Balance & stability: keeps you upright & prevents falls
Spatial Orientation: tells you if you're moving up/down, left/right, or spinning
Gaze Stabilization: adjusts eye movements (vestibulo-ocular reflex) so you can see clearly while moving
Coordination: integrates with other senses (vision & touch) for overall body awareness
What Happens:
senses motion --> signals to brain --> brain's response
Responsible for rotational movements
Anterior (superior) canal: detects forward/back head movements - e.g. nodding "yes"
Posterior canal: detects tilting head side-to-side - e.g. tipping ear toward shoulder
Horizontal (lateral) canal: detects side-to-side head turns - e.g. shaking head "no"
Spatial orientation: knowing your head's positive relative to gravity
Motion sensing: detecting linear movements & changes in velocity
Postural control: organizing motor behavior & helping you stay up upright
Ocular control (otolith-ocular reflex): generating compensatory eye movements to stabilize vision during head tilt
Utricle: detects horizontal linear acceleration & head tilt
Saccule: detects vertical linear acceleration
includes inferior vestibular nerve (IVN) & superior vestibular nerve (SVN) innervations
Structures:
Each organ contains a macula with hair cells, a gelatinous layer, and an otolithic membrane embedded with heavy otoconia (ear crystals)
Gravity Detection
when the head tilts, gravity pulls on the heavy otolithic membrane, shifting it and bending the underlying hair cells, signaling head tilt to the brain
Linear Acceleration
when you move in a straight line (like in a car or elevator), the inertia of the otolithic membrane causes it to lag or shift, bending the air cells and signaling the change in speed
Signal Transmission
bending hair cells generate electrical signals sent via vestibular nerves to the brain, which interprets the information for balance & orientation
"Lost Crystals" - Benign Paroxysmal Positional Vertigo (BPPV): -
Concussions are a process, not just an event
injury
ionic cascade
metabolic cascade
error signaling
signs, symptoms, deficits & outcomes
Injury Types:
Direct impact
Acceleration-deceleration injury
Blast injury
Signs & symptoms
headaches
Feeling slowed down
Difficulty concentrating
Dizziness
fogginess
fatigue
visual blurring/diplopia
light sensitivity
memory dysfunction
balance problems
Cardiac/Vascular
stenosis
PVD
PAD
CAD
Afib
SVT
change in pressure
VBI
Metabolic
encephalopathy
diabetes
UTI
Covid
urinary retention
NPH
Visual
disturbances
clarity
diplopia
divergent/convergence insufficiency
Vestibular
BPPV
Meniere's
paroxysmia
neuritis
labyrinthitis
Presby vestibulopathy
Psychogenic
anxiety
depression
Pulmonary
COPD
emphysema
ILD
asthma
fibrosis
pneumonia
Cancer
focal
multifocal
metastasized
Neurological
MS
PD
POTS
FND
TBI
CVA
vagus/ANSD
migraines
PPPD
CD
foot drop
Nutritional
dehydration
HLD
electrolyte imbalances
vitamin/mineral deficiencies
Autoimmune
lupus
RA
MS
thyroid disease
Musculoskeletal
cervicogenic
disuse/atrophy/deconditioning
trauma/facial fractures
dizziness
vertigo
blurred/double vision
headaches/migraines
feeling of being bulled to or leaning to one side
nausea/vomiting
fear of falling
cold sweats
motion sickness
fatigue/brain fog
nystagmus/twitching eyes
impaired balance/unsteadiness walking
tinnitus/hearing loss
ear pressure/pain
light sensitivity
En bloc movement refers to a motor pattern in which the head, neck, and trunk move together as one rigid unit, rather than rotating separately. It is commonly seen in individuals with neurological conditions such as Parkinson's disease.
Key Points:
Movement occurs as a single unit (head, trunk, pelvis rotate simultaneously)
Often due to reduced spinal flexibility and impaired motor control
Considered a compensatory strategy when normal segmental movement is limited
Turning is performed with multiple small steps instead of a smooth pivot
Leads to decreased balance and coordination
Associated with an increased risk of falls
Visual cues can help improve anticipatory eye movements and turning ability
Important for clinicians to address to enhance safety and functional mobility
Promote Segmental Movement
Goal: Help the body relearn dissociation between head, trunk, and pelvis
Practice head-first turning (eyes → head → trunk → pelvis)
Use verbal cues like: “look, turn your head, then your shoulders”
Seated trunk rotation exercises before progressing to standing
Use External Cueing Strategies
Goal: Improve motor planning and initiation
Visual cues (targets on wall to look at before turning)
Auditory cues (counting steps, metronome)
Floor markers to guide stepping during turns
Task-Specific Training
Goal: Improve functional carryover into daily occupations
Practice turning during ADLs (e.g., turning in kitchen, bathroom mobility)
Simulate real-life tasks:
Turning to sit in a chair
Navigating tight spaces
Break tasks into step-by-step sequences
Balance & Fall Prevention
Goal: Increase safety and confidence
Weight shifting exercises
Practice wide base of support during turns
Educate on avoiding quick pivots
Environmental Modifications
Goal: Reduce risk and cognitive load
Remove clutter to allow larger turning space
Ensure adequate lighting for visual cueing
Arrange frequently used items within easy reach
Compensatory Strategies
Goal: Work with the condition when needed
Encourage intentional, slower movements
Teach patients to pause before turning
Reinforce use of assistive devices if appropriate
Vestibular:
involves a vestibular apparatus & related structures dysfunction
Room is spinning (especially with head turns & rotations)
walking a plank
drunk sensation
woozy or floating
objects or words are moving
feeling pulled to one side or down
Non-vestibular
typically result from dehydration, co-morbid conditions, deconditioning, anxiety, medication side effects, etc.
