Dizziness and balance

Information for patients MSK Outpatients (Therapy)

PROUD TO MAKE A DIFFERENCE SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST How do we normally control our balance?

Visual information

Adjustments Brain to your eye combines movements input information

Balance awareness Balance

Other sensory Adjustments information to your body (e.g. body position, position motion, touch)

page 2 of 12 There are three different balance senses that send the brain information to help control our balance: 1. The eyes send information to the brain about where you are and where you are going. 2. The inner ears (also called the vestibular system) send the brain information about head movements such as looking up, bending down and turning your head as well as movements such as moving in a car or in a lift. 3. Muscles and joints (also called the proprioceptive system) send the brain information about the body’s position and how the body is moving. The brain is like a computer that receives information from these three different senses. It then makes changes as necessary by sending information back to the eyes and body. This maintains our balance and allows our vision to remain stable.

What is dizziness? Dizziness feels different to different people. Some people may feel unsteady, lightheaded, ‘woozy’ and / or a spinning sensation (sometimes called vertigo). Dizziness is not a disease or an illness but explains how we feel when our balance systems are not working normally. It is a common symptom and can get better by itself. It is very rarely due to a serious medical condition. However dizziness can still be very unpleasant and frightening and can result in other symptoms like feeling sick, being sick, tiredness and poor concentration.

page 3 of 12 Why do I feel dizzy? The brain stores a memory bank of the information it receives from the three different senses. The brain can then access this information automatically so normally we do not have to think about our balance. If one of the balance systems is not working properly then the brain starts to receive incorrect information. The brain does not recognise this information as it does not match the information stored in the memory bank. This is when we can experience dizziness and / or unsteadiness. Normally the right and left inner ear balance organs work together. However if there is a problem with one side (for example following an ear infection) the inner ears may no longer work together. The brain perceives that your head is moving when it isn’t and you will feel dizzy.

Why has my dizziness not improved? Often when a person has dizziness or a balance problem they naturally start to avoid certain movements that make them feel worse. They think “Why do something that makes me feel more dizzy or ill?” However recovery (also known as compensation) cannot occur if movements are avoided. If the brain does not sense dizziness then it does not realise something is wrong and cannot begin the recovery process.

Can my dizziness improve? The good news is yes! Many people with dizziness or balance problems benefit from balance exercises, also known as vestibular rehabilitation. It is very important that you practice the exercises regularly as advised by your physiotherapist or doctor. Medication may help to control symptoms initially but it will not cure the problem. If used long term, some medications can stop the balance systems from working normally thereby preventing full recovery. Some medications can also cause feelings of dizziness. Please discuss this with your doctor before stopping any medication.

page 4 of 12 Gaze stability exercise This is a type of exercise often given to patients with inner ear problems. Only carry these exercises out if advised by your therapist. These exercises are based on normal movements that occur in daily life so they should be totally safe unless you have been advised to avoid these movements.

A BC

Looking at a letter stuck to the wall, turn your head left to right and back 10 times in 10 seconds (as if you are shaking your head to say no). Keep your eyes fixed on the letter the whole time you are moving your head. Only turn your head as far as comfortable and definitely no more than about 45 degrees to the left or right. If this exercise makes you feel too dizzy or the letter is going blurry then slow the movement down. This exercise can be repeated by nodding your head up and down whilst looking at a letter. Try these exercises twice a day if possible. It is very unlikely, but stop the exercises if they bring on any symptoms that you do not usually have such as: feeling faint or blacking out; double vision; numbness, tingling or weakness; or severe, sharp or prolonged neck pain. If you are unsure please ring your therapist. As well as these exercises your therapist will ask you to carry out other exercises depending on what your main problems are.

page 5 of 12 How do the exercises reduce dizziness? The exercises your physiotherapist asks you to do will make you feel slight dizziness or unsteadiness due to the mismatch of signals from the balance senses. Repeating the movements that make you feel dizzy allows the brain to learn to cope with the new balance information and accept the movement is normal again. The brain can also use more information from the eyes, ankles, legs and neck to maintain balance and minimise dizziness. The key to recovery is not to avoid any movements and to gradually increase your activity each week. Try to practice the movements that are difficult if you feel it is safe to do so.

