Ask the expert: Dizziness and balance

21 January 2020

Many people with MS experience problems with balance, dizziness, feeling unsteady and lightheadedness. These symptoms can be really debilitating and make it difficult to get on with simple daily activities.

We spoke to neuro and vestibular physiotherapist David Herdman to find out about the effective strategies that are commonly used to help improve problems with dizziness and balance.

Your questions answered

What's involved in maintaining a good sense of balance?

David says: We use lots of different sensory systems for our balance and orientation. We use our inner ear balance which senses movement of our head. We also use our hearing and vision, and we use the sense that comes from our muscles and joints which tells us where our limbs are in space. The brain integrates all of these different senses and helps us to stay upright, balanced and orientated.

What causes balance problems in people with MS? What goes wrong?

David says: A disruption in any of those different senses can lead to a sensation of dizziness or unsteadiness, so there's quite a lot of things that can cause it.

A common cause of dizziness is a condition within the vestibular system – the inner ear balance mechanisms. These have connections through the inner ear up to the lower part of the brain and into the upper part of the brain as well where dizziness is perceived. Demyelinating conditions can affect those pathways and cause dizziness.

We also know that people with MS are particularly prone to a form of vertigo called benign paroxysmal positional vertigo, or BPPV. This causes symptoms of dizziness when you lay down in bed, roll over in bed or tip your head up in these kinds of positions. The dizziness usually lasts for just a short period of time and is caused by a mechanical problem of the inner ear.

If you're referred to a physio because of dizziness and balance issues, are there any tests you'd usually carry out? What can people expect?

David says: Usually a physiotherapist will ask you quite a number of different questions to try to establish what are the different characteristics of the dizziness – for example, when it might come on, what kind of movements trigger it and how long it would last.

Then they would typically do an examination which involves looking at your eye movements and certain reflexes of your head and eyes. There is a specific test for positional vertigo where they lay you down on a plinth and see whether that reproduces your symptoms. They may also look at your balance and walking.

After these tests they'll be in a position to recognise whether there's some exercises that might be able to help you or whether you might need some further investigation.

What would a physio suggest for treating problems with balance?

David says: Exercise is a key treatment for dizziness and balance problems. One of the interventions is called vestibular rehabilitation. Essentially this is an exercise-based therapy which involves different eye, head and body movements. Vestibular rehabilitation works by bringing on dizziness a little bit so that the brain can put it right. Over time, the brain desensitises to the movements and environments that at one time may have provoked the dizziness in the first place.

Exercise is a key treatment for dizziness and balance problems. One of the interventions is called vestibular rehabilitation. Essentially this is an exercise-based therapy which involves different eye, head and body movements.


Is there any medication that can help?

David says: Generally we avoid medication to treat balance problems. Usually it doesn't really work and taking medication over a long period of time can sometimes worsen the problems of unsteadiness and balance. Medication that suppresses the vestibular system can actually delay recovery and affect the parts of the brain that we need to naturally recover. Usually we don't encourage long-term use of medication, although there are a few conditions where that can be helpful. If you're concerned about medication, it's worth speaking to your doctor.

Are there any types of exercise that can improve balance problems?

David says: Yes, outside of traditional vestibular rehabilitation, think about any kind of exercise that involves head or full body rotation or movements. Racket sports can be useful for this. Also there is some evidence towards Tai Chi due to its focus on balance and posture. Any kind of exercise that you enjoy can be useful, but it's got to challenge your balance. It's got to be quite difficult in order for you to improve.

If your balance issues are as a result of lesions on the brainstem, is it still possible to treat this with physio?

David says: The brainstem is a complex structure. It depends on what part of the brainstem is affected and how that might manifest. For example, there are some eye movement disorders that typically wouldn't respond to exercise. Nevertheless, in the largest study that's been completed to date they looked at vestibular rehabilitation in people with MS and they compared the results of people with and without brainstem lesions. They found similar levels of benefit from both of those treatment groups. That suggests that even patients with brainstem lesions might benefit from vestibular rehabilitation and physiotherapy to manage their dizziness problems.

If you could give three practical tips to someone who regularly experiences dizziness, what would they be?

David says:

  • Seek the appropriate help and try to see a specialist with knowledge of the vestibular system. That can be a nurse or physiotherapist or sometimes an audiologist. It's often a bit of a myth that dizziness is not treatable. In actual fact the vast majority of causes of dizziness can be treated effectively by trained specialists.
  • Try not to avoid those movements that bring on the dizziness. It's very natural and common that if something brings on dizziness you're going to try and avoid it, but actually bringing on that dizziness, even in the short term if it makes you feel a little bit dizzy, can help the brain to recover and reduce the response to dizziness over time.
  • Exercise is safe, even if it does bring on a little bit of dizziness. However, often people go in all guns blazing and then need to rest up for longer afterwards – that kind of boom and bust cycle doesn't necessarily help. When you're exercising, it's important to start off gradually with something very simple and easy, then gradually work up as you can tolerate more and more.

David Herdman is Principal Neuro and Vestibular Physiotherapist at St George's Hospital and NIHR Research Fellow at King's College London.