lightheaded
fatigued
unsteady
legs feel tired
sensation of swaying or rotating (more slowly)
sweating/temp increase, increased HR
History
PMH - including recent traumas
occurrence situations (timing & triggers)
duration
type/frequency
resolution
Visual Assessment
ocular position
acuity - static & any diplopia presence
oculomotor - saccades, convergence, smooth pursuits
Test of skew/Cover-uncover test - alignment of the eyes without fixation
Proprioception & Balance Assessment
observation
somatosensorial testing
Romberg test
Timed up and go (TUG)
dynamic gait index
modified clinical test of sensory interaction in balance (mCTSIB)
Vertebral Artery Test (VAT)
rules in/out vascular etiology
new or sudden onset of head/neck/jaw pain unfamiliar to patient
supine/seated position options
cervical extension with side bend and rotation away from side being tested
Look for 5 D's and 3 N's
dizziness
diplopia
dysarthria
dysphagia
drop attacks
ataxia
nystagmus
nausea
numbness
Vestibular Assessment
vestibular ocular reflect (VOR)
ensures consistent vision while the head is in motion
HEAD turns 20 degrees to left, EYES move 20 degrees to the right at the same velocity
signals from one semicircular canal aides the eyes to move in a direction equal & opposition to the head in the same velocity
VOR Screen -
assesses peripheral cause of dysfunction
negative VOR dysfunction results in eyes staying fixed on target
positive VOR dysfunction results in loss of fixation and/or corrective saccade
vestibular ocular motor sensitivity (VOMS)
dynamic acuity test
Dix Hallpike & Supine Head Roll Tests
HINTS Test - Head Impulse Nystagmus Test of Skew
Nystagmus -
fast & slow component
at rest, beats toward intact side
during VOR testing, eyes fall off target on affected side
spontaneous or direction changing or vertical nystagmus --> center etiology
Test of Skew
HINTS Test
VOR Screen
Activity-Specific Balance Confidence (ABC) Scale
Vestibular Disorder Activities of Daily Living Scale (VdADLS)
Visual Vertigo Analogue
Dizziness Handicap Inventory (DHI)
Dynamic Gait Index
Modified Clinical Test of Sensory Interaction in Balance (CTSIB-M)
Central Dysfunction
severe imbalances; ataxic gait, dysmetria, dysarthria
constant dizziness (potential)
ocular misalignment
nystagmus (vertical or directional changing, doesn't fatigue)
Peripheral Dysfunction
intense spinning triggered by head movements
tinnitus, hearing loss, ear fullness
nystagmus (horizontal & fatigues)
Adaptation
Habituation
Body scheme & balance
Substitution - substituting the structural loss with something to make up for it
*Consideration of cognitive load
patching for diplopia
timed gaze at target
change backgrounds to increase challenge/focus
visual tracking (mazes, head laser, free movement laser)
Visual scanning, hart charts, accommodations
Brock string/dot cards for convergence insufficiency
computer programs/light up board
Functional tasks - reading, scanning
cross words, word searches, coloring/art
tracking movement on tv/videos (birds, butterflies, sports)
Brock String Convergence - good for diplopia/convergence
gaze stabilization/target tracking
vestibular ocular reflex
VOR x1: eyes are stationary & head moves
VOR x2: target moves in opposite direction of visual tracking
Two target VOR
Imaginary target VOR
grading - backgrounds, distance, speed of movement, change positions (seated v. standing), surface, dynamic vs. static performance
repetitive movements with minimally provoked symptoms
weight shifting & surface changes with gaze stabilization
head v. eye movments with trunk & cervical positional changes
neural grounding, task weighing, side weighing,
functional tasks - turning, rotation, shifting weight, bending, reaching
timed reaching & bending - start with greater time & gradual decrease
repetitive & frequent!!
static & dynamic sitting/standing
surface changes - flat, uneven, soft/foam
modify center of gravity with hand placement - by side, overhead, hips, across body --> add weight
proprioception/body scheme awareness
functional tasks!
bending, reaching, turning/rotating
movement transitions
community mobility training
home modifications
habit & routine modifications
performance of ADLs/IADLs
work environment & equipment
assistive devices
health promotion education
Epley Maneuver --> BPPV