is divided into the cochlear organ, which is responsible for hearing, and the vestibular organ, which is responsible for balance. This close link between the hearing and balance organs in the ear is the reason why your doctor will ask you what your hearing is like.

Outer ear Pinna Outer ear canal

Middle ear Eardrum Ossicle bones Eustacian tube

Inner ear Cochlea Labyrinth

Semi-circular canals

Bone Auditory nerve

Outer ear canal

Cochlea

Eardrum

Ossicle bones

Eustacian tube

The structure of the ear

Figure 1: Diagram showing the structure of the ear

The vestibular, or balance, organs inform the brain about the movements and position of your head. There are three sets of tubes or semi-circular canals in each vestibular organ, and these detect when you move your head around. There are also two structures called the otoliths, which inform the brain when the head is moving in a straight line and indicate the position of the head with respect to the pull of gravity. Dizziness or vertigo occurs when the right and left balance organs do not work together (in symmetry), because this makes your brain think that your head is moving or turning when it is not. This also explains why many forms of dizziness are either triggered or increased by movements of the head. However, it is important to bear in mind that the maintenance of balance is a complex function and that while the ear is a very important component of the system, it is not the only one. In order to have a good sense of balance we need to be able to see where we are and be aware of the position of certain key parts of our body in relation to the other parts and to the world around us. The brain has to know how the feet and legs are positioned with respect to the ground and how the head is positioned with respect to our chest and shoulders. This information is conveyed to the brain by detectors of position and movement located in our muscles, tendons and joints, particularly in the neck, ankles, legs and hips. A crucial aspect of the efficiency of the balance system is that our brain can control balance by using the information that is best suited at any particular point in time. For instance, in the dark, when the information conveyed by our eyes is reduced or unreliable, our brain will use more information from our lower limbs and our inner ear. If, on the other hand, we are walking on a sandy beach during the day, the information coming from our legs and feet will be less reliable and we will tend to use our vision and vestibular organs more. We almost never have to rely solely on the information provided by the balance organs of the ear, and that is why even people who have lost the function of both inner ears do not entirely lose their sense of balance. So while dizziness and imbalance usually arise from disorders of the inner ear, because of the complementary support

provided by the eyes and the detectors of movement located in our joints and muscles, most people usually regain a good sense of balance. Problems with the nerves carrying the impulses from the balance organs to the brain or problems in the balance centres of the brain can also cause dizziness, but these are less common.

What other symptoms could I have?

Even when your dizziness is caused by inner ear problems you may not suffer from any hearing problems. If you do, you are likely to have either tinnitus - a ringing or buzzing noise in one or both ears - or various degrees of hearing loss. As mentioned above, the closeness of the hearing and balance organs explains why you may experience hearing disorders in the course of your dizziness. Your doctor may also wish to know whether you have experienced any numbness, clumsiness or weakness in your legs, which may contribute to your unsteadiness. They may also ask you whether you have or have had double vision, numbness in your face or trouble with your speech, to establish if other nerves in your face or head are involved, and they will spend some time enquiring about the circumstances in which your dizziness occurs - whether it starts spontaneously, or completely out of the blue; whether it first started after you had the flu; or whether it appears to be related to the movements or position of your head. If you have had repetitive ear infections with ear discharge, the dizziness you experience could indicate that the balance organs in the ear are being affected by a previous or current infection. Accurate answers to these sorts of questions are very useful for your doctor.

What tests might I have?

