When Balance Goes Topsy-Turvy

Who doesn’t want more balance in life? Nothing improves sanity more than balancing a busy work season with a little R&R in Hawaii. But what if you do not know what being centered even feels like? Your mind may be in a perpetually stressed state just from the challenge of trying to stay upright! Before getting the mind in balance, the body needs to be calibrated too. Whether or not you have ever had a dizzy bout knock you off your feet, it is good to know about this rarely discussed function, the vestibular system.

Balance is controlled by the vestibular system, an apparatus in the body that most people are not aware of, until they have an episode of dizziness or vertigo. This system helps determines the head’s position and lets you know if you are still moving or not. My husband studied the vestibular system while working at NASA Ames Research Center. He was attempting to solve the problem of why some astronauts would become disoriented in space when adapting to weightlessness. This made it difficult for some astronauts to perform their complex cognitive tasks. The research was later used to treat seniors as well, as many people lose balance with age.

It’s not all in Your Head

You do not have to float in space to feel flighty. Due to a long-term undiagnosed vestibular issue, I frequently felt lightheaded. And I came close to fainting numerous times. Typically I blamed the loopy head on seasonal allergies, sinus issues, or subpar sleep. The constant stress on the sympathetic nervous system of trying to orient itself in space also impacts attention. Health professionals gave me many labels over the years from ADD to OCD. High school classmates nicknamed me Space Case. Later in life, an ENT doctor dismissed my concerns and handed me the name of a psychiatrist.

Due to a flushed appearance and perhaps a wobble in my gait, a well-meaning person once asked me if I was a friend of Bill’s. This apparently is code for “Are you in Alcohol Anonymous?” Bill Wilson founded AA. (I happened to be wearing a gold camel around my neck, which is an AA symbol for going a long time between drinks.) In reality, I get tipsy over the mere whiff of alcohol! All the labels affected my psyche, causing a deep sense of hurt and shame. I began to doubt my abilities, regardless of my many significant achievements.

Despite obvious intelligence, the deficiencies in my brain occasionally frustrated me–and likely others– to no end. On seeing a doctor for hormonal challenges and brain fog, she reported afterwards, “Patient vented in a random stream of consciousness.” I started to guard my feelings more, for fear of getting hurt. My Internet trail eventually led me to a lecture of psychotherapist Kenneth Erickson, M.D. to the Vestibular Disorders Organization (VeDA). In reading his article on the cognitive aspects of vestibular dysfunction, I wept as I could relate so well. People with vestibular deficiencies—like those with ADD/ADHD—can give the impression they are poor listeners, slow verbal processors, or just plain anxious. This is especially true when meeting new people, which can hyper- stimulate the nervous system.  Conversations can lack balance too, not always having linear thought patterns or a logical stopping point.

Know When You Need Help

After years of trying to get fix my brain, I toppled from my bike when becoming lightheaded at a stop light one day, and smashed my hand on the road. Due to the chronic pain condition I was blessed to be remission from, I could not afford to risk relapsing. Driving in slow-moving traffic jams also make my head spin. With California freeways becoming increasingly congested, I was concerned about getting hit by car during rush hour. Even while walking, I could trip over a flat surface. I lacked proprioceptive awareness of where my feet where–a hazard in my sport of triathlon. A sprained ankle led me to forfeit one race, but I feared worse consequences if I did not treat this soon. I hoped to compete in a Half Ironman race and needed to be in optimal health. Taking decongestants to clear my head was not cutting it anymore. Help was not just a pill away; I needed to retrain my brain.

First I needed answers. Most doctors are well aware of the major senses in the body like hearing and vision, smell and touch. But they are less familiar with the complexities of the vestibular system, and the important role it has in tracking the body’s positioning in space (This awareness, known as proprioception, helps us recover when we start to fall). Most of us give our vestibular organs little thought until our body sends out signals. We might bend over and see stars from standing up too fast, or get hopelessly dizzy from spinning on a merry-go-round. (A boyfriend once purposefully subjected me to this torture; he did not remain my boyfriend for long!) I also remember being mocked as a child, whenever I would stagger around in a stupor during any game that involved rotating in a circle.

Vestibular Dysfunction/Motion Sensitivity

You can probably relate to getting dizzy while driving down a curvy mountain road or getting green at the gills from rolling in fifteen-foot ocean waves. But now imagine getting lightheaded from merely putting a car in reverse, or tipsy from seeing a train roll by, or woozy from watching windshield wipers swish back and forth. Parking my car or driving in rain was becoming a challenge, especially with extra stressors like low visibility and heavy traffic. Seeing someone sway their body as they talked, or gesture in an animated way, was another trigger for me. But for some people, it becomes difficult to even walk or work with this problem.

With vestibular imbalance, the sensory input received from the eyes, muscles and joints, conflicts with one another. You may feel like you are still moving, long after you have returned from that turbulent whale- watching trip. Or you feel extra confused in a parking lot, when the car next to you starts backing up just as you are reversing. You may sense you are moving even if you are not, and get dizzy from crowds of people milling about.

