- •
Neurosensory disorders are the most common sequelae of mild traumatic brain injury (mTBI), and among these, balance disorders are the ones most frequently seen.
- •
Balance disorders seen after mTBI can be diagnosed and treated, and whereas some resolve with time, many of these disorders require treatment.
- •
Vestibular rehabilitation is one of the most important treatment modalities available for patients with mTBI and has been documented to be successful in this patient group.
- •
Untreated mTBI can
Early Diagnosis and Treatment of Traumatic Vestibulopathy and Postconcussive Dizziness
Section snippets
Key points
The definition of mild traumatic brain injury
There are a variety of definitions of mTBI. Although these definitions were developed by health organizations and government agencies, there is no consensus definition. For a detailed discussion of this particular topic, the reader is referred to the Centers for Disease Control and Prevention (CDC) Web site,5 which is an excellent resource for traumatic brain injury (TBI)- and mTBI-related health issues. For this article, the authors have adopted a basic functional definition of TBI as follows:
- 1.
Epidemiology
It is difficult to draw reliable conclusions from the existing epidemiologic data regarding prevalence and long-term consequences of mTBI. The lack of consensus in definitions and the fact that many mTBI cases go unreported makes epidemiologic classification problematic. It is clear that the reported prevalence of mTBI is increasing. Several reports focused on selected populations, such as high-school athletes9 or emergency departments (EDs), over limited time frames10, 11 do give estimates of
Balance disorders after blast injuries
There have been several studies examining balance disorders after blast exposure. An explosives detonation produces a shock wave, a blast wind, and an electromagnetic pulse. Primary blast injury is produced by shock wave propagation through tissue. The leading edge of the shock wave, the blast front, is an overpressure that propagates supersonically; it is followed by a negative pressure termed the underpressure. Reflections off environmental surfaces can produce more complicated exposures and
Balance disorders after blunt head injury
Blunt head injury has a well-known association with balance disorders.24, 25, 26 Suarez and colleagues24 demonstrated that the dizziness was one of the most frequent symptoms seen after mild head injury in a civilian setting. Meanwhile, Grubenhoff25 examined the relative frequency of specific types of dizziness as a function of age in an mTBI group and found that younger individuals were more susceptible to potentially treatable causes of balance disorders. Hoffer and colleagues27 examined
Diagnosis
Diagnosis of mTBI has always presented challenges. This fact is true in part because many of the symptoms are self-reported with variable intensity over time. As discussed earlier, balance disorders present a unique window into the brain for diagnosing mTBI. One of the most interesting and promising areas includes examining optokinetic and vestibular reflexes in response to a variety of visual and vestibular challenges. Working with Neuro Kinetics, Inc (Pittsburgh, PA, USA), the authors have
Treatment
Advances in treatment of mTBI have been relatively slow to develop. In general, treatment can be classified as pharmacotherapy and rehabilitation. To date, the only pharmacotherapy that has demonstrated effectiveness is N-acetyl cysteine (NAC). NAC was found to be an effective countermeasure for blast-induced mTBI.38 Working in a combat environment, a double-blinded placebo-controlled study revealed that NAC was far more effective than a control medicine at reducing symptoms measured at 7 days
Summary
mTBI is an increasingly common public health issue. Most of the acute, subacute, and chronic symptoms are neurosensory in nature and most commonly cause dizziness. Recognizing dizziness in this population is important because it provides a starting point for management of a difficult clinical entity, which can be measured objectively and treated effectively. Vestibular rehabilitation remains the standard treatment of mTBI, although clinical trials in the effectiveness of both rehabilitation and
References (44)
- et al.
Measurement of blast wave by a miniature fiber optic pressure transducer in the rat brain
J Neurosci Methods
(2007) - et al.
Computational biology–modeling of primary blast effects on the central nervous system
Neuroimage
(2009) - et al.
Head injury and blast exposure: vestibular consequences
Otolaryngol Clin North Am
(2011) - et al.
Neuroimage Clin
(2014) - et al.
Blast exposure: vestibular consequences and associated characteristics
Otol Neurotol
(2010) - et al.
Evidence of central and peripheral vestibular pathology in blast-related traumatic brain injury
Otol Neurotol
(2011) - et al.
Mild traumatic brain injury in U.S. Soldiers returning from Iraq
N Engl J Med
(2008) - et al.
Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team
J Head Trauma Rehabil
(2009) - Available at: http://www.cdc.gov/TraumaticBrainInjury/index.html. Accessed March 27,...
How is deployment to Iraq and Afghanistan affecting U.S. service members and their families? An overview of early RAND research on the topic
(2011)
A survey of the nature of trauma of post-traumatic benign paroxysmal positional vertigo
Int J Audiol
Examining postconcussion symptoms of dizziness and imbalance on neurocognitive performance in collegiate football players
Otol Neurotol
Traumatic Brain Injury in High School Athlete
JAMA
Emergency department visits associated with traumatic brain injury: United States, 1995-1996
Brain Inj
The epidemiology of traumatic brain injuries treated in emergency departments in North Carolina, 2010–2011
N C Med J
Trends in visits for traumatic brain injury to emergency departments in the United States
JAMA
Traumatic brain injury related hospitalization and mortality in California
Biomed Res Int
Injuries in professional football: current concepts
Curr Sports Med Rep
Otologic assessment of blast and nonblast injury in returning middle east-deployed service members
Laryngoscope
The implications of physical injury on otovestibular and cognitive symptomatology following blast exposure
Otolaryngol Head Neck Surg
Multiple traumatic brain injury and concussive symptoms among deployed military personnel
Brain Inj
The physics and mechanisms of primary blast injury
Cited by (16)
Balance disorders. Peripheral vertigo
2023, Medicine (Spain)Investigation of Sensorimotor Impairments in Individuals 4 Weeks to 6 Months After Mild Traumatic Brain Injury
2022, Archives of Physical Medicine and RehabilitationConcurrent validity of the Vestibular/Ocular Motor Screening (VOMS) tool with the Dizziness Handicap Inventory (DHI) among adolescents with vestibular symptoms/impairment following concussion
2022, Physical Therapy in SportCitation Excerpt :Given the high prevalence of these symptoms and impairments and the association with concussion prognosis, vestibular rehabilitation has become an increasingly common treatment recommendation for dizziness and gait/balance impairment following concussion (Alsalaheen et al., 2019; Quatman-Yates et al., 2020). Vestibular and oculomotor symptoms, including dizziness, and impairments are identified using both questionnaire and performance-based measures such as the King-Devick Test, Dizziness Handicap Inventory (DHI) and Vestibular Ocular Motor Screening (VOMS) tool (Hoffer et al., 2015). The DHI (Jacobson & Newman, 1990) is a self-report questionnaire evaluating a patient's perceived degree of impairment from dizziness and has been widely used in those with balance and vestibular disorders (Ojha & Clamp, 2020).
Postconcussion Symptoms
2018, Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and RehabilitationTone-induced cervical and ocular vestibular-evoked myogenic potentials: Comparing abnormalities in traumatic and non-traumatic vestibular disease
2018, Journal of Laryngology and Otology