Balance disorder

A balance disorder is a disturbance that causes an individual to feel unsteady, for example when standing or walking. It may be accompanied by feelings of giddiness, or wooziness, or having a sensation of movement, spinning, or floating. Balance is the result of several body systems working together: the visual system (eyes), vestibular system (ears) and proprioception (the body's sense of where it is in space). Degeneration or loss of function in any of these systems can lead to balance deficits.[1]

Balance disorder

Signs and symptoms

Cognitive dysfunction (disorientation) may occur with vestibular disorders. Cognitive deficits are not just spatial in nature, but also include non-spatial functions such as object recognition memory. Vestibular dysfunction has been shown to adversely affect processes of attention and increased demands of attention can worsen the postural sway associated with vestibular disorders. Recent MRI studies also show that humans with bilateral vestibular damage undergo atrophy of the hippocampus which correlates with their degree of impairment on spatial memory tasks.[2][3]

Causes

Problems with balance can occur when there is a disruption in any of the vestibular, visual, or proprioceptive systems. Abnormalities in balance function may indicate a wide range of pathologies from causes like inner ear disorders, low blood pressure, brain tumors, and brain injury including stroke.[4]

Presyncope

Pre-syncope is a feeling of lightheadedness or simply feeling faint. Syncope, by contrast, is actually fainting. A circulatory system deficiency, such as low blood pressure, can contribute to a feeling of dizziness when one suddenly stands up.[5]

Related to the ear

Causes of dizziness related to the ear are often characterized by vertigo (spinning) and nausea. Nystagmus (flickering of the eye, related to the Vestibulo-ocular reflex [VOR]) is often seen in patients with an acute peripheral cause of dizziness.

  • Benign Paroxysmal Positional Vertigo (BPPV) – The most common cause of vertigo. It is typically described as a brief, intense sensation of spinning that occurs when there are changes in the position of the head with respect to gravity. An individual may experience BPPV when rolling over to the left or right, upon getting out of bed in the morning, or when looking up for an object on a high shelf.[6] The cause of BPPV is the presence of normal but misplaced calcium crystals called otoconia, which are normally found in the utricle and saccule (the otolith organs) and are used to sense movement. If they fall from the utricle and become loose in the semicircular canals, they can distort the sense of movement and cause a mismatch between actual head movement and the information sent to the brain by the inner ear, causing a spinning sensation.[7]

Diagnosis

The difficulty of making the right vestibular diagnosis is reflected in the fact that in some populations, more than one third of the patients with a vestibular disease consult more than one physician – in some cases up to more than fifteen.[8]

Treatment

There are various options for treating balance disorders. One option includes treatment for a disease or disorder that may be contributing to the balance problem, such as ear infection, stroke, multiple sclerosis, spinal cord injury, Parkinson's, neuromuscular conditions, acquired brain injury, cerebellar dysfunctions and/or ataxia, or some tumors, such as acoustic neuroma. Individual treatment will vary and will be based upon assessment results including symptoms, medical history, general health, and the results of medical tests. Additionally, tai chi may be a cost-effective method to prevent falls in the elderly.[9]

Vestibular Rehabilitation

Many types of balance disorders will require balance training, prescribed by an occupational therapist or physiotherapist. Physiotherapists often administer standardized outcome measures as part of their assessment in order to gain useful information and data about a patient's current status. Some standardized balance assessments or outcome measures include but are not limited to the Functional Reach Test, Clinical Test for Sensory Integration in Balance (CTSIB), Berg Balance Scale and/or Timed Up and Go[10] The data and information collected can further help the physiotherapist develop an intervention program that is specific to the individual assessed. Intervention programs may include training activities that can be used to improve static and dynamic postural control, body alignment, weight distribution, ambulation, fall prevention and sensory function.[11]

Bilateral vestibular loss

Dysequilibrium arising from bilateral loss of vestibular function – such as can occur from ototoxic drugs such as gentamicin – can also be treated with balance retraining exercises (vestibular rehabilitation) although the improvement is not likely to be full recovery.[12][13]

