vestibular system

Why Vestibular Rehab is important and how it can get you to perform at a level you never imagined.

The vestibular system, and vestibular rehab, is one of the most underrated system in our body. We all take it for granted until it affects us. As a Sports Medicine Physical Therapist who has helped 1000’s of active youths to adults in Long Beach, I did not take this system seriously until I started to specialize in concussion management of athletes. You will need to make sure an ENT, ear nose throat physician, or specifically called an otolaryngologist, oversees your case too.

If you take a step back, everyone in pain has some form of physical tension. You might variations of this definition of tension. Stiffness. Discomfort. Limited range of motion. This is where there is a disconnect between your family General Practitioner, Orthopedist, or Spine Surgeon’s ability to understand the value of adding an otolaryngologist to your rehabilitation program.

We are going to make an assumption that you do not have immediate dizziness or vertigo. If you do, just scroll down to Vestibular Rehab 101 and we will help you understand more about your condition. For many of you, please read on how Vestibular Rehab will make you run faster, lift heavier, or hit better.

If you have arthritis, one would say you have tension more at your joints.

When you have a muscle strain or ligament sprain, you have local tension to your muscle or connective tissues. You get a massage and hope it takes this tension away.

What happens if it does not? What happens if it feels good, but for minutes?

It has been long recognized that a tighter a muscle, the weaker you are. This is based on the stress-strain curve. The keyword to note is “tighter”. There are many reasons for having tight muscles.

Muscle and joint tension is dictated by your nerves. Your nerves react based on your brain and brain stem. The brain and brain stem filters and makes decisions based on your senses.

Your senses impact whether you can relax or not!

Touch. Sight. Sound. Smell. Taste.

For the sake of this article, we will focus on one sensory system that is not talked about enough and the role of the inner ear system. The vestibular system helps to keep up balanced and know where our body in relationship to space.

Basically, the vestibular system helps us know when we are laying down, looking up, walking sideways, and upside down. This is crucial for many athletes. Imagine if you are skateboarding and cannot tell which direction you and your body are in.

Now imagine, you have a hyper ability to sense directions and how to move better on the skateboard. Why wouldn’t you want to get this ability? It is a skill.

Okay. So what is vestibular rehab?

Vestibular Rehab 101

The vestibular system is a sensory organ. It is made up to the Cochlea and the Labyrinth organ. The system is encased in the bone called the bony labyrinth. The inner workings are made of the membranous labyrinth.

The cochlea organ is what helps us to hear. The vestibular side of the labyrinth organ is what we will focus on in this article, as it is the system that will help you to possibly improve mobility, strength, posture and to move better.

The Vestibular labyrinth organ consists of the three semi-circulatory canals and the otoliths of the ear.

There are two parts to the otoliths: utricle and saccule. Each has a specific role.

The utricle helps you to sense vertical acceleration. This is fancy for how much up and down movements are happening. Common examples include squatting, going up and down the stairs, or the small bumps while driving.

The saccule connects to the cochlear duct. Its role is to sense linear acceleration of side to side or front to back movements. An example of this is the act of cutting, skating forward, or the side to side movement that happens when skiing.

The semi-circulatory canals help to detect angular movements. The best way to describe angular movements is where your ears move along with your head. If you notice with the utricle and saccules’ example, the ear stays in the same axis of motion.

YES! Explaining this in words is not easy.

vestibular rehab

At the ends of the canals are dilated crista endings called ampulla. Within the crista is embedded cupula within the membrane material of the labyrinth. As you can see nerve fibers and hair cells. The cupula and the canals have fluid called the endolymph.

As you move your head, the fluid bends away or to the canals. The direction of hair cells movement tells your inner ear and brain which direction your head is going. Your eyes will stay on target based on this input. If this is not happening, your eyes will follow the direction of your head movement. Your eyes tell your vestibular systems how to move your spinal core and neck muscles athletically.

They are called vestibular-ocular, vestibular-colic, and vestibular-spinal reflexes. They respectively tell your eyes, neck, and body-posture how to react.

