The Vestibular  System


We all rely on good balance to function normally and this depends on our eyes, inner ears, brain and our musculoskeletal system (or muscles, joints and nerves) working together.

The inner ear or the labyrinth consists of the cochlea (hearing organ) and the vestibular (or balance) organ. 

The vestibular organ consists of 3 semicircular canals filled with fluid which detect movements of the head, and 2 structures called otoliths which inform your brain if your head is moving in a straight line or moving up or down. 

Feelings of dizziness or vertigo occur when these systems don’t work normally and your brain thinks your head is moving when it isn’t.

Good balance also depends on your eyes and muscles and joints working together telling your brain where you are, which position parts of your body are in in relation to other parts of your body and in relation to the world around you.  Joint and muscle sensors especially in the neck, back and lower limbs tell your brain which position your joints are in so that when you move, certain muscles and joints are activated to stop you from overbalancing or falling over.

Our Physiotherapist Cathy Gordon

Vestibular and TMJ (Jaw) problems are the specialist area of Physiotherapist Cathy Gordon, who is the co-founder of the Association of Chartered Physiotherapists in Temperomandibular Disorders (ACPTMD). There’s more about Cathy here.

Symptoms of Dizziness and Imbalance

  • Feelings of unsteadiness, floating and veering especially when walking.  These sensations can also be felt in the dark or turning quickly, and you can sometimes feel like you are on a boat.
  • Lightheadedness or wooziness which can be constant or intermittent.
  • Spinning which can be brought on by turning over in bed, looking up to the ceiling or down to the floor, or turning your head.
  • Difficulty focussing on an object or following a moving object or blurred vision in busy visual environments or crowded places, in supermarkets or in places with fast moving cars or objects.
  • Discomfort with loud noises and bright lights.
  • Loss of hearing.
  • Headaches and neck pain and increased tension.
  • Reduced independence and reluctance to go outdoors leading to changes to lifestyle, work and hobbies.

What causes dizziness and loss of balance?

Vestibular Neuritis or Labyrinthitis

Vestibular neuritis or labyrinthitis is a viral infection of the inner ear and dizziness symptoms usually come on suddenly accompanied by nausea and unsteadiness.  These symptoms can be very debilitating and last for days or weeks, although they usually subside, often with persistent visual and balance disturbances which can affect everyday life significantly.  Vestibular rehabilitation can be very helpful in resolving these persistent visual and balance problems and restore normal function..

Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is caused by the movement of minute calcium carbonate crystals into the semi-circular canals which disrupt normal eye movements causing repetitive jerky eye movements called nystagmus in certain head positions (such as turning over in bed).  Sensations of room spinning, vertigo and nausea usually accompany this although they are shortlived and only last for seconds. Causes of BPPV can occur from a head injury, whiplash or for no reason, often in the elderly. BPPV can be diagnosed by the Hallpike test and usually can be treated with canalith repositioning manoeuvers such as the Epley.

Vestibular Migraine

Vestibular migraine can occur with or without a headache and often presents with lightheadedness and intolerance to movement and moving images.  Other symptoms are nausea and vomiting, visual disturbances, difficulty concentrating and sensitivity to noise and light. Common triggers are stress, lack of sleep, certain food and drink, smoking and certain medications.  The cause is unknown but can be triggered by anxiety and depression or other forms of dizziness such as Menieres, which is it often confused with, and they can both co-exist. Treatment is orientated around addressing the causes of the triggers and therefore improving sleep, diet, hydration and reducing stress.


Menieres is a disease characterised by symptoms of vertigo, or spinning sensations, tinnitus, a full or deep pressure feeling in the inner ear, and hearing loss.  These symptoms can last for minutes or hours, and their cause is not fully understood. This is usually treated by medication although vestibular rehabilitation can be effective for any balance problems.

