PT on the Net Research

Why Your Client’s Back Pain Keeps Returning: The Vestibular System

In the health and fitness world THE most commonly encountered limitation in training is spinal pain, immobility or lack of stability. In fact, low back pain is the most ubiquitous “musculoskeletal” pain experienced around the world and is the leading cause of disability in Americans under 45 years old (AAPM Facts and Figures on Pain, 2014).

Think back over the last month and there is a high likelihood that you’ve had at least one client miss a session entirely because of spinal pain. Or, their training session required tons of regressions because of some type of spinal complaint.

With this being the case, it would be logical to assume that there have been tremendous breakthroughs over the last 50 years in dealing with spinal pain. Unfortunately, this is not the case! The truth is that despite increasingly sophisticated imaging techniques and exercise protocols, MANY health and fitness clients continually struggle with chronic spinal issues.

And, as we are all aware, one definition of insanity is, “Doing the same thing over and over while expecting a different result.” Perhaps it is time for us to begin thinking about spinal complaints from a broader perspective.

Learning Objectives:

  1. Understand the basic anatomy and function of the human vestibular system.
  2. Explore the role of the vestibular system in maintaining appropriate flexion/extension synergy in the spine.
  3. Learn basic assessment techniques to evaluate the influence of the vestibular system on back stability and mobility.

Let’s Think Differently

One glaring problem in the current approach to dealing with spinal compromise is the ongoing insistence on evaluating and working with the back as a mechanical system rather than a NEUROmechanical system. The fact is that there is far more going on than meets the eye when we discuss something like spinal mobility, stability and strength.

Spinal movement is a complex symphony of muscular activation and inhibition combined with the ongoing influences of the spinal structures themselves (vertebrae, ribs, etc), fascial tension planes, dermal adhesions, etc. And, most importantly, all of these structures are in a virtually continuous state of flux and adaptation as we move and are forced to continually re-orient against gravity.

As a result, it is a bit naïve and reductionist to always attempt to point to one muscle, one joint, or one biomechanical entity as the SOLE cause of the complaint; whether that be blaming all of a client’s back pain on a disk injury or blaming their inability to perform a plank on poor abdominal strength. While those answers may be a part of the story, they are almost never the full story…

Meet the Vestibular System

If you are going to assess and work with clients with spinal complaints it is imperative to have a working knowledge of the human vestibular system because it plays a key role in the spinal movement symphony (Herdman & Clendaniel, 2014).

Also known as your inner ear, the human vestibular system is one of the most brilliant bio-engineering marvels on the planet. It also happens to be one of the “oldest” portions of human anatomy and its pathways, because they are related to stabilizing our vision and body and orienting us against gravity, are among the first to undergo myelinization while we are still in utero (Tecklin, 2007). What does all of that mean? It means it’s a really, really important system!

How Does It Work?

The vestibular system has two primary “divisions:”

  1. The Semicircular Canals
  2. The Otolith Organs (Utricle and Saccule)

Working together, these two divisions comprise 5 different receptors on each side of your head that work conjointly to keep you upright and moving through the world efficiently and safely.

The Spinal Complaint Connection

When you delve into the neurology of the vestibular system you are quickly going to encounter two different pathways from the inner ear into the body. These pathways are called the lateral and medial vestibulospinal tracts. Let’s take a quick look at their functions:

Lateral Vestibulospinal Tract – This tract projects ipsilaterally down the spinal cord (e.g., the right inner ear projects down the right side of the body) and helps maintain balance and posture by stimulating EXTENSOR MUSCLES of the spine and lower extremity (Fitzgerald, Gruener & Mtui, 2012). Just think about how often you have told clients they REALLY need to work on their POSTERIOR CHAIN!

Medial Vestibulospinal Tract – This tract is found only in the cervical spine and above. It projects bilaterally down the spinal cord and is particularly involved in controlling the neurons associated with the spinal accessory nerves (Cranial Nerve XI),which innervate the trapezius and sternocleidomastoid muscles. These muscles are prime movers and stabilizers of the head and neck in flexion, extension, lateral flexion and rotation. As a result they are intrinsically related to both neck stability and mobility. And, if you spend any time evaluating necks and shoulders for a living, you know that they are OFTEN dysfunctional and overly tense. Additionally, this tract also projects upward and helps keep the eyes “yoked” together during rapid head movement, so you can keep your eyes on a target even as you move. This makes the medial vestibulospinal tract intimately tied to both head- and whole-body orientation and posture (Fitzgerald, Gruener & Mtui, 2012).

Are you starting to get a sense that this system might be implicated in some spinal issues?

Imagine this scenario: You are a young, active, mid-30’s office worker who likes to workout and play basketball on the weekend. During a game, your legs are cut out from under you and you take a hard fall, landing on your shoulder and banging your head a bit. Soon after, you begin to experience chronic neck and upper back tension and pain that interfere with your workouts and results in headaches when you spend a long day working on the computer. You see different professionals that provide temporary relief via a wide range of modalities but you never seem to fully heal… because the potential underlying cause of this neck and back tension hasn’t yet been addressed.

If this sounds like a familiar story, you may be hearing a desperate plea from your body and nervous system for a vestibular assessment!

Next Steps

Once you begin really looking at the massive impact of the vestibular system on movement, it becomes a virtual certainty that you are going to want to include some base level assessments and drills into your work with clients, as well as know how and when to make an appropriate referral. Because this is such a complex topic, please refer to the video that coincides with this article for examples of starting points that you can use with your clients. Stay tuned for Part 2 of the video...

For now, let me STRONGLY encourage you to begin an educational process for yourself around the complexities of the vestibular system. Both research and experience have shown that vestibular deficits often co-exist and are potentially causative in a wide variety of issues that seem far removed, including:

As I have mentioned in a previous article, (, in the emerging neuroscience of exercise and movement – understanding the neural contributors to movement efficiency is key, and this is especially important when we are dealing with the spine. The vestibular system is one of the primary players in this process and deserves special attention and training as a result

Adding basic vestibular assessments and training to your work is a fantastic service to your clients that will benefit almost any training environment and continue to set you apart as a movement professional. Good luck!


American Academy of Pain Medicine Facts and Figures on Pain. (2014). Retrieved from

Fitzgerald, M.J., Gruener, G & Mtui, E. (2012). Clinical neuroanatomy and neuroscience (6th ed.). Elsevier Limited.

Herdman, S.J., & Clendaniel, R. (2014). Vestibular rehabilitation (4th ed.). F.A. Davis Company.

Tecklin, JS. (2014). Pediatric physical therapy (5th ed.). Baltimore, MD: Lippincott Williams & Wilkins