Research

Scientists at the National Institute on Deafness and Other Communication Disorders (NIDCD) are working to understand the various balance disorders and the complex interactions between the labyrinth, other balance-sensing organs, and the brain. NIDCD scientists are studying eye movement to understand the changes that occur in aging, disease, and injury, as well as collecting data about eye movement and posture to improve diagnosis and treatment of balance disorders. They are also studying the effectiveness of certain exercises as a treatment option.[14]

References

  1. ^ Sturnieks DL, St George R, Lord SR (2008). "Balance disorders in the elderly". Clinical Neurophysiology. 38 (6): 467–478. doi:10.1016/j.neucli.2008.09.001. PMID 19026966.
  2. ^ Smith PF, Zheng Y, Horii A, Darlington CL (2005). "Does vestibular damage cause cognitive dysfunction in humans?". J Vestib Res. 15 (1): 1–9. PMID 15908735.
  3. ^ Template:Cite ukjournal
  4. ^ Joseph, Nancy S. (28 April 2011). Neuro Equilibrium (VI ed.). Southfield: Don Jackson. Retrieved 28 April 2011.
  5. ^ "Balance Disorders Symptoms, Causes, Treatment – What are the symptoms of a balance disorder?". MedicineNet. Retrieved 2014-03-02.
  6. ^ Bhattacharyya N; Baugh RF; Orvidas L; et al. (2008). "Clinical practice guideline: benign paroxysmal positional vertigo" (PDF). Otolaryngol Head Neck Surg. 139 (5 Suppl 4): S47–81. doi:10.1016/j.otohns.2008.08.022. PMID 18973840. Archived from the original (PDF) on May 26, 2011. Lay summaryAAO-HNS (2008-11-01).
  7. ^ Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS (2008). "Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review)". Neurology. 70 (22 (part 1 of 2)): 2067–2074. doi:10.1212/01.wnl.0000313378.77444.ac. PMID 18505980.
  8. ^ "Van Der Berg et al – 2015".
  9. ^ Noll, DR (January 2013). "Management of Falls and Balance Disorders in the Elderly". Journal of the American Osteopathic Association. 113 (1): 17–22. Archived from the original on 2016-03-05.
  10. ^ O'Sullivan, Susan; Schmitz, Thomas (August 2006). "8". In Susan O'Sullivan. Physical Rehabilitation. 5. F. A. Davis Company. ISBN 978-0-8036-1247-1.CS1 maint: Uses editors parameter (link)
  11. ^ O'Sullivan, Susan; Schmitz, Thomas (August 2006). "13". In Susan O'Sullivan. Physical Rehabilitation. 5. F. A. Davis Company. ISBN 978-0-8036-1247-1.CS1 maint: Uses editors parameter (link)
  12. ^ Horak FB. (2010). "Postural compensation for vestibular loss and implications for rehabilitation". Restor Neurol Neurosci. 28 (1): 57–68. doi:10.3233/RNN-2010-0515. PMC 2965039. PMID 20086283.
  13. ^ Alrwaily M, Whitney SL (2011). "Vestibular rehabilitation of older adults with dizziness". Otolaryngologic Clinics of North America. 44 (2): 473–496. doi:10.1016/j.otc.2011.01.015. PMID 21474018.
  14. ^ National Institute on Deafness and Other Communication Disorders

Further reading

External links

Acid–base homeostasis

Acid–base homeostasis is the homeostatic regulation of the pH of the body's extracellular fluid (ECF). The proper balance between the acids and bases (i.e. the pH) in the ECF is crucial for the normal physiology of the body, and cellular metabolism. The pH of the intracellular fluid and the extracellular fluid need to be maintained at a constant level.Many extracellular proteins such as the plasma proteins and membrane proteins of the body's cells are very sensitive for their three dimensional structures to the extracellular pH. Stringent mechanisms therefore exist to maintain the pH within very narrow limits. Outside the acceptable range of pH, proteins are denatured (i.e. their 3-D structure is disrupted), causing enzymes and ion channels (among others) to malfunction.

