A Complex Coordination of Central and Peripheral Systems

By the Vestibular Disorders Association, with contributions by Mary Ann Watson, MA, and F.
Owen Black, MD, FACS
Good balance is oten taken or !ranted. Most
"eo"le don#t ind it diicult to walk across a
!ra$el dri$eway, transition ro% walkin! on a
sidewalk to !rass, or !et out o bed in the
%iddle o the ni!ht without stu%blin!.
&owe$er, with i%"aired balance such
acti$ities can be e'tre%ely ati!uin! and
so%eti%es dan!erous. Sy%"to%s that
acco%"any the unsteadiness can include
di((iness, $erti!o, hearin! and $ision
"roble%s, and diiculty with concentration
and %e%ory.
What is balance?
Balance is the ability to %aintain the body#s
center o %ass o$er its base o su""ort.
)
A
"ro"erly unctionin! balance syste% allows
hu%ans to see clearly while %o$in!, identiy
orientation with res"ect to !ra$ity, deter%ine
direction and s"eed o %o$e%ent, and %ake
auto*%atic "ostural ad+ust%ents to %aintain
"osture and stability in $arious conditions
and acti$ities.
Balance is achie$ed and %aintained by a
co%"le' set o sensori%otor control
syste%s that include sensory input ro%
$ision ,si!ht-, "ro"rioce"tion ,touch-, and the
$estibular syste% ,%otion, e.uilibri*u%,
s"atial orientation-/ integration o that
sensory in"ut/ and motor output to
the eye and body %uscles. 0n+ury, disease, or
the a!in! "rocess can aect one or %ore o
these co%"onents.
Sensory input
Maintainin! balance de"ends on inor*%ation
recei$ed by the brain ro% three "eri"heral
sources1 eyes, %uscles and +oints, and
$estibular or!ans ,Fi!ure )-. All three o these
sources send inor%ation to the brain in the
or% o ner$e i%"ulses ro% s"ecial ner$e
endin!s called sensory receptors.
Input from the eyes
Sensory rece"tors in the retina are called rods
and cones. When li!ht strikes the rods and
cones, they send i%"ulses to the brain that
"ro$ide $isual cues identiyin! how a "erson is
oriented relati$e to other ob+ects. For
e'a%"le, as a "edestrian walks alon! a city
street, the surroundin! buildin!s a""ear
$ertically ali!ned, and each storeront "assed
irst %o$es into and then beyond the ran!e o
"eri"heral $ision.
Input from the muscles and joints
2ro"rioce"ti$e inor%ation ro% the skin,
%uscles, and +oints in$ol$es sensory
rece"tors that are sensiti$e to stretch or
"ressure in the surroundin! tissues. For
Vestibular Disorders Association www.vestibular.org 2a!e ) o 3
e'a%"le, increased "ressure is elt in the ront "art o the soles o the eet when a standin! "erson
leans orward. With any %o$e%ent o the le!s, ar%s, and other body "arts, sensory rece"tors
res"ond by sendin! i%"ulses to the brain.
4he sensory i%"ulses ori!inatin! in the neck and ankles are es"ecially i%"ortant.
Sensory inor%ation about %otion, e.uilibriu%, and s"atial orientation is "ro$ided by the $estibular
a""aratus, which in each ear includes the utricle, saccule, and three se%icircular canals. 4he utricle
and saccule detect !ra$ity ,$ertical orientation- and linear %o$e%ent. 4he se%icircular canals,
which detect rotational %o$e%ent, are located at ri!ht an!les to each other and are illed with a
luid called endoly%"h. When the head rotates in the direction sensed by a
2ro"rioce"ti$e cues ro% the neck indicate the direction in which the head is turned. Cues ro% the
ankles indicate the body#s %o$e%ent or sway relati$e to both the standin! surace ,loor or !round-
and the .uality o that surace ,or e'a%"le, hard, sot, sli""ery, or une$en-.
Input from the vestibular system
"articular canal, the endoly%"hatic luid within it la!s behind because o inertia and e'erts "ressure
a!ainst the canal#s sensory rece"tor. 4he rece"tor then sends i%"ulses to the brain about
%o$e%ent. When the $estibular or!ans on both sides o the head are unctionin! "ro"erly, they
send sy%%etrical i%"ulses to the brain. ,0%"ulses ori!inatin! ro% the ri!ht side are consistent
with i%"ulses ori!inatin! ro% the let side.-
Integration of sensory input
Balance inor%ation "ro$ided by the
"eri"heral sensory or!ans5eyes, %uscles
and +oints, and the two sides o the
$estibular syste%5is sent to the brain
ste%. 4here, it is sorted out and inte*
!rated with learned inor%ation
contributed by the cerebellu% ,the
coordination center o the brain- and the
cerebral corte' ,the thinkin! and %e%ory
center-. 4he cerebellu% "ro$ides
inor%ation about auto%atic %o$e%ents
that ha$e been learned throu!h re"eated
e'"osure to certain %otions. For e'a%"le,
by re"eatedly "racticin! ser$in!
a ball, a tennis "layer learns to o"ti%i(e
balance control durin! that %o$e%ent.