Can the exercises be harmful? Sometimes to begin with the exercises can make you feel more dizzy. Don’t worry, you are not doing any harm to your balance systems. Sometimes the brain can become a little ‘overloaded’ with new information it is receiving from the balance systems during the exercises. It is therefore best to start the exercises gradually and build up your tolerance to the movements slowly.

If you find the exercises stop you from being able to carry out your daily activities then discuss this with your physiotherapist. You may need to reduce the number of exercises or perhaps do them more slowly to begin with. On the other hand if the exercises do not make you feel dizzy at all then it may be that you need to start doing more difficult exercises. When you are carrying out the exercises always make sure you are safe. If you are worried about falling or feeling very dizzy then have someone with you while you are doing the exercises.

page 6 of 12 How quickly will it improve? The process of recovery can take a long time and does vary from person to person. Often the exercises start to feel easier as the balance systems are working better. However, it can then take time for the brain to adjust to the new information. People normally start to feel an improvement after around 3 to 6 months. Studies have shown that 4 out of 5 people who carried out exercises to reduce dizziness felt better within a few months. Those who did not do the exercises showed no improvement.

Will I make a full recovery? You should be able to make a good recovery following the exercises despite having an inner ear or balance problem. The recovery process is not always 100% efficient and you may feel better on some days and worse on others. This can often be due to stress, tiredness or illness and is quite normal. It does not mean that the original problem is coming back or that your problem is getting worse. You should find that, as you continue to practice the exercises, there are fewer bad days.

page 7 of 12 How and why does stress affect my dizziness? Dizziness and balance problems can cause worries, anxieties and stress. People may also have worries about work, social activities or family commitments. This can lead to a vicious cycle of stress, making the feelings of dizziness worse. One reason why stress increases dizziness is because when we become aware of dizziness or feeling off balance our brain consciously takes over and our balance is no longer automatic. This can trigger a response known as the ‘fight or flight’ reflex. This can cause symptoms like the heart beating fast, breathing quickly, feeling sick, feeling hot and sweaty or cold and clammy. This is a reaction to the feelings of dizziness but again can result in feeling more dizzy. People also find they are less able to cope with dizziness when under stress. If the body is trying hard to deal with the stress, it then finds it difficult to cope with the balance problem too. This is another reason why stress can increase dizziness. It is therefore important where possible to reduce anxiety, tension and stress as this can help to reduce dizziness too. It is important to speak to your physiotherapist if you feel this is a problem. There is further help you can get with this and it is a quite normal part of feeling dizzy. Breathing and relaxation exercises can help to reduce stress and allow people to feel in control in difficult situations.

page 8 of 12 Is there anything else I can do to help myself? Keeping active by walking and taking part in sports are good ways to challenge your balance, keep you fit and keep your muscles strong. T’ai chi has also been shown to improve balance. Talking to your friends and family about your dizziness and sharing your concerns can be really helpful. For people with certain conditions (like migraine or Ménière’s disease) keeping a food diary can be useful to see if there are certain foods or drinks that trigger dizziness.

How long do I need to continue the exercises? It is important to continue to exercise even after you have been discharged. Keeping your balance strong will help to minimise any problems in the future caused by illness, stress and tiredness as these are known to increase dizziness symptoms. Your physiotherapist or doctor can discuss this further with you before you are discharged.

page 9 of 12 Can I get any further information on dizziness? The following are some useful websites which are also recommended by the Department of Health: Action on Hearing Loss (previously The Royal National Institute for the Deaf) has some useful factsheets on its website regarding balance and ear problems. • www.actiononhearingloss.org.uk/supporting-you/factsheets-and-le aflets.aspx The Menière’s Society has a self help book on vertigo and dizziness which can be downloaded. • www.menieres.org.uk/information-and-support The Brain and Spine Foundation have produced a book on dizziness and balance problems. • www.brainandspine.org.uk/our-publications/booklets/dizziness-an d-balance-problems/ NICE (Department of Health) also publishes Clinical Knowledge Summaries which are a good source of information. • http://cks.nice.org.uk/vertigo • http://cks.nice.org.uk/menieres-disease Labyrinthitis.org.uk is a website developed by two patients to give advice and support to other patients with a similar condition. • www.labyrinthitis.org.uk Vesitbular Disorders Association • www.vestibular.org

page 10 of 12 page 11 of 12 Contact details

Your Physiotherapist:

• 0114 271 3090

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PD7888-PIL3279 v3 Issue Date: July 2019. Review Date: July 2022