May: Dizziness and Dysequilibrium

The inner ear: an overlooked looked system critical for balance control

Ignite Neuro Fitness
May 10, 2025

This month at ignite we are adding exercise challenges to work on dizziness and its role in imbalance for people with Parkinson’s. This is a topic that is near and dear to my heart. In my physical therapy practice I love working with patients with vertigo and dizziness. This is partially because it is a fascinating system, but also because therapy is very effective at improving these problems.

I want to start with a little anatomy education. You all have likely heard of this system as the inner ear, but it is formally known as the vestibular system. This is one of our forgotten senses (yes we have more than 5 senses) and one of our most critical senses for balance. The vestibular system is made up of 3 fluid filled canals and one jello mold with crystals on top. Really! I am not making this up! There are nerve endings that sense fluid movement through the canals and near the jello mold when move our head, accelerate, and change position relative to gravity. These nerve endings send this information to our brains and also to our posture and lower body muscles so that we can react appropriately. And all of this happens without us being aware of it. Is that not fascinating?

Now you know what the vestibular system is, but why is this relevant for people with Parkinson’s? We know that imbalance is a common complaints and falls are a large risk for many people with Parkinson’s. Impairments in vestibular function are often neglected as a contributor to this issue.

In a recent review article they noted that studies show that 83% of people with PD were found to have vestibular impairments with testing and at least 43% of them also complained of dizziness. They also reported that there is association found with vestibular dysfunction and balance, sleep disruption, freezing of gait, and changes in posture including bending to the side.

Before we dive further into this topic, I think it is important to take a moment to discuss Neurogenic orthostatic hypotension. This is one of the most common reasons for dizziness for people with Parkinson’s, but is not related to vestibular dysfunction. This is a phenomenon leading to a drop in your blood pressure when you move into standing. If the number gets low enough this leads to less blood flow to your brain and a feeling of lightheadedness. If it drops low enough orthostatic hypotension can lead to fainting. You can easily self assess for this issue at home by taking your blood pressure in sitting and then again in standing. If the blood pressure drops by >20 mmHg for the top number and/or >10 mmHg for the bottom number then that is a positive test. It is important to complete testing over a few days to see if this is a consistent pattern. If it is then please discuss with your neurologist. Other suggestions are to increase hydration, avoid quick position changes, and wear compression.

Let’s get back to dizziness and imbalance from the vestibular system now. More importantly, let’s discuss what you can do to improve this. In this systematic review about vestibular rehab therapy for people with Parkinson’s they found that although more research is definitely need, there was significant improvements in balance and dizziness with vestibular rehab. Another study also found that vestibular rehab also had significant improvement on fatigue. Lastly, completing vestibular rehab can also significantly help reduce the sensation of dizziness (unrelated to blood pressure issues), which is fairly common complaint for people with PD.

Now it is time to teach you all a little vestibular exercise that you can perform at home. Please keep in mind that sometimes starting to work on these types of exercises can initially cause some dizziness while you are doing them, but do not fear, this typically improves rather quickly. Below are examples of vestibular exercises that help improve dizziness, balance with turning, balance with head movements, and posture awareness especially with movement.

Lastly, I would like to take a moment to talk about positional vertigo. Those of you that have felt true vertigo know it and never want to feel it again. It is very alarming and disorienting and can make people immediately fall to the ground, become motion sick, and even vomit. The most common reason for vertigo is called BPPV (benign positional paroxysmal vertigo). This occurs when those crystals sitting on top of the jello mold we discussed early become dislodged and fall into the fluid filled canals. Then when you change position and that fluid moves it continues moving longer than it should due to the extra weight in the canals. This gives you the sensation that your head is continuously turning, ie vertigo. Studies show that 5% of the general population can get BPPV, but that statistic increases to 11% for people with Parkinson’s. There has also been new research showing that people over 65, especially with neurologic disorders, sometimes begin to lack the ability to sense vertigo. Instead they will report feeling “off balance, brain fog, fatigue, etc” They found that >40% of people that were tested without complaints of vertigo had positive testing for BPPV. Thats a lot of people with balance issues walking around out there with a disorder that has a very quick fix! That’s right…We can fix BPPV with a simple maneuver that takes no more that 5 minutes. It is extremely effective. Below is a picture of the epley maneuver, the most common maneuver to fix BPPV. It can be performed at home with someone helping, but we would prefer you visit your physical therapy for assessment and treatment so they can identify which canal is involved as that changes which maneuver is completed.

I hope this newsletter inspires you all to integrate vestibular challenges into your exercise routine. If you are something with Parkinson’s who also has dizziness or even vertigo that reach out to your neurologist and ask for a new PT referral. Make sure you shcedule with a physical therapist who is educated in vestibular rehab. In the meantime use these as part of your weekly balance exercise program. And most of all, keep movnig.

We will be starting an educational series on May 31st for people with Parkinson’s and their carepartners. This will be a 4 part course that breaks down the Parkinson’s Foundation exercise recommendations. We will be starting with reviewing and given evidence for Aerobic exercise. If interested people join us in person or virtually with the link below.

In person: https://ignte.as.me/?appointmentType=70259794

Virtual: https://ignte.as.me/?appointmentType=70259801

As always please feel free to share this newsletter with anyone you think will benefit and reach out with any questions.

The more your move your head, the stronger your inner ear

Laura

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