Balance Disorders

A balance disorder is any condition that makes you unsteady, especially when standing or walking. It may cause you to feel a sense of dizziness or lightheadedness. There can be many causes, most of which can be identified and successfully treated with proper testing. Most commonly, balance disorders are caused by problems in your inner ear, or vestibular [vess-TIB-yoo-ler] system. This system was designed to help you:

• Know when you’re moving or standing still
• Move accurately and confidently
• Keep your visual clarity when walking

A balance disorder can make you feel like you’re moving when you’re sitting still. This dizziness can make you feel nauseated and is sometimes be described as a sense of floating or spinning.

Balance is something we don’t think about until something is wrong with it. Good balance is the result of your brain sensing information from your eyes, inner ears, and feet, and then sending messages to your muscles to make coordinate and stabilized movements. These 3 sensory systems help you know where your body is at all times and keep your balance particularly when you are moving.

One of the most powerful parts of the balance system is your inner ear or vestibular system. The vestibular system’s only job is to help us literally “stay balanced”. It is exquisitely sensitive to motion and posture. Constant signals coming from sensitive “hair cell movement sensors” that are compared and integrated/coordinated with our other sensory systems are what keep you balanced.

If your inner ear is not working right, then the messages from your inner ear will not match the messages from your eyes and the rest of your body. Your body will be confused about its position and you will feel unsteady and dizzy.

These are some of the things you may experience when you have a balance disorder:

• Dizziness or lightheadedness
• Vertigo (feel like you are spinning or the world is spinning)
• Unsteadiness, like you might fall, veer and or stagger
• Blurry vision
• Nausea
• Fatigue

Balance disorders can be quite scary as they can make you feel like you aren't in control and can't balance or steady yourself. You may feel very stressed and can even develop anxiety, panic and/or depression. Balance disorders can be very disruptive and disabling as they change your ability to do daily activities.

Commonly, these moments of dizziness will come and go (such as the lightheadedness you can feel when you stand up too quickly). But if you have dizziness, vertigo, or unsteadiness that doesn’t go away and is interfering with your capacity to walk and move, you need to see your doctor. You should also see your doctor if you have experienced falling and/or unsteadiness feelings like you may fall.

• Positional vertigo, or benign paroxysmal [par-uh k-siz-uh muhl] positional vertigo (BPPV). This is by far the most common cause of dizziness and is quite easily identified and treated. It is a disorder of the inner ear that can cause a temporary strong feeling of vertigo (spinning) specific to when move your head. It is particularly noted when you first lay down, roll over, and/or look up.  It happens because tiny crystals that are normally “glued into place” in the center of your inner ear, become “unglued” and fall out of place into the outer canals. When you move your head, the crystals “fall in the canal” and make you feel like your spinning. This is just something that most commonly just can happen (like we can pull muscles, get a back ache, or crystals can unglue) but can happen more often the older we get. Less frequently BPPV can be caused by head injury or other inner ear problems.
• Inner Ear Infection (Labyrinthitis [lab-uh-rin-thy-tis] or vestibular neuritis [ve-stib-yuh-ler noo-rahy-tis}). This is where your inner ear gets damaged from a viral infection. Inner ear infection can cause a more severe and persistent vertigo that often takes people to the Emergency Department and can last for days. And with labyrinthitis, you may not only notice problems with balance and vertigo but it can also cause you to suffer a loss of hearing as well. It is often associated with upper respiratory infections like the flu. Inner ear infections have great potential to heal but can take weeks of time and those who don’t heal in a timely manner can respond very well to exercise.
• Migraine. Migraines can cause a person can experience distinct spells of quite alarming dizziness/vertigo. This dizziness can happen with or without a headache although often the two will occur together. Migraine can be cause of dizziness if you have a history prior disabling headaches, your inner ear testing is found to be normal and you are also reporting other common migraine complaints such as light/sound sensitivity, nausea and head pain.
• Ménière's disease. With Ménière's disease, a person has episodes of dizziness that come and go. During the episode, a person has vertigo and balance problems as well as hearing problems. The person may feel like the ear is blocked up and full, and they can’t hear as well. They also have tinnitus [ti-ny-tuhs] (ringing or buzzing in the ear) that gets worse during episodes but often does not go away even between episodes. The cause of Ménière's disease is not yet known.
• Persistent Postural Perceptual Dizziness (PPPD). PPPD is also one of the more common causes of a more persistent or daily dizziness.  This is something that is most often triggered by inner ear event, migraine, or concussion. It is believed to be a complication to healing and literally represents a shift in the way your balance system is working because of prior triggering/disturbing dizziness event. The person may complain of a less intense dizziness that is present most of the day. They complain of visual motion intolerance such as grocery stores, scrolling computer screens, and even busy carpets. This has been found be very responsive to some medicines and exercise.
• Perilymph fistula [per-i-limf fis-choo-luh] or Superior Canal Dehiscence. Sometimes an injury, or for not well understandably causes, there can be abnormal opening of your inner ear that either allows the inner ear fluid to leak into your middle ear (perilymph fistula) or more commonly allows pressure to irritate the inner ear (Superior Canal Dehiscence). It causes dizziness and trouble with balance that gets worsen with straining or pressure changes. It can be caused by a head injury or an ear injury from changes in pressure that might happen, for example, in scuba diving. It can also happen from having a lot of serious ear infections.
• Otosclerosis [oh-tuh-skli-roh-sis]. One of the small bones in the middle ear has a problem or growth that keeps the middle ear and inner ear from working right and this can cause hearing loss.
• Ototoxicity [oh-tuh-tok-sis-i-tee]. Sometimes certain medicines can cause damage to the nerve or hair cells in the inner ear.
• Mal de Débarquement syndrome. This is a very rare type of dizziness that feels like more of a rocking sensation. It is most often is triggered after a person has been traveling on a boat or ship. You may feel like you are still rocking as though you are on the sea even when you return to land. The feeling usually goes away within hours to days after you get to land. Rarely, it can last longer than that, but we don’t yet know why this happens.
• Peripheral Neuropathy. One of the most common balance disorders, not related to your inner ear, is a progressive numbness in your feet. This usually happens slowly over time and is most commonly associated or caused by diabetes.
• Medicines: Lots of different medicines have a side effect of dizziness. Starting new medicines, being on multiple medicines, certain combinations of medicines, or incorrect dosage of medicines can be a common cause for dizziness. This is something your doctor can help to determine and often just a slight medicine change or time will help this time of dizziness resolve.
• Orthostatic Hypotension. Although it can be common for all of us to experience some lightheadedness when we first stand up, sometimes this effect can be very severe and related to unstable more severe drops in blood pressure.  Making sure your blood pressure is regularly checked and managed can help this form of dizziness.
• Tumor. Rarely, a balance disorder can happen because of a tumor that is growing on the vestibular nerve.