Maybe you are not the motion-sensitive type, but can relate to the lightheaded feeling that comes with being overly tired from staying up too late, or perhaps getting dehydrated from a day in the sun. This is all the more reason that people with balance issues need to drink (and eat) regularly and get sufficient shut-eye!

Vestibular System 101

First, what exactly is the vestibular system?  It is a series of canals in the ears that tell you whether your head and body is moving. This is what gives a sense of spatial orientation and equilibrium. The vestibular system pulls together various signals from your body, including your feet, to provide this information. Sensory organs of your eyes, muscles and joints, and the vestibular apparatus—located above each ear—send information to the brain stem in the form of nerve impulses. (If you recall from high school biology, impulses from nerve endings receive information from the organs.)

The balance information is sorted out and combined with other information from the cerebellum, the coordination center of the brain that is responsible for muscle memory. It also draws from the cerebral cortex, the brain’s thinking and memory center. For example, when you practice a tennis serve over and over, it becomes automatic due to muscle memory. But when you integrate new environmental information, like adjusting to a new court surface, your thinking brain recruits a different movement pattern to best execute the swing.

Causes of Vestibular Dysfunction

Deficits with the vestibular system can especially affect the elderly. This system declines with age, which is why those with balance issues often stumble and fall in showers or tubs. It is not just from slippery floor surfaces, but from reaching up or looking down and losing equilibrium. Balance deficiencies can occur from the natural aging process, from improper neural development early on in life, and from improper biomechanics, especially with the neck and spine. Medication, disease, infection, concussion, and pain or trauma can all affect the vestibular system as well. A minor car accident or whiplash can cause it too.

Vestibular dysfunction can be worsened by stress, but is not solely caused by stress. And it is not considered a psychiatric disorder. Feeling dizzy and not processing sounds correctly can be stress-inducing in itself. So it is a vicious cycle. Even panic attacks can bring on dizziness– or be caused by them. Stressors like dental visits or exposure to strong smells can also be a trigger, along with barometric pressure, weather changes, pain, changing hormones and food sensitivities. Stress can also be caused by an overactive sympathetic nervous system. Many people with sleep disorders, such as Upper Airway Restricted Breathing (UARS), can also suffer from lightheadedness or dizziness. This is described in a helpful podcast article, “Tired of being Tired?” by Dr. Steven Park.

Tests For Vestibular Issues

Assessing vestibular dysfunction includes more than checking for loose crystals in the ears, signs of a virus, or improper postural mechanics. Vestibular diagnostics cover a wide variety of tests to assess the balance portion of the auditory and visual systems. Practitioners measure physiologic responses in the ears and eyes. A common test is the Computerized Dynamic Postural Topography Tests (CDP), which tests how the vision, proprioception, and vestibular systems each function and how they work together.

Tests include positioning the head and body in certain ways and measuring a person’s ability to maintain balance in response to various stimuli. At Stanford University Ear Clinic, Otolaryngologist and Neurologist, Dr. Kristen Steenerson, tested me for involuntary or rapid eye movements with a VNG test (Video Nystagmography technology) These movements, known as nystagmus, which I had, affect depth perception, balance and coordination. I was also strapped in a harness to an open-ended machine that resembled an airport scanner. While standing on a platform, I was bombarded with visual stimuli to test how my body would react. I pitched forward. The floor moving did not cause me to stumble–the floor moved up to catch my fall. I was diagnosed with Vestibular Migraines, also known as Migraine Associated Vertigo (MAV), and Persistent Postural-Perceptual Dizziness (PPPD).

An audiologist also performed tests to check fluid and pressure in the ears, and to see how the inner ears responded to sound stimuli. He also looked for abnormalities in the auditory pathway, from the external ear to the top of the brain. But the primary focus was to assess the ability of the auditory system’s ability to maintain balance. In a subsequent test, I was strapped into a tilting table to check my heart rate variability changes (followed up by a deep breathing heart rate variability test). It showed I had very low heart rate variability, a sign of a stressed nervous system. I now pay more attention to heart rate training on my Garmin activity tracker on triathlon training days, and take regular rest breaks.

Multi-faceted Treatments

A functional neurologist, Dr. Minh Tran, at the Norcal Brain Center in San Jose, CA was the first to treat my vestibular dysfunction. I sought him out after years of dealing with sleep issues and high stress hormone levels, despite years of using a C-PAP machine to regulate breathing. (People with vestibular dysfunction often have sleep apnea).

Dr. Tran takes a multi-faceted approach to diagnose and treat balance problems: “Not only do we have to look at the triggers, but we need to have perfect recalibration of the vestibular system and cerebellum.” He explains that his approach includes “specific head and eye positioning maneuvers to ‘sync’ the information coming from the environment with what is being processed in the brain.” In other words, the brain needs to be retrained, so that routine movements and triggers are no longer disorienting.

