Vestibular disease

Dizziness after a traumatic brain injury

This information is intended as a general introduction to this topic. As everyone is affected differently by balance and dizziness problems, you should speak to your doctor for individual advice.

For reasons of better readability, the generic masculine is used and the simultaneous use of the language forms male, female and diverse (m/f/d) is dispensed with. Unless otherwise indicated, the personal designations used in this patient information refer to all genders.

What are dizziness and balance disorders after a TBI?

A mild traumatic brain injury (TBI) is a violent impact to the head, either directly (e.g. a blow to the head) or indirectly (e.g. a force transmitted from the body to the head). You do not have to hit your head or lose consciousness to suffer a TBI. A TBI is also called a concussion.

TBI is one of the main causes of disability. People who suffer a TBI can suffer damage to the vestibular system. The damage can occur to the peripheral (inner ear), central (brain) vestibular structures or both.

"Vestibular" refers to the movement sensors in the inner ear and the parts of the brain that interpret the signals from these sensors. These sensors in the inner ear and the brain control our balance and how we perceive the space around us. If these sensors don't work properly or the brain misinterprets the signals, it can lead to a range of symptoms such as dizziness and balance problems.

Different terms are used depending on which part of the vestibular system is affected by a TBI. A disorder of the inner ear sensors or the vestibulocochlear nerve (8th cranial nerve) leading to the brain is referred to as a peripheral vestibular disorder. A disorder in the brain is called a central vestibular disorder. Some people have both a peripheral and a central vestibular disorder after a TBI.

In people who have suffered a TBI, dizziness is the second most common symptom after headaches. Almost 8 out of 10 people suffer from dizziness after a TBI.

Although awareness is growing in clinics, damage to the vestibular system caused by TBI is often undiagnosed or underestimated.

Most people make a full recovery from a TBI. A minority suffer from persistent symptoms known as post-commotion syndrome. Dizziness after a TBI can have a negative impact on well-being and is a known risk factor for post-commotion syndrome.

Summary

What causes dizziness and balance disorders after a TBI?

The causes of SCT include sports injuries, collisions with motor vehicles, falls, accidents at work, physical attacks and the effects of explosions.

The force applied to the head during a TBI moves the brain within the skull bone. This sudden jolt can cause injury to the brain's white matter and long nerve fibers (axons). This process is called a 'diffuse axonal injury' in medicine. The result is changes in brain tissue at the cellular level. This leads to a rapid onset of neurological changes. The vestibular system (balance system) can also be damaged, causing dizziness and balance disorders.

The main causes of dizziness and balance disorders after a TBI include

  • Central vestibular dysfunction
  • Dysfunction of the vestibulo-ocular reflex (VOR)
  • Visually induced dizziness
  • vestibular migraine

Peripheral causes of dizziness and balance disorders after a TBI include

  • benign paroxysmal positional vertigo (BPLS)
  • Perilymph fistula
  • Labyrinth vibration
  • secondary endolymphatic hydrops (SEH)
  • Bilateral vestibulopathy (BVP)
  • Dysfunction of the vestibular nerve
  • Archway dehiscence
  • Petrous bone fracture

Non-vestibular causes of dizziness and balance disorders after a TBI include

  • physical deconditioning
  • Anxiety and post-traumatic stress
  • Side effects of medication
  • Low blood pressure when standing up from a sitting or lying position (orthostatic hypotension)
  • Pituitary dysfunction and resulting pituitary hormone deficiency
  • Autonomic dysfunction leading to cardiovascular dysregulation
  • Dissection of the vertebral artery

Some vestibular symptoms may appear immediately after a TBI. Others may not appear immediately. And some symptoms change over time.

