Tbi balance

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  • 1. Copyright © 2011 Model Systems Knowledge Translation Center (MSKTC).People with traumatic brain injury (TBI) commonly report problems withbalance. Between 30% and 65% of people with TBI suffer from dizziness anddisequilibrium (lack of balance while sitting or standing) at some point intheir recovery. Dizziness includes symptoms such as lightheadedness, vertigo(the sensation that you or your surroundings are moving), and imbalance.How bad your balance problem is depends on many factors:ƒƒ How serious your brain injury is.ƒƒ Where in your brain you were injured.ƒƒ Other injuries you had along with your brain injury. For example, in amotor vehicle crash, you could suffer a TBI, cervical spine injury, and riband leg fractures. All of these injuries will affect your ability to maintainyour balance.ƒƒ Some medications used to manage the medical issues connected with thetraumatic event or accident.What is “balance”?Balance is the ability to keep your body centered over your feet.The abil-ity to maintain your balance is determined by many factors, including yourphysical strength and coordination, your senses, and your cognitive (thinking)ability.Most people can control their body movement within certain limits beforelosing their balance and needing to adjust their posture or take a step tokeep from falling. Adjusting your posture or taking a step to maintain yourbalance before, during, and after movement is a complex process that isoften affected after brain injury.Why is balance important?When you have poor balance you have a high risk of falling and havinganother brain injury or broken bone. Maintaining balance while sitting andstanding is important for all of our daily activities, including self care andwalking. Poor balance can keep you from taking part in many types of activi-ties, such as sports, driving, and work.Diagnosing balance problemsMany different kinds of health care providers may be involved in diagnosingand treating balance problems, including physiatrists (physical medicine orrehabilitation doctor), neurologists, otolaryngologists (ENT), and neuro-oph-thalmologists.The first place to start is by having your physician review yourmedications, since this is a common cause of balance problems. Physical andoccupational therapists may also help identify and treat balance problems.Balance Problems afterTraumatic Brain InjuryTraumaticBrainInjuryModelSystemConsumerInformationThis publication wasproduced by the TBI ModelSystems in collaborationwith the Model SystemsKnowledge TranslationCenter (http://msktc.washington.edu) withfunding from the NationalInstitute on Disability andRehabilitation Researchin the U.S. Departmentof Education, grant no.H133A060070.Visithttp://tbimodelsystems.org/socialto sign up.Follow us!The Rocky MountainRegional Brain Injury SystemCraig Hospital3425 South Clarkson StreetEnglewood, CO 80113303-789-8344http://www.craighospital.org/Research/Abstracts/TBIMS.asp
  • 2. Balance Problems after Traumatic Brain InjuryTraumaticBrainInjuryModelSystemConsumerInformation Two commonly used tests for identifying balanceproblems are the Berg Balance Scale and the Dy-namic Gait Index. Both of these tests can be usedto track your progress as your balance improveswith therapy and to provide information aboutpotential risk of falls.What are common causes of balanceproblems after traumatic brain injury?Medications: A number of commonly usedmedications can cause dizziness, lightheadednessand decreased balance.These include some bloodpressure medications, antibiotics, tranquilizers,heart medications, and anti-seizure medications.Ask your doctor if any of the medications youare taking may be causing dizziness or balanceproblems.A change in medications or dosagesmay improve the problem.A drop in blood pressure when standing or sit-ting up suddenly (called postural hypotension)can make you feel lightheaded and dizzy. It mayoccur when you get up quickly from sitting onthe toilet or a chair, or getting out of bed. Havingyour blood pressure taken while in a lying, sit-ting and standing position may also help diagnoseblood pressure-related balance problems.Problems with eyesight (vision impairments):Eyesight is one of the key senses you need tokeep your balance. Eyesight problems such asdouble vision, visual instability, partial loss of vi-sion, and problems with depth perception canmake your balance worse.Inner ear problems (vestibular impairments):Your inner ear contains many tiny organs thathelp you keep your balance (called the vestibu-lar system/labyrinth). Your inner ear has threeloop-shaped structures (semicircular canals) thatcontain fluid and have fine, hair-like sensors thatmonitor the rotation of your head. It also hasother structures (otolith organs) that monitorlinear movements of your head.These otolithorgans contain crystals that make you sensi-tive to movement and gravity. If your vestibularsystem is damaged from a head injury, you mayhave problems with balance, dizziness, or a sud-den sensation that you’re spinning.Three types ofvestibular impairments are:ƒƒ Benign paroxysmal positional vertigo(BPPV) is one of the most common causes ofvertigo.With trauma, the crystals in the innerear can be moved out of place, making yousensitive to changes in gravity. BPPV is char-acterized by brief episodes of mild to intensevertigo. Symptoms are triggered by specificchanges in head position, such as tipping yourhead up or down, and by lying down, turningover or sitting up in bed.You may also feel outof balance when standing or walking.