GPs refer patients who complain of dizziness to a number of different hospital consultants. They may be referred to see a neurologist - a doctor who specialises in disorders of the brain and nerves, or they may be referred to an otologist - a doctor who specialises in problems of the ear. The latter may be either an audiological physician or an ear, nose and throat specialist (an ENT surgeon). In some specialised departments or dizzy patient units, you may see more than one of these specialists. The tests that you have may vary slightly according to the type of specialist you see. You may have a head or brain scan (e.g. CT or MRI scan), which are basically carried out to rule out any cysts, growths, inflammation or blood supply disorders of the brain. Your doctor may request a number of hearing tests. During some of these you have to say if you can hear certain tones and in others the hearing system itself is assessed directly using wires that are temporarily glued to your scalp. You may also have to undergo special balance tests. The most common of these records your eye movements with wires attached to the skin surrounding your eyes. This is called ENG (electronystagmography). This test is performed because the balance organs of the ear control the movement of the eyes very precisely and a problem with the ear or brain centres controlling balance can cause abnormalities in eye movement. Another balance test called the caloric test is very informative. During this test you will have some cool or warm water run into your ears so that the temperature of the balance organs in the inner ear can be modified. This test creates a minor and temporary difference between the balance organs on the left and right sides of your head and makes you feel dizzy for a couple of minutes. You should bear in mind that all these tests and scans will not be necessary for everyone. Some people may not need any tests at all.

There is one test, however, that almost everyone complaining of dizziness or vertigo will be asked to undergo, and this is called the positional test. This is a clinical test - that is one that will be carried out by the doctor during the examination. This test or manoeuvre will establish if the dizziness is triggered or made worse by movements of the head. Your doctor will ask you to sit on the couch, and then he or she will ask you to lie down rapidly with your head turned to one side and then to the other. Certain forms of dizziness will be brought on by this procedure, but this dizziness will always be short-lived, lasting no more than a minute, and the procedure will not make your dizziness worse. Your doctor will know by the presence of any eye movements during and immediately after the test what form of dizziness you have. It is therefore of utmost importance that you keep your eyes open while your doctor performs this test. Certain conditions, such as benign paroxysmal positional vertigo (or BPPV), can only be diagnosed by performing this manoeuvre and effective treatment can only be prescribed if the diagnosis is made correctly.

What diseases can cause dizziness?

Many diseases can give rise to dizziness or off-balance sensations, e.g. blood disorders such as anaemia or certain heart conditions, but if you have been referred to a neurologist or otologist such general conditions will usually have been excluded in advance. You should also be aware that a number of medications can cause dizziness as an unwanted side effect. Being tense or irritable can also provoke dizziness or a sense of imbalance, and this can be a vicious circle, as being dizzy can also make you feel anxious or depressed. In this section we will describe some of the specific conditions that can lead to dizziness. The treatments given for any of the specific diseases that cause dizziness will also be described. Dizziness as a

symptom - independently of what has caused it - can also be treated, but we will deal with that later, in the section What treatments are available? Most cases of dizziness, vertigo or other off-balance sensations are due to one of the seven following conditions: 1. 2. 3. 4. 5. 6. 7. Viral labyrinthitis Benign paroxysmal positional vertigo Mnires disease Vertigo of vascular origin Post-traumatic vertigo Peripheral vestibular disorder Central or neurological causes.

Viral labyrinthitis
As the name indicates, this is a viral infection of the labyrinth, or inner ear. Other names frequently used for this condition are vestibular neuronitis (as some doctors think that the problem lies in the nerve cells or neurons connected to the inner ear) or epidemic vertigo, because small epidemics of this condition can sometimes occur. With this condition there is rather sudden onset of a spinning vertigo, accompanied by nausea or sickness and unsteadiness. These symptoms frequently develop a few days or weeks after a bad cold or flu. People with this condition often prefer to stay in bed because any movement makes the vertigo worse, which may just last for a few days or may persist for two or three weeks. Some people remain a little unsteady afterwards, but most make a full recovery. Only a minority of patients with viral labyrinthitis will experience persistent, troublesome dizziness or will suffer recurrences of the condition either spontaneously or associated with later bouts of the common cold or flu. Viral labyrinthitis does not cause any hearing problems, but the initial dizziness is intense and distressing. The minority of people who

experience prolonged or recurrent problems do not suffer from intense symptoms, but they are nevertheless a nuisance and limit them in their everyday working or social lives. Treatment in the initial stages of viral labyrinthitis includes anti-vertiginous drugs, which are medicines that are identical or similar to those used for car or sea sickness.