Central vestibular dysfunction
Central vestibular dysfunction is usually related to a concussion of the vestibular structures in the brainstem and cerebellum. Symptoms include:
- Nausea with dizziness and balance problems
- Spatial disorientation, making it difficult to determine body position, movement and height relative to the ground


Dysfunction of the vestibulo-ocular reflex (VOR)
The VOR ensures gaze stabilization during head movements. It is controlled by the cerebellum. Symptoms include some or all of the following:
- a feeling of "lag" during rapid head movements
- oscillopsia, giving the impression that objects in the field of vision are jumping back and forth
- dizziness
- balance problems
- spatial disorientation, making it difficult to determine body position, movement and height in relation to the ground
- nausea and vomiting


Visually induced vertigo
Visually induced vertigo is a collective term for a group of symptoms caused by certain disorders of the vestibular system. It refers to chronic dizziness or balance disorders that are usually triggered by being in a busy visual environment or observing movement. Symptoms include some or all of the following:
- Dizziness
- Gait unsteadiness
- Drowsiness
- Disorientation
- Nausea
- Vomiting
- Sweating
- Salivation
- Fatigue
- Blanching


Vestibular migraine
Headaches and migraine attacks are very common after a TBI, estimated to occur in around 60-80% of those affected. New symptoms can occur, the attacks can become chronic and develop into a vestibular migraine. Symptoms include some or all of the following:
- recurrent spontaneous attacks of dizziness lasting from minutes to several days
- dizziness on positioning (lying down, standing up from a lying position)
- visually induced dizziness
- nausea
- feeling of disturbed spatial orientation

Benign paroxysmal positional vertigo (BPLS)
Studies indicate that BPLS is the most common vestibular disorder following a TBI. The characteristic symptom of BPLS is rotational vertigo lasting less than 60 seconds. A TBI can cause otoliths (tiny calcium carbonate crystals) to dislodge from their normal position in the inner ear and fall into one of the fluid-filled semicircular canals. This disrupts the normal interaction between the fluid and the hair cells in the semicircular canal. The inner ear becomes sensitive to changes in head position to which it would not normally respond. This causes you to experience a spinning sensation (as if you or your surroundings are spinning). This sensation is called rotatory vertigo. Usually only one ear is affected (unilateral BPLS).
The vast majority of BPLS cases are resolved in a single session with so-called release maneuvers. As a rule, such a release maneuver only needs to be repeated 2-3 times until the BPLS is resolved. If the symptoms are not resolved, other causes and treatments need to be considered.


Perilymph fistula
Even a mild TBI can result in a tear or rupture in one or both oval or round windows of the inner ear. A perilymphatic fistula can cause both balance and hearing symptoms, usually occurring shortly after the head trauma, including some or all of the following:
- Rotational vertigo
- Impaired balance
- Dizziness when sneezing, coughing or propping up (pressure-induced)
- Dizziness with loud noises (sound-induced)
- Discomfort with movement
- Nausea and/or vomiting
- Sudden or progressive sensorineural hearing loss, that sometimes gets better or worse (fluctuating)
- Tinnitus
- Sensitivity to everyday sounds (hyperacusis)
- Sensation of fullness or pressure in the ears


Labyrinthconcussion
A labyrinth concussion is an injury to the fluid-filled canals and ventricles in the inner ear. It usually improves as the brain adapts and regains balance control over weeks or months. This process is called vestibular compensation. A labyrinthine concussion causes dysfunction in the inner ear on one (unilateral) or both (bilateral) sides. Symptoms may include some or all of the following:
- Rotational vertigo
- Unsteady posture or gait
- Sensorineural hearing loss
- Tinnitus
- Nystagmus (rapid involuntary eye movements), often worsened by rapid head movements
- Nausea and/or vomiting


Secondary endolymphatic hydrops (SEH)
A TBI can cause an accumulation of fluid in the inner ear called SEH. It can occur weeks or months after the injury. Symptoms may come and go and include some or all of the following:
- Rotational vertigo
- Sensorineural hearing loss
- Tinnitus
- Fullness or pressure in the ears


Bilateral vestibulopathy (BVP)
A TBI can damage the vestibular system in both inner ears. "Bilateral" means that the damage occurs on both sides. The main symptoms of bilateral vestibulopathy (BVP) are:
- severe balance problems and unsteady gait
- blurred or jumpy vision when the head moves quickly (oscillopsia)


Dysfunction of the vestibular nerve
A TBI can cause an injury to the vestibulocochlear nerve (8th cranial nerve). As a result, the nerve impulses to the brain do not function properly. As a result, the brain no longer receives important information from the balance sensors in the inner ear. Previous research suggests that the head movement associated with TBI may cause stretching and injury to the vestibulocochlear nerve.