ƒƒ Labyrinthine concussion or injury to thenerve to the vestibular system are also causesof vertigo and imbalance after brain injury.ƒƒ Traumatic endolymphatic hydrops occurswhen there is a disruption of the fluid balancewithin the inner ear. When this happens, youmay have periods of vertigo, imbalance andringing in your ears that last for hours to days.Problems with your ability to sense things (sen-sory impairments): For example, nerves inyour feet send messages to your brain that helpyou keep your balance. If these nerves are dam-aged from your brain injury, your brain may notget the messages it needs.The brain may need torely more on your eyesight and inner ear to keepyour balance.Brainstem injury:A traumatic injury to thebrainstem and cerebellum (parts of the brain thatcontrol movement) can make it hard for you towalk and maintain your balance.Leakage of inner ear fluid into the middle ear(called perilymph fistula) sometimes occursafter head injury. It can cause dizziness, nausea,and unsteadiness when walking or standing. It canget worse when you are more active and may getbetter with rest.Mental health issues: Sometimes people withbrain injuries have anxiety, depression or a fearof falling.These conditions can cause or increasebalance problems. Doctors call this psychogenicdizziness.Treatment optionsBalance problems can have many different causes,each one requiring a different treatment.Yourdoctor, physical and occupational therapists and/Page 2 of 3
  • 3. Balance Problems after Traumatic Brain InjuryTraumaticBrainInjuryModelSystemConsumerInformation or other health care providers will work withyou to understand and treat all the differentcauses.Ways you can improve your balance:Increasing your strength and flexibility will helpyour balance. Specific exercises include stretchesfor your ankle and hip muscles or strengthen-ing activities for your legs, such as mini-squats,toe- raisers, or standing leg lifts. Go to www.nia.nih.gov/Go4Life for more information aboutthese exercises, or talk to your doctor or physi-cal therapist.Find your limits in balance by moving your bodyover your feet as far as you can without liftingyour feet. This will help you develop balancestrategies to prevent losing your balance. Youcan also practice movements that allow you totransition from one position to another, suchas going from sitting to standing, reaching aboveyour head to get something off a shelf, or pickingup something off the ground.Practice standing or walking in different condi-tions. For example, you can practice standingwith your eyes closed to decrease your depen-dency on vision for balance or stand on a pillowto improve your ability to use vision for balance.Change how far apart your feet are and work onbalance by bringing them closer together, in frontof one another or even stand on one leg.Practice activities that will improve your balancewhile walking, such as walking longer distances;walking and keeping up with someone else whilecarrying on a conversation; walking over differ-ent surfaces, such as on grass and sidewalks; andwalking in crowded places such as the grocerystore.Be cautious when working on your balance, andmake sure you work at an appropriate level toavoid falling when no one is around. A physicalor occupational therapist can help design a pro-gram that is safe for you to practice at home.BPPV is treated by using movements to relocatethe crystals in your inner ear back to where theybelong. To learn more about the treatment ofBPPV go to http://www.tchain.com/otoneurol-ogy/disorders/bppv/bppv.html.How quickly can your balance im-prove?How quickly your balance problems improvedepends on the extent of injury and your healthstatus before your injury. A condition such asBPPV can be treated effectively in one or twotreatment sessions. Injuries that involve manytypes of impairments can take weeks, months oryears. Research shows:ƒƒ Most people with TBI are able to walk in-dependently within three months of injury.Although most can return to walking, manycontinue to have problems with moving quick-ly and with balance needed to return to high-level activities such as running or sports.ƒƒ With hard work, people with TBI can continueto improve their balance for many years afterinjury but balance problems are still identifiedmore frequently in people with TBI than inpeople without TBI.ReferencesKatz DI, et al. Recovery of ambulation after traumatic braininjury. Arch Phys Med Rehabil. 2004; 85(6):865-9.McFayden BJ, et al. Modality-specific, multitask locomotordeficits persist despite good recovery after a traumaticbrain injury. Arch Phys Med Rehabil. 2009; 90(9):1596-606.Maskell F, Chiarelli P, Isles R. Dizziness after traumatic braininjury: overview and measurement in the clinical setting.Brain Inj. 2006;20(3):293-305.Patla AE, Shumway-Cook A. Dimensions of mobility: defin-ing the complexity and difficulty associated with commu-nity mobility. J Aging Phys Activity. 1999: 7: 7-19.Williams GP, Schache AG. Evaluation of a conceptualframework for retraining high-level mobility followingtraumatic brain injury: two case reports. J Head TraumaRehabil. 2010: 25(3): 164-72.DisclaimerThis information is not meant to replace the advice froma medical professional.You should consult your health careprovider regarding specific medical concerns or treatment.SourceOur health information content is based on research evi-dence whenever available and represents the consensus ofexpert opinion of the TBI Model System directors.AuthorshipBalance Problems after TBI was developed by MichellePeterson, PT, DPT, NCS, and Brian D. Greenwald, MD, incollaboration with the Model Systems Knowledge Transla-tion Center.Page 3 of 3