“I’m so dizzy – My head is spinning”

Differential diagnosis and treatment of vestibular problems in TBI

Andrew McVittie, Chartered Physiotherapist, SP Therapy Services

VESTIBULAR DYSFUNCTION AND REHABILITATION IN TBI

It is well known that traumatic brain

Andrew McVittie injury (TBI) is the most common cause of disability in the general population under the age of 40. TBI diagnosis is increasing as clinicians recognise the potential long-term impacts of even mild TBI.

Around a 1/3rd to over ¾ of this population also report chronic symptoms of vestibular dysfunction when investigated.

It is perhaps not so commonly known that longterm unemployment can be up to three times higher in TBI survivors with chronic vestibular dysfunction. Yet vestibular dysfunction appears under diagnosed and treatment complicated.

Vestibular dysfunction can alter balance and bring an associated lack of movement confidence. This directly impacts quality of life, involvement in activities of daily living and mobility.

Altered balance and associated loss of confidence, are recognised as two major risk factors for future falls. Dizziness, another commonly reported vestibular symptom, doubles the risk of a person falling.

Add to this the greater consequences of a fall for those already having suffered a TBI and vestibular rehabilitation is clearly an area where accurate diagnosis combined with evidenced treatment could make a huge difference.

This prompted the Physiotherapy team at SP Therapy Services to produce a practitioner treatment guide to be used as a screening tool at all assessments involving TBI.

HISTORICAL UNDERDIAGNOSIS

Vestibular dysfunction seems to have been historically under diagnosed in the TBI population. Acute vestibular symptoms are often expected by the patient following a TBI, leading to them being under reported.

These vestibular related issues are almost expected to self-resolve post acutely and it often appears that they do. But it is now thought that chronic adaptive brain mechanisms uncouple vestibular symptoms from signs effectively masking them. The brain and body adapt around the deficiencies. This extra level of processing, in a population often already experiencing cognitive difficulties, results in decreased capabilities.

Complicating matters further are symptoms sometimes taking weeks to become apparent. This may not be recognised as a new symptom, or one associated with the TBI, when presented to health care practitioners who may not be trained, or attuned, to identifying vestibular problems.

Perception issues can also leave TBI patients unaware they are even experiencing vestibular dysfunction symptoms.

Not just an inner ear problem

COMPLEX PRESENTATION

Classic symptoms that are frequently associated with vestibular dysfunction conditions such as Benign Paroxysmal Positional Vertigo (dizziness and nausea) are easily recognised by most practitioners. But the complex presentation of a TBI with its associated cognitive, communication, fatigue, mood and perception problems can mean symptoms are not so easy to tease out.

Those with vestibular dysfunction in the TBI population are roughly equally split between those with a peripheral issue (eyes and ears), a central issue (dysfunction within the areas of the brain that interpret the information and control balance) and a mix of both. This complexity of presentation, with symptoms caused by two systems, can make diagnosis and treatment very difficult. There is often a pattern of patients having seen many different health professionals, in different settings, over a long period of time, but without receiving a clear diagnosis leading to effective treatment.

Information received from afferent sensory pathways is interpreted centrally

ASSESSMENT

Where appropriate, assessment should include all aspects of the postural control system, motor, sensory and cognitive. Muscle strength testing, sensation, range of joint motion, coordination and tone are all potential contributory factors. Observation of posture and gait, and assessment of neck range of motion is also suggested. As community-based Physiotherapists these are tasks we perform daily and we are ideally suited to restoring function, balance, and strength through exercise.

If a patient has subconsciously compensated for their deficits, or has cognitive impairment, they may not even be aware of their symptoms. Therefore knowing what questions to ask, or signs to be aware of, relies on a detailed knowledge of what they may be and how they may present in a TBI patient.

HOW CAN WE HELP?

The ultimate aim of rehabilitation is to help patients become as fully functional as possible, within all aspects of their lives in the context of their disability. For a patient with the complex presentation of vestibular dysfunction combined with TBI assessment and treatment requires an understanding of the complex inter related nature of both conditions

Vestibular rehabilitation is a programme which includes the administration of a set of graduated, customised exercises. It may also, where appropriate, include additional components such as education and referral to MDT colleagues.

Rehabilitation should be customised to the individual, and thus is not purely dependent on the diagnosis. Again as Physiotherapists working with patients in their own environments we can obtain an holistic picture of their situation and individualise treatment accordingly.

At SP Therapy services our Physiotherapists and Occupational Therapists are passionate about patients with complex needs and strive to provide the best possible care to people with neurological conditions. Therefore, we are inclusive to all and we have developed problem, rather than, diagnosis specific protocols.

Following the evidence we gathered in peer support sessions we have an improved ability to screen patients for vestibular symptoms that may otherwise have been un-detected. When symptoms are identified we are able to provide comprehensive vestibular assessment, risk assessment and individualised treatment.

We are happy to collaborate with local health care providers and other services. We regularly share our experience and knowledge and speak to our colleague therapists, local patient groups and charities to benefit the wider community, especially patients with complex needs like those who sustain TBI.

Tel: 0161 764 3799 Web: www.sptherapyservices.co.uk