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Balance disorder

A balance disorder is a disturbance that causes an individual to feel
unsteady, giddy, woozy, or have a sensation of movement, spinning, or
floating. An organ in our inner ear, the labyrinth, is an important part of
the vestibular system which is responsible for balancing the body. The
labyrinth interacts with other systems in the body, such as the visual
(eyes) and skeletal (bones and joints) systems, to maintain the body's
position. These systems, along with the brain and the nervous system, can be
the source of balance problems.

Three structures of the labyrinth, the semicircular canals, let us know when
we are in a rotary (circular) motion. The semicircular canals, the superior,
posterior, and horizontal, are fluid-filled. Motion of the fluid tells us if
we are moving. The semicircular canals and the visual and skeletal systems
have specific functions that determine an individual's orientation. The
vestibule is the region of the inner ear where the semicircular canals
converge, close to the cochlea (the hearing organ). The vestibular system
works with the visual system to keep objects in focus when the head is
moving. Joint and muscle receptors also are important in maintaining
balance. The brain receives, interprets, and processes the information from
these systems that control our balance.

Movement of fluid in the semicircular canals signals the brain about the
direction and speed of rotation of the head--for example, whether we are
nodding our head up and down or looking from right to left. Each
semicircular canal has a bulbed end, or enlarged portion, that contains hair
cells. Rotation of the head causes a flow of fluid, which in turn causes
displacement of the top portion of the hair cells that are embedded in the
jelly-like cupula. Two other organs that are part of the vestibular system
are the utricle and saccule. These are called the otolithic organs and are
responsible for detecting linear acceleration, or movement in a straight
line. The hair cells of the otolithic organs are blanketed with a jelly-like
layer studded with tiny calcium stones called otoconia. When the head is
tilted or the body position is changed with respect to gravity, the
displacement of the stones causes the hair cells to bend.

The balance system works with the visual and skeletal systems (the muscles
and joints and their sensors) to maintain orientation or balance. For
example, visual signals are sent to the brain about the body's position in
relation to its surroundings. These signals are processed by the brain, and
compared to information from the vestibular and the skeletal systems. An
example of interaction between the visual and vestibular systems is called
the vestibular-ocular reflex. The nystagmus (an involuntary rhythmic eye
movement) that occurs when a person is spun around and then suddenly stops
is an example of a vestibular-ocular reflex.

What Are the Symptoms of a Balance Disorder?

When balance is impaired, an individual has difficulty maintaining
orientation. For example, an individual may experience the "room spinning"
and may not be able to walk without staggering, or may not even be able to
arise. Some of the symptoms a person with a balance disorder may experience are:

   * A sensation of dizziness or vertigo (spinning).
   * Falling or a feeling of falling.
   * Lightheadedness or feeling woozy.
   * Visual blurring.
   * Disorientation.

Some individuals may also experience nausea and vomiting, diarrhea,
faintness, changes in heart rate and blood pressure, fear, anxiety, or
panic. Some reactions to the symptoms are fatigue, depression, and decreased
concentration. The symptoms may appear and disappear over short time periods
or may last for a longer period of time.

What Causes a Balance Disorder?

Infections (viral or bacterial), head injury, disorders of blood circulation
affecting the inner ear or brain, certain medications, and aging may change
our balance system and result in a balance problem. Individuals who have
illnesses, brain disorders, or injuries of the visual or skeletal systems,
such as eye muscle imbalance and arthritis, may also experience balance
difficulties. A conflict of signals to the brain about the sensation of
movement can cause motion sickness (for instance, when an individual tries
to read while riding in a car). Some symptoms of motion sickness are
dizziness, sweating, nausea, vomiting, and generalized discomfort. Balance
disorders can be due to problems in any of four areas:

   * Peripheral vestibular disorder, a disturbance in the labyrinth.
   * Central vestibular disorder, a problem in the brain or its connecting
     nerves.
   * Systemic disorder, a problem of the body other than the head and brain.
   * Vascular disorder, or blood flow problems.

What Are Some Types of Balance Disorders?

Some of the more common balance disorders are:

   * Benign Paroxysmal Positional Vertigo (BPPV)--a brief, intense sensation
     of vertigo that occurs because of a specific positional change of the
     head. 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. The cause of BPPV is not known, although it
     may be caused by an inner ear infection, head injury, or aging.

   * Labyrinthitis--an infection or inflammation of the inner ear causing
     dizziness and loss of balance.

   * MŽniŹre's disease--an inner ear fluid balance disorder that causes
     episodes of vertigo, fluctuating hearing loss, tinnitus (a ringing or
     roaring in the ears), and the sensation of fullness in the ear. The
     cause of MŽniŹre's disease is unknown.

   * Vestibular neuronitis--an infection of the vestibular nerve, generally viral.

   * Perilymph fistula--a leakage of inner ear fluid to the middle ear. It
     can occur after head injury, physical exertion or, rarely, without a
     known cause.

How Are Balance Disorders Diagnosed?