In humans and many other animals, acid–base homeostasis is maintained by multiple mechanisms involved in three lines of defence:

The first line of defence are the various chemical buffers which minimize pH changes that would otherwise occur in their absence. They do not correct pH deviations, but only serve to reduce the extent of the change that would otherwise occur. These buffers include the bicarbonate buffer system, the phosphate buffer system, and the protein buffer system.The second line of defence of the pH of the ECF consists of controlling of the carbonic acid concentration in the ECF. This is achieved by changes in the rate and depth of breathing (i.e. by hyperventilation or hypoventilation), which blows off or retains carbon dioxide (and thus carbonic acid) in the blood plasma.The third line of defence is the renal system, which can add or remove bicarbonate ions to or from the ECF. The bicarbonate is derived from metabolic carbon dioxide which is enzymatically converted to carbonic acid in the renal tubular cells. The carbonic acid spontaneously dissociates into hydrogen ions and bicarbonate ions. When the pH in the ECF tends to fall (i.e. become more acidic) the hydrogen ions are excreted into the urine, while the bicarbonate ions are secreted into the blood plasma, causing the plasma pH to rise (correcting the initial fall). The converse happens if the pH in the ECF tends to rise: the bicarbonate ions are then excreted into the urine and the hydrogen ions into the blood plasma.Physiological corrective measures make up the second and third lines of defence. This is because they operate by making changes to the buffers, each of which consists of two components: a weak acid and its conjugate base. It is the ratio concentration of the weak acid to its conjugate base that determines the pH of the solution. Thus, by manipulating firstly the concentration of the weak acid, and secondly that of its conjugate base, the pH of the extracellular fluid (ECF) can be adjusted very accurately to the correct value. The bicarbonate buffer, consisting of a mixture of carbonic acid (H2CO3) and a bicarbonate (HCO−3) salt in solution, is the most abundant buffer in the extracellular fluid, and it is also the buffer whose acid to base ratio can be changed very easily and rapidly.An acid–base imbalance is known as acidaemia when the acidity is high, or alkalaemia when the acidity is low.

Angelman syndrome

Angelman syndrome (AS) is a genetic disorder that mainly affects the nervous system. Symptoms include a small head and a specific facial appearance, severe intellectual disability, developmental disability, speaking problems, balance and movement problems, seizures, and sleep problems. Children usually have a happy personality and have a particular interest in water. The symptoms generally become noticeable by one year of age.Angelman syndrome is typically due to a new mutation rather than one inherited from a person's parents. Angelman syndrome is due to a lack of function of part of chromosome 15 inherited from a person's mother. Most of the time, it is due to a deletion or mutation of the UBE3A gene on that chromosome. Occasionally, it is due to inheriting two copies of chromosome 15 from a person's father and none from their mother. As the father's versions are inactivated by a process known as genomic imprinting, no functional version of the gene remains. Diagnosis is based on symptoms and possibly genetic testing.No cure is available. Treatment is generally supportive in nature. Anti-seizure medications are used in those with seizures. Physical therapy and bracing may help with walking. Those affected have a nearly normal life expectancy.AS affects 1 in 12,000 to 20,000 people. Males and females are affected with equal frequency. It is named after a British pediatrician, Harry Angelman, who first described the syndrome in 1965. An older term, "happy puppet syndrome", is generally considered pejorative. Prader–Willi syndrome is a separate condition, caused by a similar loss of the father's chromosome 15.

Audiology

Audiology (from Latin audīre, "to hear"; and from Greek -λογία, -logia) is a branch of science that studies hearing, balance, and related disorders. Its practitioners, who treat those with hearing loss and proactively prevent related damage, are audiologists. By employing various testing strategies (e.g. behavioral hearing tests, otoacoustic emission measurements, and electrophysiologic tests), audiologists aim to determine whether someone has normal sensitivity to sounds. If hearing loss is identified, audiologists determine which portions of hearing (high, middle, or low frequencies) are affected, to what degree (severity of loss), and where the lesion causing the hearing loss is found (outer ear, middle ear, inner ear, auditory nerve and/or central nervous system). If an audiologist determines that a hearing loss or vestibular abnormality is present he or she will provide recommendations for interventions or rehabilitation (e.g. hearing aids, cochlear implants, appropriate medical referrals).