Benign Paroxysmal Positional Vertigo (BPPV)

The dizziness experienced in this condition is intense and also has a rotational or spinning character. It is, however very short-lived, lasting a minute or less, and is typically brought on by certain head movements. Examples are the movements associated with turning over in bed or looking up to hang clothes on the washing line. Most people with this form of vertigo know exactly what type of movements can induce the symptoms and so learn to avoid them. It is now pretty well established that the cause of this vertigo is the accumulation of certain particles or crystals within one of the tubes of the balance organs, the posterior semi-circular canal. The diagnosis can only be established by the positional test described earlier on. Due to the intricate connections between the balance organs of the ears and the eye muscles, BPPV often causes a highly specific nystagmus (jerky movements of the eyes) which is unique to the condition. Recent developments have allowed new treatments to be devised to clear out the particles trapped in the semi-circular canal. These include the so-called particle repositioning procedures, the more commonly used of which are the Epley manoeuvre and the Semont manoeuvre. These can be performed in the doctors or physiotherapists room and consist of a series of movements of the head guided by the doctor or physiotherapist, without the need for any specialised instruments. These procedures offer a non-invasive and effective form of treatment but are fairly new, and not all doctors are yet familiar with them.

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Mnires disease
People with Mnires disease suffer from repetitive attacks of intense, spinning vertigo. Each attack typically lasts for two, up to 24 hours and affected people are frequently sick. People usually experience noticeable changes in their hearing either before or during the vertigo attacks, including both tinnitus and a loss of hearing. There is usually a tenderness or pressure in one of the ears either before or during these attacks of vertigo. In between attacks the person may have fairly good balance and experience no dizziness, but they will experience various degrees of hearing loss. This hearing loss is initially fluctuating - that is, it improves after attacks but there is a tendency for it to get worse over time and become permanent. Approximately one third of people with Mnires disease have symptoms in both ears. Usually there is no warning that one of these vertigo attacks is going to occur, and this leads to anxiety that they may happen in public places. This is largely because patients are worried that people might think they are drunk because they are all over the place and sick. The actual cause of Mnires disease is not known, but each episode or attack is due to a build-up of pressure in the inner ear - a phenomenon called endolymphatic hydrops. That is why one of the main treatments for this condition is a strict low-salt diet and a diuretic - water tablets- which help get rid of excess salt and fluid in the body. In this way the risk of a build-up of salt, fluid and pressure in the ear is reduced. This form of treatment can be of benefit in reducing the frequency and intensity of each vertigo attack, but will not necessarily slow down the progression of the deafness. Antivertiginous drugs can help some people if taken as soon as the first symptoms develop, but they may be brought up when they are sick, making them useless. Some anti-vertiginous drugs come as suppositories and they can reduce the intensity of the vertigo attacks.

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Vertigo of vascular origin

The term vascular is given to describe conditions that are caused by a reduced supply of blood reaching a particular organ. In the case of dizziness, the organs in question are the labyrinth and the lowermost part of the brain which contains the balance centres. The blood vessels that supply both the labyrinth and the balance organs of the brain are shared, and therefore vascular dizziness can come from a combination of peripheral (inner ear) and central (brain) dysfunction. The symptoms can include double vision, slurred speech, blurred vision and numbness in the face or limbs. Unless the deficit in blood supply has caused a stroke, the dizziness and accompanying symptoms are likely to come and go. There are essentially two types of vascular dizziness. With the first type, the symptoms appear during certain types of migraine, generally in younger people (less than 50 years of age). These people may benefit from anti-migraine treatment. In older people, the symptoms are usually an indication of general vascular disease and relate to the so-called vascular risk factors such as high blood pressure, smoking, high levels of blood cholesterol, obesity or a family history of vascular disease (high blood pressure, heart attacks, and strokes). Treatment here is aimed at reducing the vascular risks, and most doctors will also prescribe a small aspirin a day to thin the blood as long as there are no reasons why aspirin should be avoided (such as stomach ulcers).

