Vertigo in Traumatic Brain Injury Patients

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Imagine you got on the largest roller coaster in the world. After a big drop, you endure its twists and turns and periods of being upside down. You can feel a swaying in your body where you don’t feel well or balanced after getting off. You feel dizzy, as if the world is spinning all around you, and you can’t do anything but wait until it passes so you can get on the next ride. While this experience might be due to external factors, such as a rollercoaster ride, for people with traumatic brain injuries (TBI), this dizziness and spinning feeling, known as vertigo, is an experience that may happen more than is necessary, is often random, and can even be life-altering.

These dizziness and spinning sensations are symptoms that can often be persistent and debilitating for a lot of TBI patients (Complete Concussion Management, 2017). For TBI patients, dizziness is one of the most commonly reported symptoms: 25% of patients report dizziness 12-months post-injury (Ouchterlony et al., 2016). This condition is also known as vertigo, or “A subtype of dizziness in which asymmetric or impaired input into the vestibular system results in the illusion of movement, or the sensation or feeling of being off-balance” (Lindberg, 2020; Complete Concussion Management, 2017). A patient often feels like they are spinning or describes the world as turning around them. Vertigo experienced after a traumatic brain injury is specifically referred to as post-traumatic vertigo. 

TBIs and Vertigo Symptoms

Head trauma can impact the ear part of the vestibular system, or the three pairs of canals located behind the ears, a system essential to internal and external feelings of balance and coordination (Complete Concussion Management, 2017). The canals, called “semicircular canals,” are filled with fluid that changes with movement. The ears have a sensor that sends information to the brain based on the fluid’s positional changes (Johns Hopkins Medicine, 2020). 

To show how the sensors in our ears move in relation to the body's movement and gravitational force

Health Jade. (2018, April 05). Balance Problems, Gait Problems, Poor Balance In Elderly. Retrieved November 30, 2020, from https://healthjade.net/balance-problems/

The system prevents us from falling by detecting the movement or accelerating of our heads with the rest of our bodies/gravity. It coincides with and counters the head’s movement by repositioning the eyes, neck, and limbs to maintain uprightness and stability within our bodies (Complete Concussion Management, 2017). A blow to the head may destabilize this entire system, causing dizziness and balance issues. This rings true for TBI patients as 30-65% of TBI patients suffer from dizziness and disequilibrium (the lack of balance while sitting or standing) post-traumatic brain injury (Petersen and Greenwald, 2020). The longevity of vertigo issues for TBI patients is dependent on a variety of internal and external factors.

Following a TBI, the prevalence of vertigo or balance issues is dependant upon the following factors:

  • The severity of brain injury
  • Location of brain injury
  • Additional injuries besides the brain injury (i.e., a cervical spine injury may contribute to vertigo and balance issues)
  • Medications for medical issues related to the traumatic brain injury may cause dizziness or balance issues (Petersen and Greenwald, 2020)
  • Postural Hypotension, or drops in blood pressure upon standing or sitting up suddenly, can make people feel vertigo-like symptoms such as lightheadedness or dizziness.
  • Vision Impairments, as the eyes are a crucial part of a person’s balance. Issues such as double vision, depth perception, and visual instability can balance and, therefore, vertigo-like issues (Traumatic Brain Injury Resources in Alabama, 2017).  

Specific Type of Vertigo in TBI Survivors

Although many factors may cause post-traumatic vertigo in TBI patients, there is one form of vertigo commonly found. The most common cause/form of post-traumatic vertigo is Benign Paroxysmal Positional Vertigo (BPPV), occurring in roughly 28% of people with post-traumatic vertigo from head injuries and whiplash (Complete Concussion Management, 2017; Hain, 2019). After trauma to the head, the amount of force experienced can cause the debris (otoliths) within the inner ear canals to break free, moving around and signaling to the brain that the body is moving, when in all actuality, it is not (Complete Concussion Management, 2017). The ears then become increasingly sensitive to gravity changes, causing brief or elongated periods of vertigo, triggered by changes in head positions, lying down, or getting up. The vertigo symptoms then cause balance issues, which can be experienced while standing or walking (Traumatic Brain Injury Resources in Alabama, 2017). Trauma accounts for 8.5-20% of all BPPV cases, with BPPV due to head trauma being present in both ears compared to the incidence of BPPV in the general population (non-TBI patients), which is only found in one ear (Wycherly, n.d.; Complete Concussion Management, 2017). 