It can be difficult to diagnose a balance disorder because of all the many possible causes. Unlike diabetes, where a doctor can take a single blood test and determine your problem, there is not just a single test that can be used to diagnose a balance problem. Often patients and their doctor will have to do some real detective work to get to bottom of these problems. The inner ear, which is so often the reason for dizziness is buried deep in your skull and it isn’t possible to look and see what is wrong. But how you talk about your dizziness can greatly help your doctor in diagnosing and more importantly treating your problem.

You can help your doctor make a good diagnosis by describing your symptoms well. Be ready to tell the doctor:

• What does the balance problem and dizziness feel like? Do you feel like you’re floating? Lightheaded? Like the room is spinning?
• When did it start? When does the dizziness happen? How often does it happen?
• Have you actually fallen? How often, or how many times?
• Do you have any other symptoms besides dizziness? Have you noticed any trouble hearing? Headaches? Vision problems?
• What medicines do you take? When do you take them, and how often? Include all prescriptions, over-the-counter medicines, vitamins, and supplements.

Your doctor may refer you to an ear, nose, throat doctor (ENT), also called an otolaryngologist [oh-toh-lar-ing-GOL-uh-jist]. This doctor may do some other tests such as:

• Blood test
• Hearing test
• Vestibular Testing (Video Nystagmography)
• MRI, CT scan, or other imaging of your head
• Posture and balance control assessment (posturography). The test measures how your body responds to the movement of a platform you stand on or to the movement of an image you look at on a screen.

Your doctor may also send you to a neurologist. A neurologist can help to test for more serious causes of dizziness and any headache-related dizziness.

Treatment for a balance disorder depends on the type of disorder and its cause.

• If the problem is caused by an inner ear infection it is most commonly due to a viral infection, and this can’t be treated with antibiotics. So just like with a cold or flu, you must wait for the infection to run its course. If a bacterial infection is found, then the doctor will try to treat the infection with antibiotics but this is not as common. Because of the degree of unsteadiness that you experience, you will need to take precautions that you don’t fall. Your unsteadiness will gradually resolve over days to weeks. Your body has a great potential to heal this problem very well. For those who are struggling, feel unsafe or don’t heal in a timely manner you can be referred to specialized therapist who can prescribe exercises can be help you heal and improve balance.
• If the problem is caused by a reaction to one of your medicines, the doctor will adjust/stop the medicine.
• For Benign Paroxysmal Positional Vertigo (BPPV), the out of place crystals can be repositioned back to where they belong. Your doctor can either provide a specific repositioning treatment at your visit or give you some simple exercises or maneuvers to do at home. Sometimes the maneuver works the first time, but you may have to do it a few times before your symptoms go away. If you are feeling quite unsteady, unsafe and/or these first treatments don’t seem to be working, your doctor can also refer you to a therapist with specialized training who can help to more optimally perform the specific repositioning and help to re-establish your stability and motion tolerance.
• If the cause is Ménière's disease, it can be difficult to treat and often can just resolve on its own. The doctor may recommend starting with just a change in diet and/or medicine (water pill). The doctor can also recommend medicine to help lessen the vertigo during the episodes. Drowsiness is a side effect of this medicine. You may also want to do things that will keep you safe when you are dizzy. There can be more aggressive ways to treat including injections and surgery if more these more simple measures don’t help. Exercises can’t prevent or stop these spells, however head motion and balance exercises can help to lessen lingering symptoms and basically help you heal better. This can help you feel dizzy and less unstable.
• With Otosclerosis, surgery can be used to correct a problem with one of the bones in your ear.
• More persistent dizziness and instability can often respond to exercises given by specialized physical therapists. 

Although we can lessen are chances at developing a balance disorder, it is impossible to completely prevent it from happening. Staying active is the best way to help your balance system and body stay healthy and to lessen falls. In some cases, depending on the cause of your dizziness, there may be an identifiable trigger which you can learn to avoid.

Intermountain Healthcare BPPV education fact sheet

Vestibular Disorders Association

National Institute of Deafness and Other Communication Disorders, "Balance Disorders"

A balance disorder is any condition that makes you unsteady, especially when standing or walking. You can also feel a sense of dizziness or lightheadedness. There can be many causes, most of which can be identified and successfully treated with proper testing. Most commonly, balance disorders are caused by problems in your inner ear, or vestibular [vess-TIB-yoo-ler] system. This system was designed to help you:

• Know when you're moving or standing still
• Move accurately and confidently
• Keep your visual clarity when walking