Post-traumatic vertigo
Dizziness commonly occurs after moderate to serious head injuries and frequently occurs after only minor head injuries. The actual mechanism that makes people feel dizzy can again be a combination of peripheral (inner ear) and central (brain) disorders. Patients may have additional symptoms, limb fractures or worries related to the head injury and the treatment will have to take all of these issues into consideration.

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Peripheral vestibular disorder

In many cases doctors are only able to diagnose that the cause of the dizziness is a peripheral vestibular disorder - that is, the problem is in the ear, not the brain - without being able to establish the exact underlying disease. Strictly speaking, viral labyrinthitis, BPPV and Mnires disease are all peripheral vestibular disorders, but we reserve the term here for conditions that cannot be properly classified into any of the well-defined groups. In some cases, abnormalities may show up in the specialised balance tests, but in others even these tests will be normal. There may be relatively minor permanent symptoms (but disabling nevertheless) or recurrent episodes of vertigo, which may or may not be triggered by certain factors, such as head movements, tiredness, stress, menstrual periods or viral infections. Dont worry if your doctor cannot be 100 per cent sure of the cause of your balance disorder because it has been shown that in the long term, the majority of people in this group improve with time. Recovery can be helped by rehabilitation procedures (see What treatments are available?).

Central or neurological causes of dizziness

A minority of people complaining of dizziness have a neurological disease. The part of the brain that organises balance is the lowermost part of the brain and includes what is called the brain stem and the cerebellum. This part of the brain also deals with the organisation of movement, posture and speech, which can therefore also be affected. Strokes or demyelination (for instance, multiple sclerosis), inflammation or tumours in this area and bony deformities of the back of the head and the upper spine can all cause dizziness and balance disorders. Any of these problems can be picked up in the neurological examination carried out by the doctor and from brain scans.

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What treatments are available?

Although many causes of dizziness, such as viral labyrinthitis, BPPV, post-traumatic and non-specific peripheral vestibular disorders, tend to recover on their own, if you have been referred to a hospital consultant it is quite possible that the dizziness has not cleared up of its own accord in your case. If this is the case then do not despair! You are also likely to do well in the long term. The mainstay of treatment, common to almost all the conditions mentioned above, is vestibular rehabilitation.

Vestibular rehabilitation
It has been shown that if the vestibular system is damaged, a number of mechanisms operate in the brain which tend to improve the functioning of the balance system. As explained earlier, most symptoms of dizziness and vertigo appear as a result of an imbalance between the functioning of the right and left vestibular organs in the inner ear. The processes, which tend to correct this imbalance are known as vestibular compensation. This compensation can be achieved even when the damage to the inner ear is permanent. In essence, vestibular compensation relies on your brain learning to cope with the disorientating signals coming from the inner ears and learning to use alternative signals from your eyes, ankles, legs and neck to keep you balanced. As a result, the tendency to fall or veer to one side, the jerky eye movements (nystagmus) and the dizziness gradually disappear. One way of helping the development of vestibular compensation is by doing so-called vestibular exercises. These exercises involve movements of the eyes, the head, the trunk and finally the whole body under different visual conditions (e.g. with the eyes open and then closed, while looking at steady objects or at a moving ball). A point that cannot be stressed too much is that in order for the brain to put into place the mechanisms of vestibular compensation, it has

