Correspondence (reply): In Reply

Dr Gorris-Vollmer describes successfully treating dizziness in patients with blockades of the upper cervical spine. There is no doubt that many patients with dizziness have symptoms and findings in the neck and the back of the neck areas and that this association exists in individual cases. However, the association is often assumed for no reason, especially since established clinical tests or apparatus-based diagnostics are not available to confirm this. This dilemma is also highlighted in a review article published in 2015 (1). Nothing has changed: if after a thorough medical history and examination of patients with dizziness problems these patients also have symptoms affecting their cervical spine that require treatment, then these should be treated independently of the dizziness. If the dizziness reduces in tandem with the cervical spine problems, even better. However, we can report from our supraregional center that many patients have received treatment on their atlanto-occipital joint and cervical spine that did not result in any improvement of their dizziness.

Dr Walter rightly points out that in patients with dizziness, the option exists even in old age to treat causes and symptoms with medication. In our view, symptomatic treatments should be given with a clearly agreed treatment objective for a defined period of time. Non-sedating medications are preferable. In our clinical experience the treatment with betahistine as the medication of choice for endolymphatic hydrops is effective, even though high-quality clinical evidence for this treatment is still lacking (2). Adapting and adjusting the environment in order to avoid falls in patients with dizziness, as mentioned by Dr Walter, is extremely important.

Professor Ernst described the degeneration of vestibular sensory cells that occurs sequentially with increasing age. The number of vestibular hair cells in the semicircular canals and otolith organs decreases continually from adolescence onwards. Vestibular functioning is retained for a long time owing to intersensory and central compensation mechanisms (3). Balance training is useful in order to stave off the time point at which decompensation occurs to as old an age as possible and to counterbalance existing deficits. A promising approach is the mentioned neurofeedback balance training that was developed in Berlin. We can only support the notion that maintaining or substituting all sensory functions is of crucial importance for a self-determined life at an old age. In order to diagnose the deficits, standardized tests for standing posture and walking—as described by ourselves—will have to be used. These need to include aggravated conditions in order to reflect deficits that are relevant for everyday life. Apparatus-based approaches, such as posturography (mentioned above), are a valuable addition (in our view), but these are not available everywhere and they require appropriate and correct interpretation after they have been undertaken.

Dr Krause and Professor Hensen point out the role of hyponatremia as a clinically relevant cause of unstable gait in old age. The supporting evidence is documented in detail in the letter. We did not expand on useful laboratory investigations because in our experience, general practitioners can reliably conduct these in patients with dizziness and unstable gait. Electrolyte disorders and changes to the blood count (anemia), liver, kidney, and thyroid function disorders are relevant in this context. The letter rightly points out that electrolyte imbalances often arise iatrogenically, as a result of medication. Some of the drugs mentioned (carbamazepine, antidepressants) increase dizziness and unstable gait because of additional neurological side-effects.

The letters to the editor altogether underline the need for interdisciplinary thinking in assessing patients with dizziness and unstable gait (4). We are convinced that for these and other groups of patients the traditional delineations between disciplines do not suit the symptoms. Patients thus affected often seek out several medical specialists and receive help at a very late stage. The problem has been recognized. In a model project in Munich, a center was developed—supported by funding from the Federal Ministry of Education and Research (BMBF)—in which numerous disciplines in healthcare and research are collaborating on the subject of dizziness (www.klinikum.uni-muenchen.de/Deutsches-Schwindelzentrum-IFB-LMU/de/).