Importance of Balance Function in Patients with Neurological Deficits.

  • Maintaining static and dynamic balance is a complex process involving the use of senses, postural muscles, and brain processing.
  • The balance stability must be sufficient enough to adapt to changes in the environment, or during an activity which may lead to falls.
  • Vestibular and balance rehabilitation is an efficient method to treat vestibular/inner ear and a variety of other neurological disorders.

How do you stay balanced?

Keeping Balanced

  • The ability to maintain balance is a complex process that depends on multiple systems.
    • Your sensory system including the inner ear, the eyes and feet that provides information about body position.
    • Your motor system including your muscles and joints for coordinating the movement required to maintain balance.
    • Your brain’s ability to process information from all of these systems
  • In a normal healthy individual the senses of touch/position sense, vision and inner ear motions sensors work together in harmony with the brain. A person with a balance disorder, however, may have a problem with one or a combination of these systems.

Dizziness / Vestibular Disorders:


In Benign Paroxysmal Positional Vertigo (BPPV) dizziness is generally thought to be due to debris which has collected within a part of the inner ear. This debris can be thought of as “ear rocks”, although the formal name is “otoconia”. Ear rocks are small crystals of calcium carbonate derived from a structure in the ear called the “utricle". While the saccule also contains otoconia, they are not able to migrate into the canal system. The utricle may have been damaged by head injury, infection, or other disorder of the inner ear, or may have degenerated because of advanced age. Normally otoconia appear to have a slow turnover. They are probably dissolved naturally as well as actively reabsorbed by the “dark cells” of the labyrinth (Lim, 1973, 1984), which are found adjacent to the utricle and the crista, although this idea is not accepted by all.

BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. While BPPV can occur in children (Uneri and Turkdogan, 2003), the older you are, the more likely it is that your dizziness is due to BPPV. About 50% of all dizziness in older people is due to BPPV. In one study, 9% of a group of urban dwelling elders were found to have undiagnosed BPPV (Oghalai et al., 2000).

The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and nausea. Activities which bring on symptoms will vary among persons, but symptoms are almost always precipitated by a change of position of the head with respect to gravity. Getting out of bed or rolling over in bed are common “problem” motions . Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, sometimes BPPV is called “top shelf vertigo.” Women with BPPV may find that the use of shampoo bowls in beauty parlors brings on symptoms. A Yoga posture called the “down dog”, or Pilates are sometimes the trigger. An intermittent pattern is common. BPPV may be present for a few weeks, then stop, then come back again.

Vestibular Neuronitis / Labrynthitis

What is Vestibular Neuritis and Labyrinthitis?

Vestibular neuritis is a viral or bacterial infection of the vestibular nerve. Labyrinthitis is inflammation of the inner ear due to a viral or bacterial infection. Both are a form of unilateral vestibular dysfunction. This means that dysfunction is coming from the vestibular organ (the inner ear) and not the spinal cord or brain. The source of the infection may come from a respiratory or gastrointestinal infection. Symptoms associated with vestibular neuritis and labyrinthitis includes sudden onset of severe vertigo, severe gait instability, nausea and/or visual changes such as blurry or jumping vision. Hearing loss and/or tinnitus (ringing in the ear) is associated with labyrinthitis but not vestibular neuritis. At onset, symptoms of vertigo or dizziness are constant. Vertigo and disequilibrium will decrease after a few days and become intermittent with changes in head position being a precipitating factor.

When a virus or bacteria infects the vestibular nerve or the labyrinth, the vestibular nerve is affected. The vestibular nerve carries information to the brain about movement of the head and body. When inflammation and swelling occurs due to the infection, the nerve becomes weaker and does not send sufficient information about head movement to the brain. Vestibular neuritis or labyrinthitis usually affects one inner ear which results on one side becoming weaker than the other. As a result, vertigo and gait disequilibrium occurs because of the vestibular imbalance.

How will this affect my life?

You may miss work or stay at home for the first week. It usually takes 2-3 weeks to recover from vestibular neuritis/labyrinthitis. This occurs through a combination of your body fighting off the viral infection and your brain compensating (adapting) to the vestibular imbalance. After the acute phase is over, vertigo will completely resolve but you may still experience imbalance standing and walking as well as motion sensitivity with head movements. Crowded or busy environments such as a grocery aisle may be problematic. Blurry or jumping vision may also be an issue which can affect your ability to play high level sports activities such as tennis.

How will physical therapy help?

Vestibular rehabilitation, a specialized form of physical therapy, can help improve balance and decrease dizziness associated with a unilateral vestibular dysfunction. Your physical therapist will conduct a comprehensive evaluation to assess vestibular function and balance. Based on the evaluation and your personal goals, the physical therapist will devise an individualized program to address your specific needs and help you return to your previous level of activity. The program consists of head-eye coordination exercises as well as balance activities that will help your brain adapt to the incorrect messages coming from the weak or damaged inner ear. These exercises have been shown to be effective in treating inner ear dysfunction due to vestibular neuritis or labyrinthitis. You may need to see your physical therapist 2 to 3 times a week at first to determine the appropriate exercise and to help you pace through the activities. You will also be given a home exercise program which is important to be compliant with in order for your brain to adjust and decrease your symptoms of dizziness. Recovery from a damaged or weak inner ear will depend on many different factors including the extent of the weakness, the length of time you have had the symptoms, age and your prior level of activity.