Persistent Postural-Perceptual Dizziness (PPPD)

Persistent Postural-Perceptual Dizziness (PPPD) presents as dizziness and swaying or rocking unsteadiness which occurs over 15 days in a 30 day period although most people have symptoms daily.  These symptoms can be aggravated by an upright sitting or standing posture, head or body motion, and exposure to busy moving environments and visual stimuli such as computers, phones, and reading.   They normally follow a peripheral or central vestibular disorder, vestibular migraine, a mild traumatic brain injury (concussion), and other medical conditions causing dizziness or medication induced dizziness.  This can be very debilitating and disruptive to a normal life routine and can lead to stress, anxiety and depression as well as feelings of isolation. Vestibular rehabilitation in conjunction with counselling and some medication can help promote a gradual return to normal function, reducing symptoms and enabling a normal lifestyle.

Acoustic Neuroma (Vestibular Schwanoma)

Acoustic Neuroma (Vestibular Schwanoma) This benign tumour develops on the vestibular (balance) or cochlea (hearing) nerve and causes loss of balance and hearing on the affected side.  This is usually treated surgically and vestibular rehabilitation can help to improve balance and reduce feelings of unsteadiness.


Dizziness in the Elderly

Dizziness in the Elderly is multifactorial but deterioration of the peripheral vestibular system (inner ear structures), postural stability as well as joint and soft tissue injury/surgery can contribute to poor balance and lead to falls.  Other causes such as certain medication, neurological conditions (stroke), reduced vision and hearing can cause imbalance and an assessment on the balance system will take this into account and treat the problem areas.

Other Causes

Dizziness and loss of balance can be caused by neurological disorders, such as a stroke, multiple schlerosis, head injury, cerebellar conditions (which is a major balance centre in the brain) and epilepsy.  Cardiovascular conditions such as cardiac arrythmias, cerebrovascular conditions, low or high blood pressure can cause dizziness as well as certain medications, loss of hearing and vision as mentioned earlier.  Your assessment will screen for any of these conditions and a referral to an appropriate specialist will be made.

Concussion or Mild Traumatic Brain Injury (TBI)

Concussion is a mild blow to the head resulting in symptoms which can include headache, dizziness, nausea or vomiting, memory loss, unusual behaviour such as mood changes, confusion and loss of focus, clumsiness or reduced balance and the urge to fall asleep.  These can last from anything up to a few weeks to a year or longer. Treatment and management includes resting and taking a break from work or any stressful situations, and vestibular rehabilitation is effective in reducing visual disturbances and improving balance.  Psychological support and advice is very important to manage anxiety and stress caused by these symptoms and their longevity.

Your Vestibular Assessment

At your first appointment, a detailed history will be taken to diagnose the cause and rule out any conditions that may require an Ear Nose and Throat consultant, a Neurologist or another specialist referral.  An examination will then include eye coordination tests, balance tests, the Hallpike test which will diagnose the presence of BPPV and any appropriate joint and muscle testing. A diagnosis of your symptoms will then be discussed with you followed by your treatment plan which will incorporate vestibular rehabilitation as below.

What is Vestibular Rehabilitation

Following an episode of dizziness and imbalance caused by any of the above conditions, it can be very unpleasant to move your head or eyes, therefore it is normal to avoid these movements.  However, is it very important to regain these movements and resume normal function, as well as reducing any neck and back stiffness and pain which can also occur following a period of dizziness.

Vestibular rehabilitation is an exercise based programme aimed at reducing symptoms and improving balance by training the brain to recognise normal signals from the eyes, inner ears, muscles and joints.  These signals are then processed by the brain which then teaches your muscles, joints and nerves to move and function normally.

Vestibular rehabilitation involves the following:

  • The Epley or other semi-circular canal repositioning manoeuvres if BPPV is diagnosed.
  • Eye and head movement exercises will help to improve the stability of your gaze and reduce your symptoms if you struggle with increased visual stimuli.
  • Balance and trunk and lower limb strengthening exercises will help to improve joint and muscle awareness and stability.  This will also reduce your symptoms and give you confidence to return to normal life activities and work. 

Vestibular rehabilitation can make long lasting dramatic effects to your balance and dizziness symptoms.  It can reduce your neck pain and headaches and nausea, as well as sensitivity to bright lights and loud noises.  It will increase your concentration and focus, increase your balance and strength and therefore reduce the risk of falling.

If you feel that this may be appropriate for you, please contact me.

Fizziostuff UK Ltd trading as Wilmslow Physio

Wilmslow Physio: 20A Grove Street, Wilmslow SK9 1EB

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