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to sense that imbalance or dizziness are present. For example, if you are taking regular anti-vertiginous drugs or are lying absolutely still in bed, you do not experience any dizziness. If the brain does not sense any dizziness or imbalance it will not realise that something is wrong. For this reason, the physiotherapist or other professional in charge of your rehabilitation may ask you that, in agreement with your doctor, you reduce and eventually stop your anti-vertiginous medication. As you progress to the more difficult exercises of the rehabilitation programme you may experience dizziness. This should not be interpreted as a red flag to stop the exercises - quite the contrary. What this means is that an imbalance between your left and right vestibular systems still exists, and the exercises you are doing will help your brain to detect this imbalance and then gradually put it right. You should not go to the extreme of trying to induce dizziness by moving or exercising to such an extent that you are sick or become exhausted. If the surgery you attend is not familiar with vestibular exercises (sometimes called Cawthorne Cooksey or balance exercises), some of the organisations listed at the end of this booklet might be able to help.

Particle repositioning procedures

As mentioned above under BPPV (Benign Paroxysmal Positional Vertigo), this is now the treatment of choice for this condition. Although most cases of BPPV will sort themselves out within a few weeks to a few months, these repositioning procedures can bring about a rapid recovery in one or two sessions. People who have recurrences of BPPV can either have the repositioning procedure repeated or they can be shown exercises (e.g. Brandt-Daroff exercises) which they can do at home. Again, if your doctor is not entirely familiar with these procedures you can find out about them from some of the organisations listed at the end of this booklet or from regional physiotherapy or audiology centres.

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Figure 2: Self guided positional exercises One session should include six repetitions to either side, and at least three sessions should be completed daily. Eyes may be closed to reduce vertigo

1. Sit on a bed with head turned 45 to one side

2. Quickly lie down to opposite side with head still turned so that the area behind the ear touches the bed. Maintain this and every subsequent position for about 30 seconds. Sit up again and repeat on the other side. Continue five more on each side.

Anti-vertiginous drugs
A variety of drugs are available that can make you feel better during the initial or severe phases of many vestibular disorders. These tablets, however, should only be reserved for the first few days of an attack of dizziness because, as mentioned above, long-term improvement depends on vestibular compensation, not tablets. The same applies to tranquillizers, as the risks of addiction and their interference with the development of vestibular compensation usually outweigh their possible benefits in reducing anxiety.

Counselling, relaxation therapy, breathing exercises

If you have suffered from dizziness for a long period of time you may be concerned that it will never go away, or that, in spite of what

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BMJ Publishing Group

doctors tell you, there may be something seriously wrong with you. You may be worried that you are not able to look after your children properly, or you may be worried about going to work or attending social events for fear of embarrassment. In some cases what was initially thought to be a vestibular disorder may have actually been brought on by stress, fear or tension. The distinction is not always easy. For instance, some people with balance disorders suffer increased bouts of dizziness in crowds and shopping centres, or whilst driving or looking at moving images on TV or at the cinema. This occurs because their moving surroundings confuse their balance centres. However, some people who have a fear of public places or who experience panic attacks - but who have an intact balance system - also report symptoms of dizziness and unsteadiness. Sometimes this is the result of excessive breathing, or hyperventilation. People with vestibular problems will usually benefit from being reassured about the non-sinister nature of the disorder, and this together with spontaneous or rehabilitation-induced vestibular compensation will gradually reduce their feelings of anxiety. In some cases, counselling, relaxation or breathing exercises help people to feel more in control of the situation and can also cut down the episodes of dizziness which are brought on by tension or hyperventilation.

Surgery
Only a very small minority of people with dizziness have to undergo surgery to see any improvement in their symptoms. The type of operation they will undergo will vary according to the individual preferences of the ear surgeon. Surgery will only be considered if long term use of drugs and rehabilitation treatments have failed to bring about a noticeable improvement. Surgery is a more likely option for people whose dizziness is associated with ear discharge, long-standing middle ear infections or ear drum perforations.

