Los Angeles Brain

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Balance is a finely tuned function of the brain, involving the feedback of hundreds of muscles throughout the body, based on innumerable sensory inputs giving information on joint position and pressure, and regulated by circuits distributed throughout the brain that function on a millisecond scale.  Head traumas have been observed to affect the vestibular system, a system responsible for providing our brain with information about motion, head position, and spatial orientation, through direct damage of the organs or nerves responsible for these pathways (Maskell et al., 2006). Resultantly, all circuits in the brain function less precisely as damage is repaired, and during this recovery period, a sense of imbalance occurs.

 

Dizziness includes “vague symptoms of disorientation and lightheadedness as well as the more clear-cut symptoms of vertigo and imbalance” (Maskell et al., 2006). Vertigo, or the illusion of movement, and multisensory dizziness, is a common symptom related to dysfunction of the vestibular symptom along with other sensory symptoms. Additionally, pre-syncopal lightheadedness, or the sensation of impending faintness, is common and often related to postural change. 

 

A common disorder experienced after head trauma is benign paroxysmal positional vertigo (BPPV). The semicircular canals within the inner ear have gyroscope-like anatomy and provide balance input when working properly.  Head trauma can dislodge crystal-like sensors within these canals, disrupting their function.  The symptom that results is a severe sense of room-spinning vertigo that lasts for 10-30 seconds after the head turns to one side or another, followed by a sense of imbalance, unease, and often nausea that lasts afterward.  Severe vertigo that lasts a brief time with specific head movements should be presumed to be related to BPPV. 
 

Treatment

 

The risk of another head trauma during the recovery period of the first trauma is significant, so our sense of imbalance serves to protect us from engaging in activities that may lead to a subsequent fall. Through testing such as a videonystagmography (VNG), we can measure nystagmus (involuntary eye movement) for evaluation of dysfunction of the vestibular system.

 

As a next step, I recommend balance and vestibular physical therapy to aid in ongoing postconcussive dizziness (Nagib & Linens, 2020). Physical therapy targeting balance is often recommended and can hasten recovery. More specifically, treatment for symptoms of BPPV includes a treatment set of head-turning exercises called an Epley maneuver designed to reposition the dislodged crystal; these can be performed by an ENT physician, neurologist or physical therapist trained in the technique. Moreover, anxiety and stress related to imbalance can often delay recovery, and cognitive behavioral therapy focusing on imbalance is an important adjunct.  

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Summary of treatments:

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Medical evaluation for patient with post-traumatic dizziness

• Videonystagmogram (VNG)

Headache prevention

• Balance physical therapy

• Balance home exercises

• Epley maneuvers

• Meclizine 25 mg as needed

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References

:Fiona Maskell, Pauline Chiarelli & Rosemary Isles (2006) Dizziness after traumatic brain injury: Overview and measurement in the clinical setting, Brain Injury, 20:3, 293-305, DOI: 10.1080/02699050500488041