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Human Physiology · Nervous system and exercise

Posture, Balance and the Vestibular System

Staying upright depends on vision, the inner ear and sensation from the feet, combined by the brainstem and cerebellum. This page explains the vestibular system, postural strategies, why people fall, and the evidence for exercise, repositioning and vestibular rehabilitation.

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10Questions

Part 9 · Nervous System and Exercise · Chapter 44 of 47

Learning objectives

By the end of this page you should be able to:

  • Describe the sensory inputs and central integration for balance.
  • Explain how semicircular canals and otoliths detect motion.
  • Describe the vestibulo-ocular and vestibulospinal reflexes.
  • Describe ankle, hip and stepping strategies.
  • Summarise evidence for falls-prevention exercise.
  • Summarise evidence for the Epley manoeuvre and vestibular rehabilitation.

Why it matters

At least one third of people over 65 living in the community fall each year [1]. Falls cause fractures, fear and loss of independence.

Dizziness is also common, and many causes respond well to physiotherapy.

Sensory inputs

Figure 1 · Balance is multisensory

Visual, vestibular and somatosensory inputs integrated to control gaze, posture and perception Vision, the vestibular system and somatosensation from the feet and joints feed the brainstem and cerebellum, with cortical input. Outputs stabilise gaze through the vestibulo-ocular reflex, control posture through descending tracts, and give the sense of upright and motion. Visionwhere am I relativeto surroundingsVestibularhead rotation andlinear acceleration, gravitySomatosensoryfeet, joints, muscles:support surfaceBrainstem andcerebellum integrate;cortex adds attentionand predictionEyesvestibulo-ocular reflex:stable gazePosturevestibulospinal andreticulospinal tractsPerceptionsense of uprightand motion
Redundancy keeps us upright. When one input fails, others can compensate, which is the basis of balance and vestibular rehabilitation.

Figure 2 · Sensors of the inner ear

Components of the vestibular apparatus and what each senses The three semicircular canals on each side sense angular acceleration. The utricle senses horizontal linear acceleration and tilt, and the saccule vertical acceleration and gravity. Hair cells change firing as they bend, and the vestibular nerve carries the signal centrally. Semicircular canals (3 per side)angular acceleration: head turns, nods, tiltsUtriclehorizontal linear acceleration and head tiltSacculevertical linear acceleration and gravityHair cellsbend with fluid or otoconia; change firing rateVestibular nerve (VIII)carries signals to vestibular nuclei and cerebellumBPPV: loose otoconia drift into a canal, so head movement triggers brief vertigo [2]
Both sides fire at rest. The brain reads the difference between left and right; a sudden one-sided loss creates false rotation and vertigo.

The vestibulo-ocular reflex moves the eyes opposite to head rotation so gaze stays stable. When it fails, the world appears to jump with head movement, called oscillopsia.

Vestibulospinal pathways activate antigravity muscles to keep the body upright.

Postural control

Balance means keeping the centre of mass over the base of support. Anticipatory adjustments prepare for planned movement, and reactive adjustments respond to slips and pushes.

Figure 3 · Postural strategies

Ankle, hip and stepping strategies for increasing balance disturbances Small, slow disturbances are corrected with an ankle strategy, larger or faster ones with a hip strategy, and when the centre of mass leaves the base of support a stepping or reaching strategy is needed. Size and speed of disturbanceAnkle strategysmall, slow sway;body moves as oneabout the anklesHip strategylarger or faster;narrow support;bend at hipsStepping strategycentre of mass leavesthe base; step orreach to recover
Older adults and people with neuropathy shift to hip and stepping strategies earlier; training can improve all three.
Clinical testWhat it shows
Romberg (eyes closed)Reliance on vision; positive in sensory ataxia
Head impulse testVestibulo-ocular reflex on each side
Dix-Hallpike testPosterior canal BPPV
Berg Balance ScaleOverall static and dynamic balance
Timed Up and GoMobility and falls risk

Preventing falls

Sherrington and colleagues reviewed 108 trials in 23,407 people living in the community [1]. Exercise reduced the rate of falls by 23% and the number of fallers by 15% [1].