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Some dos and donts

It is important to avoid becoming inactive in order to avoid episodes of dizziness. There is a well-known vicious circle, which can set in and is to be avoided at all costs. It starts with you avoiding moving around so that you dont feel dizzy. This may extend to avoiding pleasant social activities. This inactivity prevents the process of vestibular compensation, as the brain is not exposed to the abnormal signals coming from the balance organs, and this lack of vestibular compensation means the dizziness wont go away, leading to depression, anxiety, inactivity ... and more dizziness. As far as possible, try to participate actively and with faith in the process of recovery. It is a good idea to do your exercises regularly and take part in physical activities and sports. Ball games that use eye-head-body coordination are ideal. Initially, walks may be enough. Cycling and swimming are probably less effective in helping the process of vestibular compensation, but are worth trying if they are your preferred form of exercise. Finally, try to avoid keeping everything to yourself. Dont suffer in silence. Once you talk to people about your symptoms you will realise how common dizziness is and you will also realise that most stories people tell you about themselves or friends who have experienced dizziness have a positive conclusion.

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Conclusion
Although dizziness can be a symptom of a number of diseases, in practice most cases of dizziness are due to relatively mild disorders of the balance organs of the inner ear (the labyrinth or vestibular organs). Whether you are referred to an ear or a brain specialist, the investigations they carry out and the specialised procedures (e.g. head scans) that you undergo will usually rule out any serious underlying disorder. Doctors recognise that even if the underlying disease is not life-threatening, the resulting dizziness is a nuisance to the affected person and can lead to problems in their social and working lives. Ten or 20 years ago there was not much that doctors could do to help a person with dizziness apart from prescribing anti-vertiginous, anti-motion sickness tablets. It is now realised that these tablets are only useful for the initial, acute phases of dizziness, when the person is usually almost unable to leave bed. It has now been shown that all people with dizziness can make a substantial and sustained recovery as long as they make an effort to gradually get back to being physically active, since this helps the process of vestibular compensation. This compensation process can be further assisted by specialised programmes of rehabilitation that are now available in many neurology, ENT, audiology and physiotherapy departments. In addition, the treatment of a common condition called benign paroxysmal positional vertigo or BPPV has been revolutionised by the development of particle repositioning procedures. These procedures are fairly simple head movements guided by the doctor or the therapist that are aimed at clearing the posterior semi-circular canals of the inner ear of particles trapped within them, which are the cause of BPPV.

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Glossary
Anti-vertiginous drugs
Medicines that can reduce dizziness, vertigo or car/sea sickness. Long-term treatments are usually not effective. Some examples are Stemetil (Prochlorperazine), Stugeron (Cinnarizine), Serc (Betahistine).

Central or neurological causes of vertigo

Dizziness that results from problems in the balance centres of the brain, rather than the ear. This is generally much less common than dizziness caused by peripheral vestibular disorders that is, due to inner ear problems. Strokes, multiple sclerosis, brain tumours or cysts and deformities of the upper spine or the back of the head are possible causes.

Benign Paroxysmal Positional Vertigo (BPPV)

A balance disorder caused by particles trapped in the semicircular canals which form part of the balance organs. These particles are usually crystals that have become detached from other parts of the inner ear. As the name indicates, the vertigo, which can be intense, comes on suddenly following certain movements of the head and comes and goes as clusters of attacks, and may have been present for many years.

CT scan
A computer-aided x-ray used to provide a clear picture of a part of the body, for example the brain, inside of the skull and the ear.

Demyelination
Loss of the protective insulating myelin sheath that covers nerve fibres.

Diuretic Caloric test

A balance test that relies on cooling down or warming up the balance organs. This is achieved by irrigating the ear with cool and then warm water. Tablets that are sometimes used in Mnires disease to get rid of excess salt and water in the body.

Endolymphatic hydrops
The build-up of pressure in the inner ear that causes the vertigo attacks in Mnires disease.

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ENG
An electro-nystagmogram is a recording of the eye movements during visual and rotating chair tests and is used to assess a persons balance systems. The balance organs control the movement of the eyes and when the balance organs or centres are damaged there can be nystagmus an abnormal jerkiness of the eyes.

