A bike ride sounds like fun but your bike has been garaged for years. The last time you rode, you felt shaky. Now, you're doing well to walk across the living room without losing your balance. Are you on an irreversible path toward needing a walker? Not necessarily. But the first step in the opposite direction is to see an ear, nose and throat doctor.
The inner ear is responsible for both hearing (cochlea) and balance (labyrinth). Some medical conditions affect both hearing and balance such as Mnire's disease, labyrinthitis and inner ear concussions. Other times, balance problems occur independently of hearing loss. However, research on balance is benefiting both those with hearing loss and those without. Often a better understanding of balance can improve our understanding of hearing disorders as well.
Balance disorders make people feel dizzy or unsteady. Some people with such disorders feel
as if they are spinning, moving or floating, even while lying down or standing still. Diffi culties
with balance can arise from a variety of causes, including systemic diseases and specific disorders
of the inner ear or brain. For example, there appears to be a relationship between difficulties with balance control and changes in the brain's white matter, commonly seen in MRI scans of older adults. It is also fairly common for a person to experience dizziness in combination with migraine headaches. The first step in helping restore quality of life for people with dizziness and balance disorders is to find the correct diagnosis.
A carefully designed questionnaire is one important diagnostic tool used to identify the source of a balance disorder. Joseph Furman, M.D., Ph.D., and Dawn Marcus, M.D., of the University of Pittsburgh, have developed a test that doctors and nurses can use to help them determine if a person's dizziness might be the result of migraines. Normally migraines cause a severe headache but they can also result in dizziness. Oddly, it is even possible for people to experience the dizziness associated with a migraine without getting a headache.
Another questionnaire, based on the International Classification of Function from the World Health Organization, is currently being designed to help clinicians follow improvement or degradation of a person's ability to participate in regular daily activities within their home and community because of balance problems. Physicians, physical therapists and occupational therapists from the United States, Europe, Australia and South America helped select the evaluate to determine if people with balance problems are becoming more or less able to participate in certain activities. The hope of this international group was that all healthcare professionals treating balance problems would start to look at similar indicators in order to determine if patients were improving or declining in their ability to deal with balance issues.
In addition to these new diagnostic tools, many exciting advances have been achieved in the care and management of people living with balance and dizziness disorders. During the past several years, clinicians have worked with engineers on innovative methods of helping people regain control of their balance. Some of these ideas have come from scientists, while others have employed familiar products from the computer gaming industry.
One such new technology is the Nintendo Wii™, a virtual-interactive computer game that requires some type of physical activity. The Tai Chi game provides feedback about shifting weight under your feet. The idea of using video games to help people is not new, but the new game systems are effective because the graphics are easy to see and the machines are simple to operate. No scientifi c studies have yet been completed to evaluate whether games like the Wii really do help people with balance and dizziness problems but ongoing research should soon provide answers as to whether this kind of technology is genuinely helpful. Previous studies done with people practicing activities while standing have improved their balance while standing still, but not while walking. Perhaps a Wii, or some similar new device, might be a fairly inexpensive way to improve walking balance in the future. These video games can make exercise fun and also provide feedback about how people are doing. For example, therapists could track how much practice their clients are putting in at home with these types of devices.
At the University of Pittsburgh we have developed a virtual reality grocery store within the Medical Virtual Reality Center, which is designed to help people improve their balance during everyday activities (see Figure 1). By practicing walking in the virtual store on an instrumented treadmill, we hope to help people overcome balance and dizziness problems in ways that will transfer to real world walking. We are now completing an experiment to try to determine if walking in the virtual grocery store is an effective are dizzy have trouble with moving their heads at normal speeds.
Still other studies are evaluating a device designed to gather longitudinal data about how fast the person can move their head while simultaneously focusing on a target that is fl ashed quickly on a
computer screen in front of them. Results thus far indicate that faster walking ability seems to be related to a person's ability to move their head quickly while sitting down and performing this test.
Preventing falls is a major focus of physical therapy for people with dizziness and balance disorders. Engineers around the world have been experimenting with devices that vibrate when the person begins to sway, tilt or topple, providing them with additional sensory feedback about their balance. Studies are trying to determine whether people with balance disorders can benefit from this type of technology. There is at least one study that suggests that vibration feedback under the foot can make a person steadier during walking. Others have shown that vibration feedback on a person's torso can make them more stable when they walk. We know that people with vestibular (dizziness) disorders fall much more frequently than people who do not report dizziness, so any additional sensory input that they can receive to help them with their balance may decrease the risk of falling down. A team of engineers, doctors and physical therapists from the University of Michigan and the University of Pittsburgh are working together to improve the design of vibratory feedback devices to prevent falls for people with balance disorders.
Over the last two years, investigators have been trying to record balance through the use of an accelerometer, a small, inexpensive device that can provide information about how a person moves (see Figure 3), which is helpful in individual physical therapy as well as research. Employing Bluetooth technology, the device wirelessly records body movements. After collecting data on more than a hundred people, accelerometers may soon be used in clinical settings. The accelerometer provides similar information to recordings from expensive therapy devices, while offering much more convenience, mobility and cost savings. Small accelerometers are an exciting new addition to methods that record body movement in people with balance and vestibular disorders.
At the University of Pittsburgh, we are working on moving new technology into the hands of front-line clinicians to help people with balance and dizziness problems. We hope that our research will improve quality of life of people who deal with balance problems and enable them to engage in all the activities that are important to them.
Susan L. Whitney, P.T., Ph.D., is an associate professor in the Departments of Physical Therapy and Otolaryngology at the University of Pittsburgh and is the program director for the Centers for Rehab Services at the Eye and Ear Institute, University of Pittsburgh Medical Center.
Joseph M. Furman, M.D., Ph.D., is a professor in the Departments of Otolaryngology, Neurology, and Physical Therapy at the University of Pittsburgh and is the director of the Division of Balance Disorders at the University of Pittsburgh Medical Center. The authors would like to thank Cary Balaban, Ph.D., for his assistance in coordinating this article.
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