Figure 4 · Exercise prevents falls

Rate ratios for falls with different exercise types in older people All exercise reduced the rate of falls by 23 per cent, balance and functional exercise by 24 per cent, multiple exercise types by 34 per cent and Tai Chi by 19 per cent, compared with control. All exercise23% fewer fallsBalance and functional24% fewerMultiple types (usually + resistance)34% fewerTai Chi19% fewer0.50.751Rate ratio for falls versus control (left of 1 favours exercise)108 trials, 23,407 community-dwelling people aged 60+ [1]
Balance work is the core. Programmes that reduce falls mainly involve balance and functional exercises; the effect of resistance training alone, dance or walking is uncertain [1].

Exercise may also reduce fall-related fractures [1]. Adverse events, where reported, were mostly minor and musculoskeletal [1].

Treating dizziness

Benign paroxysmal positional vertigo (BPPV) causes brief vertigo with head position changes. Hilton and Pinder reviewed 11 trials of the Epley manoeuvre in posterior canal BPPV [2].

Complete resolution rose from 21% to 56%, though recurrence was about 36% [2].

Figure 5 · Treating dizziness works

Resolution of vertigo with the Epley manoeuvre and effect of vestibular rehabilitation Complete resolution of vertigo rose from 21 per cent with sham or control to 56 per cent with the Epley manoeuvre. Vestibular rehabilitation for one-sided vestibular loss increased the odds of reduced dizziness by 2.67 times. 21%Sham or control56%Epley manoeuvreComplete resolution of vertigo in BPPV [2]Vestibular rehabilitationfor one-sided vestibular loss:OR 2.67for reduced dizzinessversus control [3]39 studies, 2,441 people;no adverse effects reported [3]
Match treatment to diagnosis. Repositioning manoeuvres suit BPPV; exercise-based rehabilitation suits one-sided vestibular loss [2, 3].

For one-sided vestibular loss, McDonnell and Hillier reviewed 39 studies with 2,441 people [3]. Vestibular rehabilitation reduced dizziness and handicap, with no adverse effects reported [3].

Practical skill · gaze stability exercise

Fix the eyes on a target at arm’s length and turn the head side to side for up to a minute, keeping the target clear. Progress speed, background and posture as symptoms settle.

Clinical relevance for the physiotherapist

  • Falls prevention. Prescribe progressive balance and functional exercise [1].
  • BPPV. Diagnose with Dix-Hallpike and treat with repositioning [2].
  • Vestibular loss. Use gaze stability and habituation exercises [3].
  • Multisensory. Check vision, feet sensation and medication.
  • Red flags. New dizziness with neurological signs needs urgent medical review.

Assessment and application

SituationInterpretationAction
Older adult with two falls this yearHigh falls risk [1]Balance and functional training, plus resistance
Brief vertigo when rolling in bed, positive Dix-HallpikePosterior canal BPPV [2]Epley manoeuvre
Persistent dizziness after vestibular neuritisUnilateral vestibular loss [3]Vestibular rehabilitation
Sudden dizziness with slurred speech and limb ataxiaPossible strokeEmergency referral

Common mistakes

  • Prescribing walking alone to prevent falls [1].
  • Giving only exercises for BPPV without repositioning [3].
  • Forgetting that BPPV often recurs [2].
  • Ignoring feet sensation and vision.
  • Missing central causes of vertigo.

Exam preparation

Long answer

Describe the vestibular apparatus and its role in maintaining posture and balance.

  • Sensory inputs and integration (Figure 1).
  • Canals and otoliths (Figure 2).
  • Vestibulo-ocular and vestibulospinal reflexes.
  • Postural strategies (Figure 3).
  • Falls and vestibular rehabilitation evidence [1, 2, 3].

Short notes

  • Vestibulo-ocular reflex.
  • Romberg test.
  • BPPV and the Epley manoeuvre [2].
  • Falls prevention exercise [1].

Viva and practical

  • “What does the utricle sense?” — horizontal linear acceleration and tilt.
  • “Which exercise prevents falls best?” — balance and functional [1].
  • “How often does BPPV resolve after Epley?” — about 56% versus 21% [2].
  • OSCE: perform a Dix-Hallpike test.

Current evidence

Exam and traditional teaching

Falls and dizziness are part of ageing; medication is the main treatment for vertigo.