In addition to diagnosing audiologic and vestibular pathologies, audiologists can also specialize in rehabilitation of tinnitus, hyperacusis, misophonia, auditory processing disorders, cochlear implant use and/or hearing aid use. Audiologists can provide hearing health care from birth to end-of-life.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear. Symptoms are repeated, brief periods of vertigo with movement, that is, of a spinning sensation upon changes in the position of the head. This can occur with turning in bed or changing position. Each episode of vertigo typically lasts less than one minute. Nausea is commonly associated. BPPV is one of the most common causes of vertigo.BPPV can result from a head injury or simply occur among those who are older. A specific cause is often not found. The underlying mechanism involves a small calcified otolith moving around loose in the inner ear. It is a type of balance disorder along with labyrinthitis and Ménière's disease. Diagnosis is typically made when the Dix–Hallpike test results in nystagmus (a specific movement pattern of the eyes) and other possible causes have been ruled out. In typical cases, medical imaging is not needed.BPPV is often treated with a number of simple movements such as the Epley maneuver or Brandt–Daroff exercises. Medications may be used to help with nausea. There is tentative evidence that betahistine may help with vertigo but its use is not generally needed. BPPV is not a serious condition. Typically it resolves in one to two weeks. It, however, may recur in some people.The first medical description of the condition occurred in 1921 by Robert Barany. About 2.4% of people are affected at some point in time. Among those who live until their 80s, 10% have been affected. BPPV affects females twice as often as males. Onset is typically in the person's 50s to 70s.

Broken escalator phenomenon

The broken escalator phenomenon, also known as the Walker effect, is the sensation of losing balance or dizziness reported by some people when stepping onto an escalator which is not working. It is said that there is a brief, odd sensation of imbalance, despite full awareness that the escalator is not going to move.It has been shown that this effect causes people to step inappropriately fast onto a moving platform that is no longer moving, even when this is obvious to the participant.

Even though subjects are fully aware that the platform or escalator is not moving now, parts of their brains still act on previous experience gained when it was moving, and so misjudge how to step onto it. Thus, this effect demonstrates the separateness of the declarative and procedural functions of the brain.

Caloric reflex test

In medicine, the caloric reflex test (sometimes termed 'vestibular caloric stimulation') is a test of the vestibulo-ocular reflex that involves irrigating cold or warm water or air into the external auditory canal. This method was developed by Robert Bárány who won a Nobel prize in 1914 for this discovery.

Dizziness

Dizziness is an impairment in spatial perception and stability. The term dizziness is imprecise: it can refer to vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness.One can induce dizziness by engaging in disorientating activities such as spinning.

Vertigo is the sensation of spinning or having one's surroundings spin about them. Many people find vertigo very disturbing and often report associated nausea and vomiting. It represents about 25% of cases of occurrences of dizziness.

Disequilibrium is the sensation of being off balance and is most often characterized by frequent falls in a specific direction. This condition is not often associated with nausea or vomiting.

Presyncope is lightheadedness, muscular weakness, and feeling faint as opposed to a syncope, which is actually fainting.

Non-specific dizziness is often psychiatric in origin. It is a diagnosis of exclusion and can sometimes be brought about by hyperventilation.A stroke is the cause of isolated dizziness in 0.7% of people who present to the emergency department.

Epley maneuver

The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals to treat one common cause of vertigo, benign paroxysmal positional vertigo (BPPV) of the posterior or anterior canals of the ear. It works by allowing free-floating particles from the affected semicircular canal to be relocated, using gravity, back into the utricle, where they can no longer stimulate the cupula, therefore relieving the patient of bothersome vertigo. This maneuver was developed by Dr. John Epley and first described in 1980.A version of the maneuver called the "modified" Epley does not include vibrations of the mastoid process originally indicated by Epley, as they have since been shown not to improve the efficacy of the treatment.