 

Benign Paroxysmal Positional Vertigo (BPPV). (2016, May 28). Retrieved November 30, 2020, from https://www.stepwards.com/?page_id=4776

There are many differences between vertigo that the general population experiences and post-traumatic vertigo in TBI patients. Post-traumatic BPPV has a higher incidence of bilaterality, a higher incidence of being present in multiple canals within the ears, affects women and men equally, and has a high prevalence in younger patients compared to regular BPPV (Wycherly, n.d.). Post-traumatic BPPV is also different from regular BPPV because it is harder to treat and often recurrent in TBI patients. This is due to the trauma causing more resistance to treatment, more treatment failures, significant system disruption, and displacement of a substantial amount of debris (otoliths) in the ear canals (Wycherly, n.d.) Vertigo is likely to be long-lasting, especially in those with multiple head injuries or persistent symptoms past 4-6 months post-TBI. Fifteen percent of TBI patients already experience long-lasting symptoms, vertigo included, and are at a higher risk of falling or hitting their head again due to vertigo (Jahangiri, 2020). 

Other Types of Post-Traumatic Vertigo

Other types of post-traumatic vertigo are caused by Labyrinthine Concussion (injury to the nerve of the vestibular system), Traumatic Ednoymphatic Hydrops (disruption of the fluid balance within the inner ear), Brainstem Injury (damage to the brainstem and cerebellum, the parts of the part that control movement), or Perilymph Fistula (the leakage of inner ear fluid into the middle ear) (Traumatic Brain Injury Resources in Alabama, 2017). These conditions can cause periods of vertigo, imbalance, ringing in the ears, dizziness, nausea, onset hearing loss, death/deterioration of inner ear cells, and unsteadiness (Lindberg, 2020; Traumatic Brain Injury Resources in Alabama, 2017).  

Diagnosis and Treatment of Post-Traumatic Vertigo

There are many ways to assess and treat post-traumatic vertigo/BPPV in TBI patients. Vertigo can be evaluated and diagnosed in the following ways:

  • Assessment:
    • Injury Causation/History: doctors will want to know how and when the head or neck was injured, whether or not you were unconscious, and the duration of time unconscious
    • Signs and Symptoms: do you have symptoms such as dizziness, light-headedness, etc
    • Objective Measures: Dizziness Handicap Inventory, Dynamic Gait Index, and the Berg Balance Scale
    • Physical exam: or orthostatic vital signs, cranial nerve examinations, nystagmus, saccades observations, bedside vestibular-ocular (VOR) reflex testing, Dix-Hallpike maneuver, and cerebellar testing

Assessment of body during a doctor's appointment

  • Diagnosis:
    • Laboratory tests, such as an ENG, MRI, or CT scan of the inner ear (temporal bone CT scan) 
    • Otolaryngology and Audiology consultation: electro-oculagraphy (EOG), video-oculography (VOG), optokinetic nystagmus, caloric testing, etc (Lindberg, 2020; Hain, 2019)

Post-Traumatic Vertigo Treatment for TBI Patients

Most vertigo types, BPPV included, are managed more by physical therapies than medications, and management may depend on the severity of the injury (Complete Concussion Management, 2017). Surgery is seldom utilized as a vertigo solution, as vertigo indicates the result of a damaged part of the body, and inciting more trauma is rarely curative (Hain, 2019). The most common therapy to combat vertigo in TBI patients is Vestibular and Balance Rehabilitation Therapy (VBRT) (Lindberg, 2020). VBRT uses neural mechanisms and techniques to manage vertigo by doing repeated exposure to stimuli, using head movements that produce longer plastic changes in the ears, gaze stabilization, postural control, and specifically for BPPV – the Dix-Hallpike maneuver (Lindberg, 2020). This maneuver positions and holds the head in various sequential positions to remove the debris from the canal, ultimately eliminating or working to eliminate the vertigo symptoms (Complete Concussion Management, 2017). A clinical study in 2009 found that 81% of patients with vertigo showed complete or moderate relief from vertigo following these maneuvers (Complete Concussion Management, 2017). 

Dix-Hallpike maneuver to treat vertigo and change placement of debris (otoliths)

Enoz, M., MD. (2020, January 4). Dix Hallpike Maneuver: Evaluation of Balance Stones (Ear Rocks / Small Crystals / Otoconia) in Inner Ear. Retrieved November 30, 2020, from https://www.ent-istanbul.com/2020/01/dix-hallpike-maneuver.html

Vertigo may be a consequence of a traumatic brain injury, but it doesn’t have to be debilitating or life-altering. That’s where we step in. The Power of Patients Dashboard allows you to track your vertigo symptoms, effectively noting the triggers, and this can now be noted multiple times a day! Get started at powerofpatients.com to regain balance in your TBI symptoms and take control of your vertigo now!

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