Dehiscence of the semicircular canals
The force of a TBI can lead to a tiny hole (known as a dehiscence) in one or more of the semicircular canals in the inner ear. This is called semicircular canal dehiscence. Symptoms include a sudden onset of hearing and balance problems. People with semicircular canal dehiscence often hear internal sounds such as their own voice, heartbeat or even the movement of the eyeball.


Fracture of the petrous bone
The petrous bone (also known as the temporal bone) is a hard, thick bone at the base of the skull. It is the most complex bone in the human body. It protects many vital structures, including the hearing and balance sensors in the inner ear. Balance and hearing disorders are common, especially in the case of a transverse fracture, and can be accompanied by other symptoms:
- rotational vertigo
- nystagmus
- conductive or sensorineural hearing loss

Diagnosis of dizziness and balance disorders after a TBI

Although clinical awareness is growing, vestibular disorders following TBI are often undiagnosed or underestimated.

Thanks to improved testing procedures for peripheral vestibular function, balance disorders in the inner ear can now also be diagnosed that would not have been recognized in the past. Unfortunately, the waiting times for an appointment with specialized doctors and clinics are usually very long. Many people are not diagnosed until many months after the onset of symptoms.

Doctors can have different opinions about what they mean by a TBI and how it is diagnosed. For people with TBI symptoms, it is an additional challenge to be confronted with these different approaches. Unfortunately, although TBI research is progressing rapidly, new information is not reaching doctors as quickly.

Vestibular disorders caused by TBI can be diagnosed by a neuro-otologist or otolaryngologist who specializes in dizziness. These specialized doctors will take a thorough medical history, perform a neurological examination and various tests to assess the function of your vestibular system.

Depending on your symptoms, you can have some of the following diagnostic tests carried out:

  • Examination of eye movements
  • Hearing tests and vestibular function tests
  • Balance tests
  • Blood tests
  • Imaging procedures (CT or MRI scans), which are usually used to rule out a more serious brain injury

The symptoms of vestibular dysfunction caused by a TBI overlap. Therefore, your doctor must consider all possibilities before making a diagnosis.

Treatment of dizziness and balance disorders after a TBI

Each assessment and treatment of dizziness after a TBI must be individualized. Assessment by a doctor with expertise in TBI is necessary to find the best treatment method for you.

A TBI can lead to many symptoms, some primary, some secondary. Due to the widely varying types and severity of symptoms and underlying causes, there is no single treatment or cure for dizziness and balance disorders following a TBI. Treatment by an interdisciplinary team is most effective.

Depending on the diagnosis, treatment may include the following:

  • Liberation maneuver with BPLS
  • Vestibular rehabilitation therapy
  • Physiotherapy for injuries to the cervical spine
  • Use of virtual reality (VR)
  • Lifestyle changes
  • Medication
  • Injections into the ear
  • Operation

Dizziness is considered a risk factor for prolonged recovery after a TBI. However, once a treatment plan is started, all peripheral and most central vestibular symptoms usually improve over time. This is attributed to functional recovery or central compensation.

Vestibular rehabilitation therapy

There is growing evidence that vestibular rehabilitation therapy for balance disorders and dizziness after TBI reduces symptoms and contributes to a faster recovery in most patients.

Cognitive behavioral therapy combined with vestibular rehabilitation therapy can improve its effectiveness.

However, vestibular rehabilitation therapy does not help with acute, active, recurrent, spontaneous vertigo - e.g. in the early stages of secondary endolymphatic hydrops (SEH) and vestibular migraine - because the brain cannot adapt to the changing nature of these disorders.