Additional Resources

The Vestibular Disorders Organization (

The American Hearing Research Foundation (

APTA Neurology Section: Vestibular SIG (

Meniere’s Disease:

What is Meniere’s Disease?

Meniere’s Disease is a disorder of the inner ear that causes episodic vertigo, tinnitus (ringing in the ear), a feeling of fullness in the ear and/or fluctuating hearing loss. It affects 0.2% of the population but 2% of the U.S. population report that they have it.

What causes it?

A “Meniere’s attack” is believed to be caused by fluctuating pressure of the fluid in the inner ear. Normally, the inner ear is filled with fluid called endolymph which produced by an organ attached to the inner ear called the endolymphatic sac. During an attack, either the endolymphatic sac is producing too much fluid or it’s not reabsorbing the fluid due to a possible blockage. In either case, the increased fluid dilates the inner ear organ and causes the symptoms associated with Meniere’s disease. Currently, there is no known cause for Meniere’s disease. It is thought to be an autoimmune disease. For some patients, genetics may also play a role.

What are the symptoms of Meniere’s Disease?

Patients with Meniere’s disease typically report episodes of vertigo (spinning), severe imbalance, nausea and/or vomiting that can last between 2-4 hours to a full day. These “Meniere’s attacks” may be preceded by warning signs that include fullness in the ear or sudden loss of hearing. Symptoms and duration of symptoms can vary greatly from on individual to another.

How can physical therapy help?

Initially, balance will remain relatively normal in between Meniere’s attacks. However, as the disease progresses, it will start to affect the inner ear structures and balance can be potentially impaired. Physical therapy can help establish a baseline measure of your balance and dizziness. Based on the evaluation and your personal goals, the physical therapist will devise an individualized program to address your specific needs and help improve your balance. Physical therapy can also help in reducing compensations related to Meniere’s disease.

What Outcomes Are Linked To Falls?

  • Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. These injuries can make it hard to get around or live independently, and increase the risk of early death.6,7
  • Falls are the most common cause of traumatic brain injuries (TBI).8 In 2000, TBI accounted for 46% of fatal falls among older adults.4
  • Most fractures among older adults are caused by falls.9 The most common are fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.10
  • Many people who fall, even if they are not injured, develop a fear of falling. This fear may cause them to limit their activities leading to reduced mobility and loss of physical fitness, which in turn increases their actual risk of falling.11

Who is at Risk?

Fall-related Deaths

  • In 2008, 82% of fall deaths were among people 65 and older.
  • Men are more likely to die from a fall. After taking age into account, the fall death rate in 2007 was 46% higher for men than for women.
  • Older whites are 2.5 times more likely to die from falls as their black counterparts.
  • Many people who fall, even if they are not injured, develop a fear of falling. This fear may cause them to limit their activities leading to reduced mobility and loss of physical fitness, which in turn increases their actual risk of falling.

Fall Injuries

  • The chances of falling and of being seriously injured in a fall increase with age. In 2009, the rate of fall injuries for adults 85 and older was almost four times that for adults 65 to 74.
  • People age 75 and older who fall are four to five times more likely than those age 65 to 74 to be admitted to a long-term care facility for a year or longer.
  • Women are more likely than men to be injured in a fall. In 2009, women were 58% more likely than men to suffer a nonfatal fall injury.
  • Rates of fall-related fractures among older women are more than twice those for men.
  • Over 90% of hip fractures are caused by falls. In 2007, there were 264,000 hip fractures and the rate for women was almost three times the rate for men.
  • White women have significantly higher hip fracture rates than black women.

How Can Older Adults Prevent Falls?

Older adults can remain independent and reduce their chances of falling. They can:

  • Exercise regularly. It is important that the exercises focus on increasing leg strength and improving balance, and that they get more challenging over time. Tai Chi programs are especially good.
  • Ask their doctor or pharmacist to review their medicines—both prescription and over-the counter—to identify medicines that may cause side effects or interactions such as dizziness or drowsiness.
  • Have their eyes checked by an eye doctor at least once a year and update their eyeglasses to maximize their vision. Consider getting a pair with single vision distance lenses for some activities such as walking outside.
  • Make their homes safer by reducing tripping hazards, adding grab bars inside and outside the tub or shower and next to the toilet, adding stair railings and improving the lighting in their homes.

To lower their hip fracture risk, older adults can:

  • Get adequate calcium and vitamin D—from food and/or from supplements.
  • Do weight bearing exercise.
  • Get screened and treated for osteoporosis.

Data provided by cdc, please click for more details:

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