The first major step towards treatment was to improve intestinal issues and to determine food sensitivities through food elimination testing. Initially, I thought my chronic congestion was causing the headaches, but both the neurologists I met with concluded that migraines and inflammation was likely causing the congestion. And I was prescribed heavy doses of exercise. My kind of medicine! I now rarely take anything for headaches. (Note, migraines can also present without head pain, and cause vision and hearing changes, or floaty feelings of lightheadedness and dizziness). I was also urged to drink far more water to support the brain and nervous system, to eat frequent small meals and stick to a clean Mediterranean style diet with protein. And to take magnesium supplements.

Balance and Attention

I did many exercises to improve balance and hand-eye coordination and to strengthen attention. Attention and focus issues often come hand in hand with balance problems, as the body is working hard already just to stay upright. My eyes grew better accustomed to tracking movement. (It is not just an eye issue; it is how the brain processes what it sees.) I practiced moving my eyes to track images, lines and dots, while keeping my head still. Over time I was able to focus without the images moving or getting blurry.

Other exercises involved double and triple tasking memory tests to assess auditory and visual attention. I had to view word or letter patterns from a large TV screen that would then disappear. And then I touched the locations on the screen where I remembered seeing them. Or I repeated a recited list, in different orders. The more I recalled, the quicker I had to process the list, or the more words I had to remember. As a bonus challenge, I had random words read to me that I would provide rhyming words for. The hardest exercise was one where I practiced flipping mirror images (sideways or up and down), in order to improve spatial orientation. Over time, my brain learned to handle harder tasks without causing dizziness.

Vestibular Rehabilitation

I also did vestibular rehabilitation exercises with a physical therapist. Exercises included walking in a straight line (like a drunk test), standing on uneven surfaces, and looking at busy images scrolling by on paper or a computer screen. Going to Costco on a busy day was another one, to teach the brain not to overreact to crowds of swarming people. Lots of one-legged balance exercises helped me improve the initial stumbling, and I worked up to staying still on one leg for one minute with my eyes closed. Gait stability with static and dynamic balance exercises helped reduce running injuries.

Just as allergy sufferers are continually exposed to allergy shots with gradually higher dosages of allergens, those with balance issues are exposed to repeated challenges of increasing complexity. At first, the testing brought on symptoms and some were administered while I was lying down. But I quickly improved, from standing on a flat surface and looking straight ahead, then up and down and to each side. The doctor measured the amount of body sway I had. I progressed to standing with closed eyes on a flat surface, then on a moving disc. Then I moved up to balancing on one leg, while standing on a cushioned surface. The goal is to see what triggers the imbalance, and to desensitize people to motion stimuli by gradually increase the demands on the nervous system.

Balance Therapy Benefits

Like many people with vestibular issues, I thought the unsteadiness I experienced was normal; I did not know any better anymore, as I had learned to compensate. While my head fog improved with allergy treatment, the lightheadedness and other balance-related symptoms were harder to resolve. So I tolerated them and found ways to deal with it. People often lack time, stamina, or finances to find treatment. Or, they may see numerous doctors, receive normal test results, and continue to feel off-center. Yet proper testing and rehabilitation can be life-changing.

Vestibular therapy also helped my spatial memory, so I no longer constantly lose track of where I set things down. Having a Tile app on my phone helps locate important items in a pinch. Keeping up with regular balance exercises has improved my proprioception, which reduces joint pain, as I no longer perpetually tilt forward. (Some physical therapists thought this postural tendency was just due to sloppy habits.)

In keeping up balance exercises, my brain does not have to work so hard, so I am less tired. Basic executive tasks, daily chores, and sustained reading efforts are less taxing. People always thought I had endless energy, when in fact I often exercised to feel awake or to clear my head. I am now less prone to falling asleep in inappropriate places. My husband recalls the time I nodded off while riding on the back of his motorcycle. And he threatened to strap me into a life jacket if I kept dozing off in our back yard hot tub.

Finding a New Normal

It was liberating to discover that my fatigue, lightheadedness and spaciness was not from a psychiatric disorder but a neurological one, and that the general anxiety and restlessness was not a sign of emotional weakness but a compromised nervous system. Yet obviously physical conditions can have psychological consequences.

With vestibular problems, as with many complex health issues, we might settle for feeling out of synch. Or we are not fortunate to find someone to offer sustainable solutions. As with my recovery from a rare pain disorder, it takes stubborn determination and advocacy to keep seeking help. But the key is to keep searching for a compassionate doctor who treats the whole person, and does not settle for you feeling less than your best.

When piling endless demands on bulging schedules and overtaxed nervous systems, it is easy to skimp on the regular rest and recovery time our brains all need. The best gift, I have learned, is to grant myself permission to slow down, become more mindful, and to find more grace in each moment. Once I finally learned what calm and relaxation felt like, I learned to make more thoughtful decisions and to set boundaries. And I freed myself from the feeling of having to achieve in order to prove competency or worth. Regardless of what future ambitious goals I set, I will consider it a success just to reach the starting line!

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