Diagnosis of a balance disorder is complicated because there are many kinds
of balance disorders and because other medical conditions--including ear
infections, blood pressure changes, and some vision problems--and some
medications may contribute to a balance disorder. A person experiencing
dizziness should see a physician for an evaluation.

The primary physician may request the opinion of an otolaryngologist to help
evaluate a balance problem. An otolaryngologist is a physician/surgeon who
specializes in diseases and disorders of the ear, nose, throat, head, and
neck, with expertise in balance disorders. He or she will usually obtain a
detailed medical history and perform a physical examination to start to sort
out possible causes of the balance disorder. The physician may require tests
to assess the cause and extent of the disruption of balance. The kinds of
tests needed will vary based on the patient's symptoms and health status.
Because there are so many variables, not all patients will require every
test.

Some examples of diagnostic tests the otolaryngologist may request are a
hearing examination, blood tests, an electronystagmogram (ENG--a test of the
vestibular system), or imaging studies of the head and brain.

The caloric test may be performed as part of the ENG. In this test, each ear
is flushed with warm and then cool water, usually one ear at a time; the
amount of nystagmus resulting is measured. Weak nystagmus or the absence of
nystagmus may indicate an inner ear disorder.

Another test of the vestibular system, posturography, requires the
individual to stand on a special platform capable of movement within a
controlled visual environment; body sway is recorded in response to movement
of the platform and/or the visual environment.

How Are Balance Disorders Treated?

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, or multiple sclerosis.
Individual treatment will vary and will be based upon symptoms, medical
history, general health, examination by a physician, and the results of
medical tests.

Another treatment option includes balance retraining exercises (vestibular
rehabilitation). The exercises include movements of the head and body
specifically developed for the patient. This form of therapy is thought to
promote compensation for the disorder. Vestibular retraining programs are
administered by professionals with knowledge and understanding of the
vestibular system and its relationship with other systems in the body.

For people diagnosed with MŽniŹre's disease, dietary changes such as
reducing intake of sodium may help. For some people, reducing alcohol,
caffeine, and/or avoiding nicotine may be helpful. Some aminoglycoside
antibiotics, such as gentamicin and streptomycin, are used to treat
MŽniŹre's disease. Systemic streptomycin (given by injection) and topical
gentamicin (given directly to the inner ear) are useful for their ability to
affect the hair cells of the balance system. Gentamicin also can affect the
hair cells of the cochlea, though, and cause hearing loss. In cases that do
not respond to medical management, surgery may be indicated.

A program of talk therapy and/or physical rehabilitation may be recommended
for people with anxiety.

What Research Is Being Done for Balance Disorders?

Scientists are working to understand the various balance disorders and the
complex interactions between the labyrinth, other balance-sensing organs,
and the brain. Scientists are studying eye movement to understand the
changes that occur in aging, disease, and injury. Scientists are collecting
data about eye movement and posture to improve diagnosis and treatment of
balance disorders. Scientists are also studying the effectiveness of certain
exercises as a treatment option.

Recent findings from studies supported by the National Institute on Deafness
and Other Communication Disorders (NIDCD) suggest that the vestibular system
plays an important role in modulating blood pressure. The information from
these studies has potential clinical relevance in understanding and managing
orthostatic hypotension (lowered blood pressure related to a change in body
posture). Other studies of the otolithic organs, the detectors of linear
movement, are exploring how these organs differentiate between downward
(gravitational) motion from linear (forward-to-aft, side-to-side) motion.

Other projects supported by NIDCD include studies of the genes essential to
normal development and function in the vestibular system. Scientists are
also studying inherited syndromes of the brain that affect balance and coordination.

The Institute supports research to develop new tests and refine current
tests of balance and vestibular function. For example, scientists have
developed computer-controlled systems to measure eye movement and body
position by stimulating specific parts of the vestibular and nervous
systems. Other tests to determine disability, as well as new physical
rehabilitation strategies, are under investigation in clinical and research settings.

NIDCD, along with other Institutes at the National Institutes of Health,
joined the National Aeronautics and Space Administration (NASA) for
Neurolab, a research mission dedicated to the study of life sciences.
Neurolab focused on the most complex and least understood part of the human
body, the nervous system (including the balance system).

Exposure to the weightlessness of space is known to temporarily disrupt
balance on return to Earth and to gravity. A team of NIDCD and NASA
investigators had previously studied the effects of microgravity exposure on
balance control in astronauts who had returned from short-duration space
flight missions, but these studies did not include an aged individual.
During the October 29-November 7, 1998, Space Shuttle Discovery mission,
NIDCD and NASA collaborated in another study of postflight balance control.
For the first time, a previously experienced, but now elderly astronaut,
Senator John Glenn, participated. Data collected during this mission, which
are still being analyzed, may help to explain the mechanisms of recovery
from balance disorders experienced on Earth as well as in the space
environment. Scientists also hope that this data will help to develop
strategies to prevent injury from falls, a common occurrence among people
with balance disorders, particularly as they grow older.

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