September 1, 2013 Features

When Dizziness Lingers

Knowing the differences between post-concussion symptoms and vestibular problems can help providers better manage patients with post-concussion syndrome.

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At 67 years old, while assisting her husband in his real estate business, Mary fell down a flight of stairs, hit her head on a concrete floor and suffered a mild-moderate traumatic brain injury. Nine months later, she receives outpatient treatment to address her residual cognitive-communication disorder, characterized primarily by mild word-retrieval deficits and moderate short-term memory impairments.

When Dizziness Lingers

During several appointments with her speech-language pathologist, Mary reports frequent, significant dizziness—especially when she turns or lifts her head. Mary's symptoms prevent her from attending treatment regularly and, more significantly, restrict her ability to participate in everyday activities.

In the acute phase of her recovery immediately after the accident, several specialists—including a neurologist, cardiologist, primary care provider, physical therapist, occupational therapist, audiologist and speech-language pathologist—evaluated and treated Mary's brain injury. To each, she voiced concerns about her debilitating dizziness. In turn, each specialist
attributed Mary's dizziness to post-concussion syndrome, a diagnosis that accounts for the symptoms of neurologic dysfunction following traumatic brain injury.

Care providers advised Mary to be patient and to allow her dizziness, along with her other post-concussion symptoms, to resolve over time. After nine months, Mary's cognitive-communication impairment improves significantly—but her dizziness does not.

As audiologists and SLPs, we are in a unique position to note whether a patient has lingering dizziness. We often interact with TBI patients throughout their recovery as part of a multidisciplinary team. But to best help these patients, we need to do more than that: We need to be alert to the possibility that dizziness in a patient like Mary is something other than post-concussion syndrome. It could be due to other causes, such as an underlying peripheral vestibular pathology.

The overlooked symptom

Mary is one of almost 2 million Americans who suffer and survive a TBI each year. Defined as a sudden, traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force, TBI is a complex condition with symptoms that vary considerably from person to person. The most common symptoms include cognitive-communication difficulties involving attention, memory, executive function, processing speed and language.

Additionally, physical impairments such as hearing loss, headaches, seizures, nausea, incoordination, visual disturbances, paralysis, paresis and dysphagia also are quite common. Because such a wide spectrum of symptoms is associated with TBI, a multidisciplinary team typically identifies and manages these patients. Despite the benefits of a multidisciplinary approach, some TBI symptoms may fail to receive the attention they deserve, primarily because they fall under the post-concussion syndrome umbrella. One often-overlooked symptom is dizziness.

According to reports, the incidence of dizziness and disequilibrium associated with TBI ranges from 40 to 60 percent in adults. In most cases, dizziness following TBI can be attributed to post-concussion syndrome. However, underlying peripheral vestibular dysfunction following TBI—such as benign paroxysmal positional vertigo, unilateral vestibular weakness, perilymph fistula or superior canal dehiscence—may also produce dizziness, vertigo and imbalance. A vestibular evaluation completed by an audiologist can identify concurrent or mitigating vestibular dysfunction or, conversely, confirm normal vestibular function. Using a wait-and-see approach, as noted with Mary, may result in prolonged discomfort as well as diminished functional abilities.

Electronystagmography, videonystagmography and rotary-chair testing are valid, well-established tools for vestibular evaluation. An audiologist can use these tests to identify any underlying peripheral vestibular dysfunction associated with TBI. It can be difficult to distinguish post-concussion syndrome from vestibular dysfunction, especially from the presentation of symptoms alone. But identifying a potential vestibular lesion may be critical to the patient's overall management and recovery, as there are often evidence-based treatment options with the potential to resolve or
mitigate symptoms.

Proactive care

Although dizziness resulting from TBI can resolve over time, for many people like Mary, it does not. But she is lucky. Her SLP decides not to wait any longer to see whether Mary's dizziness improves on its own. Instead, she consults with an audiologist who specializes in vestibular evaluation. The audiologist's vestibular evaluation reveals Mary has a bilateral, multi-canal, benign paroxysmal positional vertigo. Mary's reported motion-provoked symptoms are also consistent with benign paroxysmal positional vertigo. After four visits consisting of canalith repositioning—Epley and log-roll maneuvers—over five weeks, Mary is free of dizziness and well on her way to recovery from her TBI. She has returned to her normal schedule of driving, assisting her husband in his business and managing a busy household.

The chart online [PDF] highlights the differences in symptoms, duration and onset, and treatment methodologies for dizziness from post-concussion syndrome, as opposed to peripheral vestibular dysfunction. In cases of prolonged dizziness following a brain injury and symptoms indicative of peripheral vestibular dysfunction, consideration of a vestibular evaluation by a qualified audiologist may be warranted. For patients like Mary, it can work out beautifully.

Steven M. Doettl, AuD, CCC-A, is a clinical assistant professor and the coordinator of the vestibular clinic at the University of Tennessee Health Science Center Hearing and Speech Center. His areas of expertise include vestibular evaluation and treatment, and auditory and vestibular electrophysiological assessment. sdoettl@uthsc.edu

Ellen I. Hamby, PhD, CCC-SLP, is a clinical associate professor at the University of Tennessee Health Science Center Hearing and Speech Center. Her areas of expertise include evaluation and treatment of adult neurogenic communication disorders. She is an affiliate of Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders. ehamby@uthsc.edu

cite as: Doettl, S. M.  & Hamby, E. I. (2013, September 01). When Dizziness Lingers. The ASHA Leader.

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