The assessment of balance and dizziness in the TBI patient

All degrees of traumatic brain injury (TBI) are associated with balance dysfunction and/or dizziness. The clinician assessing and managing patients with TBI should become familiar with vestibular and non-vestibular causes of dizziness and imbalance, and be able to perform screening tests to determine when referral to a vestibular specialist is warranted. This chapter outlines the clinical pathways to be followed in history-taking, physical examination, and assessment.

Dizziness, vertigo, balance dysfunction and gait ataxia can have their origin in the vestibular system, elsewhere, or be multifactorial. The complex anatomy and physiology of the balance canals, otolithic organs, and vestibular nerves peripherally, and the vestibular nuclei centrally, as well as the neural connections between vestibular, oculomotor, and proprioceptive systems will be covered in clinically pertinent detail.

A majority of diagnosis of dizziness/vertigo can be made after a proper history has been obtained. This can be challenging in all dizzy patients, and more so in the TBI patient in whom memory and recall may be impaired. The reader will learn how to use tools such as dizziness questionnaires as well as targeted history taking to elicit the information. Similarly, the addition of a programmatic, targeted physical examination of the dizzy patient will allow the clinician to fine-tune the diagnosis between peripheral and central causes.

Once history and examination have narrowed the diagnostic possibilities, appropriate testing--in the vestibular laboratory and radiologic testing--is indicated. The reader will learn when these tests should be considered, and what the findings will show. Treatment can then be targeted for maximal outcome.

Managing TBI is challenging; the addition of dizziness or balance complaints in these individuals makes it even more so. This paper seeks to provide a useful roadmap clinical pathway for assessment of these patients with appropriate and timely referral for treatment.