Falling (sensation)

A sensation of falling occurs when the labyrinth or vestibular apparatus, a system of fluid-filled passages in the inner ear, detects changes in acceleration. This sensation can occur when a person begins to fall, which in terms of mechanics amounts to a sudden acceleration increase from zero to roughly 9.8 m/s2. If the body is in free fall (for example, during skydiving) with no other momenta (rotation, etc.) there is no falling sensation. This almost never occurs in real-life falling situations because when the faller leaves their support there are usually very significant quantities of residual momenta such as rotation and these momenta continue as the person falls, causing a sensation of dysphoria. The faller doesn't fall straight down but spins, flips, etc. due to these residual momenta and also due to the asymmetric forces of air resistance on their asymmetric body. While velocity continues to increase, the downward acceleration due to gravity remains constant. Increasing drag force may even cause a feeling of ascent.

The vestibular apparatus also detects spatial orientation with respect to visual input. A similar sensation of falling can be induced when the eyes detect rapid apparent motion with respect to the environment. This system enables people to keep their balance by signalling when a physical correction is necessary. Some medical conditions, known as balance disorders, also induce the sensation of falling. In the early stages of sleep, a falling sensation may be perceived in connection with a hypnic jerk, sometimes awaking the sleeper abruptly.

Headrush

Headrush may refer to:

Vertigo (medical), a medical symptom of a balance disorder

Orthostatic hypotension, a sudden drop in blood pressure and coordination when a person stands up too quickly

Headrush (film), a 2003 Irish film starring Steven Berkoff

Head Rush (TV series), a 2010 Discovery show

Headrush EP, by the band Creaming Jesus

HeadRush, a spinoff of the PC CD-ROM game You Don't Know Jack

Illusions of self-motion

Illusions of self-motion refers to a phenomenon that occurs when someone feels like their body is moving when no movement is taking place. One can experience illusory movements of the whole body or of individual body parts, such as arms or legs.

List of disorders

A list of types of disorders.

Mal de debarquement

Mal de debarquement (or mal de débarquement) syndrome (MdDS, or common name disembarkment syndrome) is a neurological condition usually occurring after a cruise, aircraft flight, or other sustained motion event. The phrase "mal de débarquement" is French and translates to "illness of disembarkation".

MdDS is typically diagnosed by a neurologist or an ear nose & throat specialist when a person reports a persistent rocking, swaying, or bobbing feeling (though they are not necessarily rocking). This usually follows a cruise or other motion experience. Because most vestibular testing proves to be negative, doctors may be baffled as they attempt to diagnose the syndrome. A major diagnostic indicator is that most patients feel better while driving or riding in a car, i.e.: while in passive motion. MdDS is unexplained by structural brain or inner ear pathology and most often corresponds with a motion trigger, although it can occur spontaneously. This differs from the very common condition of "land sickness" that most people feel for a short time after a motion event such as a boat cruise, aircraft ride, or even a treadmill routine which may only last minutes to a few hours. The syndrome has recently received increased attention due to the number of people presenting with the condition and more scientific research has commenced to determine what triggers MdDS and how to cure it.

Proprioception

Proprioception ( PROH-pree-o-SEP-shən), is the sense of the relative position of one's own parts of the body and strength of effort being employed in movement. It is sometimes described as the "sixth sense".In humans, it is provided by proprioceptors in skeletal striated muscles (muscle spindles) and tendons (Golgi tendon organ) and the fibrous membrane in joint capsules. It is distinguished from exteroception, by which one perceives the outside world, and interoception, by which one perceives pain, hunger, etc., and the movement of internal organs.

The brain integrates information from proprioception and from the vestibular system into its overall sense of body position, movement, and acceleration. The word kinesthesia or kinæsthesia (kinesthetic sense) strictly means movement sense, but has been used inconsistently to refer either to proprioception alone or to the brain's integration of proprioceptive and vestibular inputs.