Vestibular rehabilitation therapy can be effective in helping to normalize vestibular responses when symptoms such as dizziness, gait unsteadiness or nausea persist for more than a few days. Referral to a certified IVRT® Dizziness and Vestibular Therapist should usually be made after a thorough medical evaluation of the concussion by your primary care physician or emergency room physician. Your doctor will decide if clinical tests need to be performed before starting vestibular rehabilitation therapy.

For most people, vestibular rehabilitation therapy helps to strengthen the connection between the body, eyes, brain and inner ear. During vestibular rehabilitation therapy, your symptoms may be deliberately provoked in a safe and controlled way to gradually accustom your brain to the stimuli. The overall goal is to improve your quality of life by adapting to your condition, reducing your symptoms and improving your overall functioning.

Research shows that vestibular rehabilitation therapy is most effective when it is individualized. The type, frequency and intensity of effective exercises vary from person to person.

Vestibular rehabilitation therapy is tailored to your condition and your symptoms. Some exercises are specific and reduce your reaction to certain movements or visual stimuli, for example. Other exercises aim to reduce your limitations in everyday life (self-care, household activities, sports, driving) and at work. A certified IVRT® Dizziness and Vestibular Therapist can help you create treatment goals and an appropriate exercise program.

Problems that can prolong recovery

Some problems may overlap with TBI symptoms or make your symptoms worse. For example, if you've suffered a TBI before, it's not uncommon for recovery to take longer.

Talk to your healthcare professional about this to make sure you are on the right path to recovery.

Factors that can prolong recovery include

  • a previous SHT
  • History of migraine
  • Learning disabilities or attention deficit hyperactivity disorder (ADHD)
  • Depression or anxiety
  • older age
  • Visual and vestibular disorders

 

 

 

 

 

Post-commotion syndrome

Most TBIs resolve within the first three months. Around 15-30% of those affected still have dizziness and other symptoms after three months. They may develop post-commotion syndrome and suffer from persistent TBI symptoms.

Post-coma syndrome can include the emotional, mental, physical and sleep-related symptoms listed above, as well as some or all of the following symptoms:

  • Constant rocking sensation or swaying dizziness
  • Visually induced dizziness - episodic dizziness triggered by movements (e.g. windshield wipers) or complex visual cues (e.g. shopping aisles)
  • Social withdrawal or isolation
  • Unpredictable emotional reactions that are disproportionate to the situation, such as intense anxiety, fear and apprehension
  • Balance disorders
  • Memory problems
  • Language problems
  • Dysregulation of heart rate and blood pressure (exercise intolerance)

Vestibular rehabilitation is the basis for the treatment of dizziness caused by post-commotion syndrome.

What happens next?

What you can expect in the future.

Diffusion-weighted magnetic resonance imaging (MRI) sometimes shows subtle brain changes in people with TBI. Further studies are needed to clarify whether it is useful for the diagnosis of balance problems after TBI.

Evidence-based research on vestibular rehabilitation therapy for TBI is consistent across studies, but the quality of research is weak. Although vestibular rehabilitation is promising, high quality studies are needed to determine which treatment strategies are most effective.

Advances in virtual reality (VR) hold great promise for enhancing the effects of traditional vestibular rehabilitation therapy.

It is being investigated how aerobic training can alleviate the symptoms of post-commotion syndrome.

Recovery from dizziness and balance disorders after TBI remains an important area of research. Current rehabilitation therapies are limited in their ability to treat persistent symptoms.

Although new therapies are being researched for the treatment of TBI in general, there are few treatments that specifically address damage to the vestibular system. These include, among others:

  • Neuromodulation to promote adaptive neuroplasticity of the brain
  • Use of wearable sensors that provide visual and auditory biofeedback to improve balance
  • Transcranial magnetic stimulation (TMS)
  • Gene therapy
  • Stem cell therapy
  • Nanoparticles

 

In order to keep this patient information as short as possible, we have not included a detailed list of references. However, this can be requested at any time at info@ivrt.de.

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