What the evidence adds

Exercise reduces falls with high certainty [1].

Repositioning cures many cases of BPPV, and vestibular rehabilitation reduces dizziness [2, 3].

What the student should understand

Balance is trainable and dizziness is often treatable. Physiotherapists are central to both.

Check yourself

10 questions on this page. Tap one to see the answer and the reasoning.

Q1. At least what proportion of community-dwelling people over 65 fall each year?
  1. (A) One in a hundred
  2. (B) One third
  3. (C) Nine in ten
  4. (D) None

Answer: (B) At least one third fall each year [1].

Q2. Exercise of all types reduced the rate of falls by about:
  1. (A) 3%
  2. (B) 23%
  3. (C) 73%
  4. (D) No change

Answer: (B) Rate ratio 0.77, a 23% reduction, high-certainty evidence [1].

Q3. Which exercise type most clearly reduces falls?
  1. (A) Walking alone
  2. (B) Balance and functional exercises
  3. (C) Stretching
  4. (D) Dance

Answer: (B) Balance and functional exercises reduced the rate of falls by 24% [1].

Q4. Programmes combining several exercise types reduced falls by about:
  1. (A) 4%
  2. (B) 34%
  3. (C) 84%
  4. (D) 0%

Answer: (B) Rate ratio 0.66 [1].

Q5. The effect on falls of resistance training alone, dance or walking was:
  1. (A) Clearly beneficial
  2. (B) Uncertain
  3. (C) Harmful
  4. (D) Not studied at all

Answer: (B) Effects were uncertain [1].

Q6. With the Epley manoeuvre, complete resolution of vertigo in posterior canal BPPV rose from about 21% to:
  1. (A) 25%
  2. (B) 56%
  3. (C) 90%
  4. (D) 100%

Answer: (B) Resolution increased from 21% to 56% [2].

Q7. Recurrence of BPPV after treatment was about:
  1. (A) 3%
  2. (B) 36%
  3. (C) 86%
  4. (D) Never

Answer: (B) There is a high recurrence rate of about 36% [2].

Q8. The Epley manoeuvre was superior to:
  1. (A) Semont manoeuvre
  2. (B) Gans manoeuvre
  3. (C) Brandt-Daroff exercises
  4. (D) Nothing

Answer: (C) A single Epley was more effective than a week of Brandt-Daroff exercises [2].

Q9. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction:
  1. (A) Was ineffective
  2. (B) Reduced dizziness, OR 2.67 versus control
  3. (C) Caused many adverse events
  4. (D) Only worked with drugs

Answer: (B) Odds ratio 2.67 in favour of rehabilitation, with no adverse effects reported [3].

Q10. For BPPV specifically, in the short term:
  1. (A) Exercise-based rehabilitation beats repositioning
  2. (B) Repositioning manoeuvres are more effective than exercise-based rehabilitation
  3. (C) Both are useless
  4. (D) Rest is best

Answer: (B) Physical manoeuvres were superior in short-term cure rate [3].

Quick review

Key takeaways

  • Balance integrates vision, vestibular and somatosensory input.
  • Canals sense rotation; otoliths sense linear acceleration and gravity.
  • Ankle, hip and stepping strategies match the disturbance.
  • Exercise cuts falls by 23%; balance work is key [1].
  • Epley resolves BPPV in 56% versus 21% [2].
  • Vestibular rehabilitation reduces dizziness, OR 2.67 [3].

Further reading

SourceWhy it earns its place
Sherrington C et al. — Cochrane, 2019Exercise and falls [1]
Hilton MP, Pinder DK — Cochrane, 2014Epley manoeuvre [2]
McDonnell MN, Hillier SL — Cochrane, 2015Vestibular rehabilitation [3]

References

  1. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2019;1(1):CD012424. doi:10.1002/14651858.CD012424.pub2 PMID 30703272 Systematic review and meta-analysis
  2. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 2014;(12):CD003162. doi:10.1002/14651858.CD003162.pub3 PMID 25485940 Systematic review and meta-analysis
  3. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2015;1(1):CD005397. doi:10.1002/14651858.CD005397.pub4 PMID 25581507 Systematic review and meta-analysis

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Reviewed by the Physiotherapist India Team. · Human Physiology contents