Contributions ro% the cerebral corte'
include "re$iously learned inor%ation/
or e'a%"le, because icy sidewalks are
sli""ery, one is re.uired to use a dierent
"attern o %o$e%ent in order to saely
na$i!ate the%.
Processing of conflicting
sensory input
A "erson can beco%e disoriented i the
sensory in"ut recei$ed ro% his or her eyes,
%uscles and +oints, or $estibular or!ans
sources conlicts with one another. For
e'a%"le, this %ay occur or e'a%"le, when
a "erson is standin! ne't to a bus that is
"ullin! away ro% the curb. 4he $isual
i%a!e o the lar!e rollin! bus %ay create
an illusion or the "edestrian that he or she
5rather than the bus5is %o$in!. &owe$er,
at the sa%e ti%e the "ro"rioce"ti$e
inor%ation ro% his %uscles and +oints
indicates that he is not actually %o$in!.
Sensory inor%ation
"ro$ided by the $estibular or!ans %ay
hel" o$erride this sensory conlict. 0n
addition, hi!her le$el thinkin! and
%e%ory %i!ht co%"el the "erson to
!lance away ro% the %o$in! bus to look
down in order to seek $isual conir%ation
that his body is not %o$in! relati$e to
the "a$e%ent.
Motor output
As sensory inte!ration takes "lace, the
brain ste% trans%its i%"ulses to the
%uscles that control %o$e%ents o the
eyes, head and neck, trunk, and le!s,
thus allowin! a "erson to both %aintain
balance and ha$e clear $ision while
%o$in!.
Motor output to the muscles and joints
A baby learns to balance throu!h "ractice
and re"etition as i%"ulses sent ro% the
sensory rece"tors to the brain ste% and
then out to the %uscles or% a new "ath*
way. With re"etition, it beco%es easier
or these i%"ulses to tra$el alon! that
ner$e "athway5a "rocess called
facilitation5and the baby is able to
%aintain balance durin! any acti$ity.
Stron! e$idence e'ists su!!estin! that
such syna"tic reor!ani(ation occurs
throu!hout a "erson#s lieti%e o
ad+ustin! to chan!in! %otion en$irons.
4his "athway acilitation is the reason
dancers and athletes "ractice so
arduously. 6$en $ery co%"le' %o$e%ents
beco%e nearly auto%atic o$er a "eriod o
ti%e.
For e'a%"le, when a "erson is turnin!
cartwheels in a "ark, i%"ulses trans%itted
ro% the brain ste% inor% the cerebral
corte' that this "articular acti$ity is
a""ro"riately acco%"anied by the si!ht o
the "ark whirlin! in circles. With %ore
"ractice, the brain learns to inter"ret a
whirlin! $isual ield as nor%al durin! this
ty"e o body rotation. Alternati$ely,
dancers learn that in order to %aintain
balance while "eror%in! a series o
"irouettes, they %ust kee" their eyes i'ed
on one s"ot in the distance as lon! as
"ossible while rotatin! their body.
Motor output to the eyes
4he $estibular syste% sends %otor control
si!nals $ia the ner$ous syste% to the
%uscles o the eyes with an auto%atic
unction called the vestibulo-ocular reflex.
When the head is not %o$in!, the
nu%ber o i%"ulses ro% the $estibular
or!ans on the ri!ht side is e.ual to the
nu%ber o i%"ulses co%in! ro% the let
side. When the head turns toward the
ri!ht, the nu%*ber o i%"ulses ro% the
ri!ht ear increases and the nu%ber ro%
the let ear decreases. 4he dierence in
i%"ulses sent ro% each side controls eye
%o$e%ents and stabili(es the !a(e durin!
acti$e head %o$e%ents ,e.!., while
runnin! or watchin! a hockey !a%e- and
"assi$e head %o$e%ents ,e.!., while
sittin! in a car that is acceleratin! or
deceleratin!-.
The coordinated balance system
4he hu%an balance syste% in$ol$es a
co%"le' set o sensori%otor*control
syste%s. 0ts interlacin! eedback %echa*
nis%s can be disru"ted by da%a!e to one
or %ore co%"onents throu!h in+ury,
disease, or the a!in! "rocess. 0%"aired
balance can be acco%"anied by other
sy%"to%s such as di((iness, $erti!o,
$ision "roble%s, nausea, ati!ue, and
concentration diiculties.
4he co%"le'ity o the hu%an balance
syste% creates challen!es in dia!nosin!
and treatin! the underlyin! cause o
i%balance. Vestibular dysunction as a
cause o i%balance oers a "articularly
intricate challen!e because o the
$estibular syste%#s interaction with
co!niti$e unctionin!,
7
and the de!ree
o inluence it has on the control o eye
%o$e%ents and "osture.