Dizziness is a commonly reported symptom by people with Parkinson’s disease (PD). It is important to determine the source in order to treat the dizziness. In this October webinar hosted by Parkinson’s Wellness Recovery (PWR!), Shelley Hockensmith, a physical therapist and neurologic specialist, provides information about different types and sources of dizziness, the inner ear’s role in balance, and physical therapy’s role using vestibular rehabilitation.
PWR! is a research-based program that views exercise as medicine and a physiological tool for each individual’s journey with PD. You can learn more about PWR! and Shelly Hockensmith on their website.
If you live in Northern or Central California, contact the Stanford APDA Information & Referral Center for assistance in finding a physical therapist familiar with PD. See our “contact us” form.
If you live in other parts of the US, contact the APDA Information & Referral Center nearest you. Find resources here.
There is no link to rewatch this webinar, but I have taken notes on all of the information and demo exercises Shelley shared in this session.
— Cassandra Irizarry
Dizziness and Parkinson’s
Speaker: Shelley Hockensmith, Physical Therapist and Certified Neurologic Specialist
Webinar hosted by the Parkinson’s Wellness Recovery (PWR!)
October 21, 2020
Summary by Cassandra Irizarry, Stanford Parkinson’s Community Outreach
There are three categories of dizziness:
- Vertigo (the world feels like it’s spinning)
- Disequilibrium (sense of space is off; not sure where you are)
- Lightheadedness (common in PD hypotension)
When communicating your dizziness to your doctor, use some of the following qualifying questions to specify your symptoms, and advocate for yourself:
- Does it come suddenly?
- Or does it last all day long?
- Is it position related?
- How long has it lasted? How long do outbreaks last?
- YOU know your symptoms best.
Our body’s balancing system: how we know where we are
- Vision: where you are in relation to the world? Where is your horizon line?
- Vestibular system: inner ear; where your body/head is in space
- Somatic sensation: primarily perceived through feet, the sensation of the ground- is it hard? Soft? Tilted? These messages are important- our feet send signals to your head to communicate how to walk/proceed.
- In order to prevent falls, it is important we use all these systems the best that we can.
The Vestibular System: Vertigo and Disequilibrium
The vestibular system is part of the inner ear. It is the system responsible for sustaining our sense of balance and spatial orientation. There are two components to this system: the semi-circular canals, and the otoliths. Today, we’ll focus on the semi-circular canals, which signal rotational movements to the brain.
The semi-circular canals have a viscous fluid in them. If you move your head, the fluid moves- that’s how your head tells you’re facing in a certain direction. In the bulky area behind these canals sit the saccule and the utricle- think of them like a Jello mold with fruit on top. At the bottom of the jello are nerve fibers, and on the top are tiny crystals called otoconia. When your body moves faster or slower, these crystals move as well, triggering the nerve endings and signaling to your brain that you’re moving.
What happens when something goes wrong?
Benign Positional Paroxysmal Vertigo (BPPV):
- Intense spinning feeling- can be triggered by small movements like rolling in bed or looking back
- Dizziness comes from the dislodgement of inner ear crystals- when the head moves, dislodged crystals move, triggering inner ear sensors and sending mixed messages to the brain
Vestibular Neuronitis:
- A Herpes virus that attaches to the vestibular nerve
- Sudden onset: nausea, vertigo, vomiting
- May require treatment in a hospital
How BPPV is diagnosed and treated:
Therapy: A physician might ask you to lay down, and then watch your eyes for twitching when the inner eye is disturbed. The direction eyes are moving in tells which semi-circular canal is involved. Simple head maneuvers can be done to move the crystal back to where it’s supposed to be.
Balance clinics: If dizziness is a problem, it’s a good idea to check if it’s something with the inner ear.
Computerized dynamic posturography: BPPV can be diagnosed and treated using this method. For this test, the patient is tied into a harness so they can’t fall- the ground changes suddenly to test reflexes and balance.
Electronystagmography (ENG) or videonystagmography (VNG): These tests detect abnormal eye movement using either electrodes (ENG) or small cameras (VNG). By measuring involuntary eye movements while your head is placed in different positions or when the balance system is stimulated with water or air, these tests can help determine if dizziness is due to inner ear disease.
Vestibular exercises:
Each inner ear semi-circular canal has a pathway that senses movement. This pathway connects to the brain stem, which then connects to the eyeball muscles. This reflexive pathway allows you to stay focused on an object while moving your head. When this reflexive pathway is impaired, the world looks like a 90’s home video: the camera bounces when you walk, and your visual field is not stable. If you feel like something is off, then practice shaking your head to retrain the reflex to stay stable. This is called Vestibulo-ocular reflex (VOR) training.
Exercise 1:
Put your feet in good, full contact with the ground. If you can, sit with your back away from the backrest. Close your eyes. Now we have somatic sensation- feel your body in space, and be aware if you’re leaning or upright. Are you moving or steady? Feel the steady seat underneath you and the sensations letting you know where you are in space.
Now imagine driving down a busy road- stopping starting in traffic.
What would it feel like if you were cruising down the highway?
Open your eyes.
We just practiced using our vestibular and somatic system to feel where we are in space.
Exercise 2:
While standing, nod your head “yes” and then shake head “no.” Try this with your feet close together and then far apart to increase difficulty. This exercise uses the vestibular canals and the vestibular spinal system.
Exercise 3:
Close your eyes. Slowly turn your head to look over one shoulder, and then to look over the other. Slowly move your head back and forth. You may feel some extra movement by your feet. This exercise works on the vestibular spinal system. Depending on which side you move your head, it stimulates the left or right side of the muscles/reflex. Exercises like this that stimulate the inner ear system help you use that system better.
Exercise 4:
Stand with your feet apart. Tap your toes; wiggle your feet. Increase your awareness of what’s going on by your feet.
Gently test the limits of your stability. How far can you shift to the left? To the right? Feel how your weight distributes on each side. Now, do the same exercise using the balls of your feet. Shift your balance around in little circles, and feel your weight go from foot to foot.
If you feel a little unsteady during this exercise, it’s good to practice. This is a great exercise to do before going out, as it “wakes up” your somatic sensations. It can be done either wearing shoes or barefoot- it’s a good idea to do it both ways.
Seated exercises:
Power-ups:
Do these with your eyes open first. Sit with your legs apart, and then lean down and extend your arms so your fingers touch the ground.
Power twist:
Sitting with your legs apart, open your arms and twist your midsection to clap your hands on your left side. Return your arms to an open position, then twist to clap on your right side.
Stepping:
On a chair, lift your left leg up, and bring it out to your left side as if stepping over an imaginary basketball. Return your leg in front of you, stepping over the imaginary basketball once more. Repeat this motion with your right leg, on your right side as well.