The balance system

The balance system works by coordinating information in your brain from the three senses used for balance:

1. your balance organ in your inner ear
2. your eyes
3. the internal sense of position/movement in your body.

If you feel dizzy, it means that your brain has not been able to coordinate the information from all the balance senses properly. This could be due to a problem in the brain or with any of the balance senses.

How does the balance system work?

In vestibular disorders (e.g. Ménière’s), the balance organ in the inner ear is affected. As the balance organ is faulty, the brain becomes more dependent on information coming from the eyes and sensors in your body. This makes you much more sensitive to situations which can cause dizziness, such as disorientating environments and times when you are under stress. Therefore, not all the symptoms of dizziness experienced will be due to the balance organ, some will be caused because your balance system cannot cope with the situation you are in.

How is my brain involved in balance?

When any of the information from your three balance senses changes or is incomplete, your brain has to adjust to the different information it is receiving and coordinate it to maintain balance (or as good a sense of balance as is possible). This is a gradual process and can take up to several weeks or even months for your brain to do, depending on how big the change in the information was, and how easy it is for your brain to coordinate the new and remaining information. Until this adjustment and re-coordination has happened, you may feel dizzy, disoriented or unsteady. Your brain can only adjust to and coordinate the information it is regularly receiving from the balance senses. If your brain does not receive enough information from the balance senses (i.e. if you avoid the activities which make you dizzy), these activities will continue to make you dizzy because your brain has not had a chance to get used to them. Your brain also cannot cope with inputs that are much more extreme than you are used to (such as a fast-spinning fairground ride) - or the sudden change in inputs from one balance organ that occurs when you have a severe attack of vertigo. During the days and weeks after a severe attack your brain adjusts to the change in input and you gradually feel less dizzy. Gently practicing all kinds of movements helps your brain adjust.

What processes in the brain can affect balance?

Conflicting information from the balance senses

Dizziness can be due to conflicting information coming from the three balance senses. For example, when you are sitting on a train and the train next to you starts to move, creating the feeling that you are moving. The senses in your body and balance organ are telling your brain that you are not moving, but your eyes are telling your brain that you are moving. This conflict of information results in dizziness, even in people who do not have any problems with their balance senses. Motion sickness is another example of conflicting information from the balance senses. When you are travelling in a car, boat, escalator or lift, the signals in your body (and your eyes if you cannot see through a window) tell your brain you are not moving, but your balance organ in your ear is telling your brain that you are moving.

Emotions and thoughts

When you feel particularly stressed, anxious, angry or fearful, you may be more likely to experience dizziness. This is because some of your body’s automatic reflexes are linked to your emotions and thoughts through a process called the “fight or flight” response. Your brain interprets any strong emotions or frightening thoughts as a signal that you are in danger, and automatically prepares your body to either fight or run away. This means that your heart rate increases and your breathing gets faster as blood is pumped to your muscles. A side effect of this is that you may feel sick or dizzy, since breathing too fast causes you to take in too much oxygen, which can make you dizzy.

Your emotions can also be directly influenced by your thoughts. If you think that dizziness will lead to further problems this can make you feel even more stressed or anxious when you become dizzy. This can make your dizziness worse by setting off your fight or flight response. Dizziness can cause problems of this kind, but it is important to keep the risks in perspective and not let yourself become too overwhelmed by these concerns.

The types of thoughts that have been found to lead to distress include:

• Dizziness will result in me being physically harmed
• If I get dizzy, it means I will let people down
• I will be embarrassed if I become dizzy in public
• Dizziness means I am going to have a severe vertigo attack.

Tiredness and concentration

When you are tired or doing things you have to think about, this can affect your balance. This is because your brain has a limited capacity for what it can attend to at any one time. If you are concentrating on a mental task, your brain has less capacity spare for other tasks, such as maintaining your balance. This is why you may be asked to carry out a mental task (such as counting backwards) during some balance tests. Doing the tasks limits the capacity of your brain to correct any problems with the signals it is receiving from your inner ear and allows health professionals to get a better idea of how well your balance organ is working. Because it takes mental effort and capacity for your brain to cope with conflicting information about balance, you may become tired and unable to concentrate when you are dizzy, and while your brain is adjusting after a vertigo attack.

Medication 

Some medications list dizziness as a side effect. If you take more than four different types of medication this may also cause dizziness and increase your risk of falling.

Alcohol

Alcohol can also cause dizziness. It suppresses certain processes within the brain including those responsible for balance.

Other medical conditions

Dizziness and imbalance can also be the result of damage to areas of the brain that coordinate balance and are often the cause of dizziness in people who have multiple sclerosis, stroke or Parkinsons disease.