Proprioception has also been described in other animals such as vertebrates, and in some invertebrates such as arthropods. More recently proprioception has also been described in flowering land plants (angiosperms).

Righting reflex

The righting reflex, also known as the labyrinthine righting reflex, is a reflex that corrects the orientation of the body when it is taken out of its normal upright position. It is initiated by the vestibular system, which detects that the body is not erect and causes the head to move back into position as the rest of the body follows. The perception of head movement involves the body sensing linear acceleration or the force of gravity through the otoliths, and angular acceleration through the semicircular canals. The reflex uses a combination of visual system inputs, vestibular inputs, and somatosensory inputs to make postural adjustments when the body becomes displaced from its normal vertical position. These inputs are used to create what is called an efference copy. This means that the brain makes comparisons in the cerebellum between expected posture and perceived posture, and corrects for the difference. The reflex takes 6 or 7 weeks to perfect, but can be affected by various types of balance disorders.The righting reflex has also been studied in cats and other non-human mammals.

Sense of balance

The sense of balance or equilibrioception is one of the physiological senses related to balance. It helps prevent humans and animals from falling over when standing or moving. Balance is the result of a number of body systems working together: the eyes (visual system), ears (vestibular system) and the body's sense of where it is in space (proprioception) ideally need to be intact. The vestibular system, the region of the inner ear where three semicircular canals converge, works with the visual system to keep objects in focus when the head is moving. This is called the vestibulo-ocular reflex (VOR). The balance system works with the visual and skeletal systems (the muscles and joints and their sensors) to maintain orientation or balance. Visual signals sent to the brain about the body's position in relation to its surroundings are processed by the brain and compared to information from the vestibular, visual and skeletal systems.

Topiramate

Topiramate (brand name Topamax) is a broad-spectrum anticonvulsant (antiepilepsy) drug. In late 2012, topiramate was approved by the United States Food and Drug Administration (FDA) in combination with phentermine for weight loss. The drug had previously been used off-label for this purpose. Topiramate was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil Pharmaceuticals.The commercial usage of Topiramate began in 1996. Mylan Pharmaceuticals was granted final approval by the FDA for the sale of generic topiramate in the United States and the generic version was made available in September 2006. The last patent for topiramate in the U.S. was for use in children and expired on February 28, 2009.

Vertigo

Vertigo is a symptom where a person feels as if they or the objects around them are moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties walking. It is typically worse when the head is moved. Vertigo is the most common type of dizziness.The most common diseases that result in vertigo are benign paroxysmal positional vertigo (BPPV), Ménière's disease, and labyrinthitis. Less common causes include stroke, brain tumors, brain injury, multiple sclerosis, migraines, trauma, and uneven pressures between the middle ears. Physiologic vertigo may occur following being exposed to motion for a prolonged period such as when on a ship or simply following spinning with the eyes closed. Other causes may include toxin exposures such as to carbon monoxide, alcohol, or aspirin. Vertigo typically indicates a problem in a part of the vestibular system. Other causes of dizziness include presyncope, disequilibrium, and non-specific dizziness.Benign paroxysmal positional vertigo is more likely in someone who gets repeated episodes of vertigo with movement and is otherwise normal between these episodes. The episodes of vertigo should last less than one minute. The Dix-Hallpike test typically produces a period of rapid eye movements known as nystagmus in this condition. In Ménière's disease there is often ringing in the ears, hearing loss, and the attacks of vertigo last more than twenty minutes. In labyrinthitis the onset of vertigo is sudden and the nystagmus occurs without movement. In this condition vertigo can last for days. More severe causes should also be considered. This is especially true if other problems such as weakness, headache, double vision, or numbness occur.Dizziness affects approximately 20–40% of people at some point in time, while about 7.5–10% have vertigo. About 5% have vertigo in a given year. It becomes more common with age and affects women two to three times more often than men. Vertigo accounts for about 2–3% of emergency department visits in the developed world.

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