Nystagmus
Abnormal, jerky movements of the eyes.

Particle repositioning procedures

Treatments used for some specific types of positional vertigo. The more commonly used are the Epley manoeuvre and the Semont manoeuvre, which consist of doctor-guided head movements. These movements clear out the particles trapped in the semicircular canals.

Labyrinth
The inner ear, which contains the cochlea - the hearing organ - and the vestibular organs - the organs of balance.

Peripheral vestibular disorders

Strictly speaking all causes of dizziness due to inner ear problems. They include labyrinthitis, Mnires disease, BPPV (Benign Paroxysmal Positional Vertigo) and some vascular problems. The term is more commonly used, however, when a doctor knows that the problem is in the inner ear but is unable to be more specific.

Labyrinthitis
An inflammation, usually caused by viruses, of the labyrinth. The hearing is usually not affected.

Mnires disease
A condition in which repetitive attacks of vertigo are accompanied by pressure in the ears, tinnitus and deafness.

MRI scan
Magnetic Resonance Imaging is a technique that gives very clear pictures of an area of the body (e.g. the ear) in any plane. The pictures obtained are of very high quality and use magnetism rather than x-rays. The scan process is painless but somewhat claustrophobic, and can be noisy.

Positional test
An examination conducted by your doctor to see if certain movements or positions of the head bring on or make worse your dizziness or nystagmus (see above). This is the only way that conditions grouped as positional vertigo can be diagnosed.

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Post-traumatic vertigo
Dizziness resulting from a head injury.

Vertigo
The term used by doctors to describe a form of dizziness with a strong sensation of movement of the patient or their surroundings. Frequently, vertigo is used to mean spinning or rotational dizziness.

Semi-circular canals
The tubes of the labyrinth that detect rotations of the head. There are three canals on each side so that rotations in all planes can be sensed.

Vestibular compensation
The process that allows the brain to regain balance control when there is an imbalance between the right and left vestibular systems. It is based on reducing this imbalance and making up for the problems in this area by educating the brain to rely more on visual and joint/muscular impulses.

Symptoms
The sensations or feelings reported by patients which tell them that something is wrong - as opposed to signs, which are things the doctor observes. Dizziness is a symptom.

Tinnitus
Buzzing or ringing in the ears. This can occur with dizziness or be a symptom on its own.

Vestibular rehabilitation
(Sometimes called CawthorneCooksey exercises) Physiotherapy programmes which re-educate the balance system. These involve exercises for the eyes, neck, trunk and the whole body in different visual conditions (looking at objects far away or close up, or having the eyes closed).

Vascular vertigo
Dizziness caused by problems with the blood supply to the labyrinth or the balance centres of the brain. It can occur in people who suffer from migraine or in those with vascular risk factors i.e. people who are overweight, smokers, people with high blood pressure and people who dont take enough exercise.

Viral labyrinthitis
A viral inflammation of the labyrinth. It causes dizziness/vertigo lasting days or weeks, usually following a cold or flu. It is sometimes called vestibular neuronitis.

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Other organisations that may be able to help

Brain and Spine Helpline
Brain and Spine Foundation 7 Winchester House Kennington Park Cranmer Road London SW9 6EJ

Hearing Concern
7-11 Armstrong Road London W3 7JL

Tel: 0845 0744 600 (voice) 020 8742 9151 (textphone) www.hearingconcern.com
(Information, support campaigns, awareness/training services)

Tel: 0808 808 1000 www.brainandspine.org.uk

(Information and support on neurological disorders for patients, carers and health professionals)

Mnires Society
98 Maybury Road Woking Surrey GU21 5HX

British Tinnitus Association

4th Floor The White Building Fitzalen Square Sheffield S1 2AZ

Tel: 01483 740597 (voice) 01483 771207 (textphone)

(Information, advice and support on Mnires disease)