How does my inner ear affect my balance? 

The balance organ in the inner ear senses gravity and movement. It is made up of three semicircular canals and two structures called otoliths. The organ of hearing (cochlea) is also in your inner ear.

What do the different parts of my balance organ do?

The three semicircular canals - the horizontal, the posterior and the anterior canals – are all at right angles to each other so that together they can detect movement across all the different angles you can move through. The ‘horizontal’ semicircular canal detects movements such as turning your head from left to right (e.g. when you are crossing the road). The ‘posterior’ and ‘anterior’ semicircular canals often work together and detect movements such as nodding your head up and down (e.g. when you are looking up at a high shelf) and tilting your head sideways (e.g. holding a phone between your ear and your shoulder). The two otoliths are called the utricle and the saccule. The utricle detects whether you are upright or lying down (using gravity), and the saccule detects whether you are moving forwards and backwards (e.g. in a car). 

How can they tell I am moving?

Each of the semicircular canals and the two otoliths are covered in tiny sensory hair cells. It is these hair cells that send balance signals back to the brain. The whole inner ear is filled with the endolymphatic fluid. The fluid moves around your inner ear when you move. The hair cells in your balance organ are activated to send signals to your brain when they are moved by this fluid.

How do health professionals tell what is going on in my inner ear?

Health professionals cannot see inside your inner ear, but your inner ear is connected to your eyes by a reflex process (called nystagmus). Different eye movements relate to different parts of your balance organ and brain. This is why some balance tests involve looking at how your eyes move. As your brain coordinates information from all three balance senses (balance organ, eyes, and sensors in the body) health professionals can also tell if your balance organ is not working properly by limiting the signals that can be sent from your eyes and sensors in your body. This is why some balance tests need you to close your eyes whilst standing on a wobbly surface or marching on the spot.

How is my inner ear affected by Ménière’s disease?

How are my semicircular canals affected?
Attacks of Ménière’s change the signals being sent from the semicircular canals in your balance organ. Experts do not know exactly how or why this happens, but several processes have been suggested that may or may not be involved. These include injury/physical changes within the inner ear, changes to the inner ear fluid (the endolymphatic fluid), or the result of an immune disorder. Other suggestions have been that it could be genetic and runs partly in families, or that it could be the result of a virus. Some experts think that there might even be different causes for different people, rather than one single cause for everyone who has the disease.

How are my otoliths affected?
Some, but not all, people with Ménière’s disease experience drop attacks (also called ‘otolithic crisis of Tumarkin’). A drop attack feels as if you are being pushed violently and suddenly, causing you to fall. The symptoms are usually gone as quickly as they appear, and you can get up straight away and carry on with whatever you were doing (unless you get a drop attack at the same time as an acute attack of vertigo). During these attacks, the hair cells on your otoliths in your inner ear are suddenly activated, causing your balance to be severely disrupted. Experts do not know how or why this happens. 

How is my hearing organ affected?
Your hearing organ (cochlea) is also in your inner ear (it looks a bit like a snail because it curls around. Like your balance organ, the hearing organ is also covered in tiny sensory hair cells and is filled with the same (endolymphatic) fluid. Different pitches of sounds are detected by different parts of your hearing organ. High pitched sounds are detected at the open end of your hearing organ, nearest your balance organ. Low pitched sounds are detected at the centre of your hearing organ (the part curled up most tightly). In Ménière’s, the sensory hair cells at the centre of your hearing organ are damaged first, causing tinnitus and hearing loss for low pitched sounds first. As the disease progresses, the hair cells on the rest of your hearing organ can also become damaged, eventually affecting your ability to hear all sounds.

Do loud sounds have an effect on my balance?
The damage to the hearing organ may cause some people with Ménière’s to become oversensitive to certain sounds. Sounds which don’t seem to bother other people may seem unpleasantly loud to you, and difficult for you to tolerate (The medical term for this is called hyperacusis). Sounds do not normally affect the balance organ; however, excessively loud sounds experienced over a long period of time may cause damage to the balance organ as well as the hearing organ. Rarely, some people with Ménière’s may also experience dizziness or vertigo symptoms when they hear loud noises; known as the Tullio phenomenon. This is thought to occur because Ménière’s makes the balance organ more sensitive to the effects of loud noises. The hearing loss that results from Ménière’s means you have to concentrate to make sense of the sounds you can hear. Having to concentrate to make sense of noise in busy environments can also limit the brain’s capacity to coordinate your balance.

Can I have more than one vestibular disorder at a time?