These communication pathways happen fast.

There is a 90-100 pulse/second resting tonic contraction.

The hair cells of the cupula are the same weight as the endolymph. What this means is that vestibular input is not dependent on gravity or position. All vestibular symptoms that are coming from the semi-circular canals must be from accelerated movements!

An interesting trivia fact is that alcohol impacts the weight of the cupula. Because of this, the cupula becomes lighter than the surrounding endolymph. The cupula becomes displaced easily. The end feeling is the dizziness one will feel when consuming alcohol.

On top of the hair cells within the otolith organs are otoconia. The otoconia are called “crystals”, and have greater gravity weight than the endolymph. This is important for the management of a specific vestibular disorder called Benign Paroxysmal Positional Vertigo. The otoconia within the utricle become broken into smaller crystals and migrate into the cupula or canals. The medical terminology is respectively called based on where the otoconia reside: capulolisthiasis or canalisthiasis.

You use gravity to move the crystals back into the utricle.


A common sign that we use to know what is happening in your inner ear is called nystagmus. Nystagmus is a subconscious movement of the eye based on the inputs of your inner ear and brainstem.


In this picture, your right vestibular system is overstimulated or in a state of excitation. You turn your head to the right. Your eyes counter-rotate towards the far left so you can stay on the target directly in front of you. The brainstem realizes this and resets the reflex. Your eyes drift back to the right.

What you get is a fast-twitch of the eyes to the side of dysfunction and a slow-twitch of your eyes returning. This repeats from 10-60 seconds. You feel dizzy and crummy during this time. There is a time period at the beginning of the head movement that you do not get nystagmus. This is called latency and is due to the time of the otoconia drifting into the cupula or canals.

Based on other factors, in addition to the direction of nystagmus, we have to determine if you have a dysfunctional central or peripheral vestibular system. A central vestibular problem stems from the big brain itself, like a concussion.

Either way, the body is amazing at compensating to allow you to move to survive. This ancestral survivor adaptation makes it easy to suppress vestibular symptoms. It feels like you grow out of it.

Unfortunately, you are suppressing what needs to be optimized. The common lingering side-effects of a suppressed vestibular problem include vision deficits and/or muscular tension, tightness, or discomfort. The mild and constant tension reduces circulation and vital nutrients to the muscle.

The muscle works at less than 100%. This leads to strain or muscle tears when overworked and overwhelmed. An example is poor eye-hand or body-brain connection late into a basketball, football, or end of the day.

You feel tension so you stretch out more. Sometimes you can shake it off and there are times where you cannot. If your vestibular symptoms get suppress fast, it may feel like you are healthy and strong. You go back to your workout routine to feel the pain in a few months later.

We revealed, to many that seek our expertise in Holistic Sports Medicine Physical Therapy, that there is a vestibular dysfunction at play.


Each organ has a nerve that helps to communicate what it senses to the big boss aka the brain and brain stem. The brain tells your body how to move your neck and spinal “core” muscles. This is how neck or lower back pain can improve with vestibular rehab.

The cranial nerve 8, vestibular-cochlear nerve splits into the vestibular branch and cochlear branch. Hmmm… You can guess which nerve goes to which organ.

The Vestibular nerve further splits into superior and inferior branches. The superior part of the vestibular nerve connects and communicate what is happening at the utricle, anterior and horizontal semi-circular canal. The inferior branch communicates the input from the saccule and posterior part of the semi-circular canal.

For bonus trivia, the inner ear gets blood supply from the basilar artery. The importance of this is that if you have any vascular insult to the back of your head, it can impact your inner ear. The Basilar artery also keeps your brainstem alive and splits into an anterior and posterior branch. The posterior Vestibular artery supplies the posterior semi-circular canal, saccule, and cochlear organ. The anterior Vestibular artery supplies and keeps the anterior and horizontal semi-circulatory canal, and utricle healthy and functioning. A stroke to the latter artery cannot impact your hearing.