Tel: 0800 018 0527 www.tinnitus.org.uk

(Advice, information and self-help groups)

Migraine Action Association

Unit 6 Oakley Hall Lodge Business Park Great Folds Road Great Oakley Northamptonshire NN18 9AS

Depression Alliance
35 Westminster Bridge Road London SE1 7JB

Tel: 020 7633 0101 www.depressionalliance.org.uk

(Information, advice, support and self-help groups)

Tel: 01536 461333 www.migraine.org.uk

(Information and support)

Migraine Trust
45 Great Ormond Street London EC1N 3HZ

Tel: 020 7831 4818 www.migrainetrust.org

(Research, training, information and support)

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NHS Direct Tel: 0845 4647 www.nhsdirect.nhs.uk

(Medical advice and information on NHS services)

RNID Tinnitus Helpline

Castle Cavendish Works Norton Street Radford Nottingham NG7 5PN

RNID (Royal National Institute for Deaf People)

19-23 Featherstone Street London EC1Y 8SL

Tel: 0808 808 6666 www.tinnitushelpline@rnid.org.uk

(Information/advice on tinnitus and dizziness)

Tel: 0808 808 0123 www.rnid.org.uk

(Information, advice, communication support services, training and research)

24

Supporting the Brain and Spine Foundation

In order for the Brain and Spine Foundation to continue to fund its vital research and education work in brain and spine disorders, we need your help. YES! I would like to help. Please find enclosed a gift of 10 15 25 other Please accept this as a Gift Aid donation Yes Signature Name Mr/Mrs/Ms Address No

Note: All donations now qualify for Gift Aid if you are a tax payer. Please sign and date this form in the box below as confirmation.

Postcode Email or you may donate by Visa/Mastercard/CAF card by filling in the details below or calling our donation line on 020 7793 5900 Card Number Expiry Date Signature I am also interested in: I Making a Bequest to the Foundation in my will I Setting up a standing order I Organising a fundraising event I Current Research and Education projects I Volunteering Brain and Spine Foundation, 7 Winchester House, Kennington Park, Cranmer Road, London SW9 6EJ Telephone: 020 7793 5900 Fax: 020 7793 5939 Helpline: 0808 808 1000 Email: info@brainandspine.org.uk Website: www.brainandspine.org.uk Registered charity no.1010067 25

Publications from the Brain and Spine Foundation

We can supply one copy of each relevant publication free to patients and carers affected by neurological disorders. However, if you are able to pay for them, it will help us to cover our costs. Additional copies cost 5 each for booklets and 3 each for leaflets. (Price includes 1.00 post and packing). Please make your cheque payable to the Brain and Spine Foundation. Please complete your name and address below, tick the appropriate box/es, and post your order to us at: Brain and Spine Foundation, FREEPOST, London SW9 6BR.

Name

(Mr/Mrs/Miss/Ms)

Address Postcode
Please tick as appropriate:

Aids and the brain Angiogram (leaflet) Back & neck pain Brain tumour Craniotomy (leaflet) CT Scan (leaflet) Dizziness & balance problems Epilepsy Face Pain Headache Head injury & concussion Meningitis & Encephalitis Motor neurone disease

I I I I I I I I I I I I I

MRI Scan (leaflet) Multiple sclerosis Neurophysiology Paralysis the loss of muscle power Parkinsons disease Speech, language and communication difficulties Stroke Sub-arachnoid haemorrhage Transient ischaemic attacks and mild strokes

I I I I I I I I

I Transverse myelitis I Vascular malformations of the brain I

Brain and Spine Foundation, 7 Winchester House, Kennington Park, Cranmer Road, London SW9 6EJ Telephone: 020 7793 5900 Fax: 020 7793 5939

Email: info@brainandspine.org.uk

Website: www.brainandspine.org.uk

Registered Charity No. 1010067

26

Notes

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Notes

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Notes

4.00 ISBN 1 901893 022

www brainandspine org uk