Yes. The most common type of vestibular disorder is BPPV and the second most common is vestibular migraine. Both these disorders are more common in people with Ménière’s than they are in the general population, which has led experts to suggest that there may be a link between these disorders.

How does vision affect the balance system?

In Ménière’s and many other balance disorders of the inner ear, your brain must rely more on your sense of vision to balance than people who do not have a balance disorder. As a result of this, your balance system can be more sensitive to confusing or disorienting information about balance coming from your eyes. Dizziness can therefore be triggered by complex or moving visual environments (this is sometimes called visual vertigo). These include busy places such as busy roads, moving crowds, or walking down the aisle of a supermarket where the shelves provide repetitive complex visual patterns. Other disorienting environments include travelling in a car or going up or down in a lift or an escalator. These sorts of environments quite commonly cause dizziness in people with inner ear problems.

What visual environments can affect my balance?

Not enough visual information
Your eyes get their information about which way up you are from the environment. Information is taken from vertical structures (e.g. buildings, trees and lamp posts). These vertical structures need to be quite close to you to be useful for your balance system. Several types of environments do not provide enough visual information for your brain to be able to use for balance and can result in dizzines and unsteadiness. The most obvious of these is at night when it is dark, or when you are somewhere with dim lighting. There is also not enough visual information nearby when you are in large, flat and open spaces (e.g. a field or park) or looking down from heights. Inaccurate visual information can also result in dizziness and unsteadiness. When you are travelling in a lift or on a boat without a view, for example, you don’t have accurate visual information about how you are moving, because your environment is moving with you. The balance organ in your inner ear can tell you are moving and sends conflicting information to your brain.

Too much visual information
The balance system can become overloaded when you take in more visual information than you’re used to dealing with. This visual information conflicts with inputs coming from your other balance senses. The types of environments that can provide too much visual information include:

• Motion: standing next to a busy road, watching a car chase on TV or being in a crowded place. This is because the continuous movement across your line of sight keeps sending new signals to your brain about your visual environment. These signals are an unreliable source of information for your balance system and it can become confused as to whether it is you or your environment that is moving. Slow moving environments can also trigger dizziness and unsteadiness, e.g. escalators. 

• Complex patterns: environments where there are repetitive or complex patterns can also overload the balance system with too much visual information, causing dizziness and unsteadiness. The most common environment like this is a supermarket with long narrow aisles that are stacked high with shapes and colours. Other environments include patterned floors or looking at stripy surfaces. 

• Flickering lights: just as darkness or dim lighting prevents your eyes from getting enough information, lighting that flickers also means that your eyes are not getting reliable information about your visual environment. Your brain has a limited capacity for what it can attend to at any one time, so a change in lighting, such as sunlight through trees or fluorescent lighting, means your brain has less capacity to co-ordinate your balance. This can result in dizziness and unsteadiness. Environments that involve flickering lighting include travelling in a car when the sun is shining through the trees or at night when the oncoming car headlights are flickering, and shops or other places that use fluorescent lighting. TV programmes and older computer screens can also flicker.

How does my body affect my balance?

Sensors in your skin, muscles and joints around your body send signals to the balance system about where all the parts of your body are - if they are moving and/or touching anything. Your balance will be better when sitting than standing. Standing on two feet will give you a better balance than standing on one, as more parts of your body will be sending signals to your balance system. Balance is also affected by the surface you are on. 

Types of surfaces that can affect balance include: 

• Moving or wobbly surfaces (escalator)
• Uneven surfaces (stony path)
• Slippery surfaces (wet or icy path)
• Sloping surfaces (hill)
• Narrow surfaces (walking on a beam)
• Soft surfaces (thick springy carpet or sand)

When fewer signals are being sent from your body, your balance system is more reliant on the signals from your eyes and balance organ - e.g. when riding a bicycle. Signals from your body are dramatically reduced because you are not in direct contact with the ground. The bicycle and pedals move and you are reliant on the narrow surface of two thin wheels. Regular exercise is important for maintaining flexibility and strength, which can help you to balance. The stronger and more flexible your muscles and joints are, the better you will be able to deal with different surfaces. 

 

Acknowledgments

Thank you to Professor L Yardley and Dr S Kirby, School of Psychology, University of Southampton, for kindly providing the information for this page.

Where can I get further information and support?

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Ménière's & Vestibular UK can provide general information, but is unable to provide specific medical advice. You should always check with your medical professional for information and advice relating to your symptoms/condition. Device links on this page are external. Ménière's & Vestibular UK can not recommend a particular manufacturer, product, device or organisation. Please speak with your medical professional to find the most suitable hearing aid/system to suit you.