“Balance and Parkinson’s with Dr. Nate Coomer” – Webinar Notes Stanford PD Community Blog

In July 2026, the Northwest Parkinson’s Foundation (NWPF) hosted a webinar on how balance is affected by Parkinson’s disease (PD). Dr. Nate Coomer, a physical therapist who works daily with those with neurological conditions, discussed why people with PD are at higher risk for falls than those of similar age. He described what physical and environmental factors contribute to falls for people with PD, and shared strategies physical therapists use to help people with challenges such as freezing of gait and poor proprioception. He also reviewed some exercises that can be used at home to practice improving one’s balance.

A recording of the webinar is available on the NWPF Vimeo channel

These are the major points from the webinar:

Multiple factors inform balance, including the inner ear, visual feedback, and our proprioceptive system in our joints. These must work together to provide continuous corrections to our balance, whether we’re standing still or moving.
People may lose their balance or fall for a variety of reasons, including environmental tripping hazards, distractions, or sudden movements or impacts they can’t compensate for. Those with PD are at a much higher risk of falls than the general population, even when controlling for age.
PD progression affects many aspects of movement, from small motions to large ones. Freezing of gait is a particularly common challenge. PD can also affect someone’s sense of where they are in space, and prevent them from moving their eyes and head to accurately view their environment. These changes impair people’s ability to correct their balance and to catch themselves if they do fall.
Those with PD should work with a physical therapist to maintain their range of movement and balance. Generalized exercises can help with many issues, including building strength. For specific challenges such as freezing of gait, or a tendency to lean or fall in one direction over others, the expertise of a physical therapist is recommended.

You can find many resources for balance, fall prevention, freezing of gait, and exercise for those with PD on the Stanford Parkinson’s website:

If you are lucky enough to live in Northern or Central California, consider these in-person PD exercise classes and in-person fall prevention classes:

Nate Coomer founded the DailyDosePD, a subscription to online exercise videos you can use at home. Access is $34.99 per month.

Below are my full notes.

– Jordan

“Meet the Expert: Balance and Parkinson’s with Dr. Nate Coomer”

Speaker: Nate Coomer, DPT, NCS, physical therapist, The Parkinson’s Fitness Project in Seattle, Washington.

Webinar Host: Northwest Parkinson’s Foundation (NWPF)

Webinar Moderator: Jen Johnson

Webinar Date: Monday, July 14, 12pm

Summary by: Jordan Dagan, Stanford Parkinson’s Community Outreach

WHAT INFORMS OUR BALANCE SYSTEM

Inner ear (Vestibular system). Fluid in the inner ear moves as we do, which tells the brain where we are in space and how to make adjustments.
Visual feedback from seeing our own body, and from around us. As balance gets worse, looking down at surroundings and our own body is a compensation mechanism. Plus peripheral vision limitations, and dim or dark environments, contribute to falls.
Proprioceptive system in joints. Every joint, from hips to toes to fingertips, sends signals to the brain. The brain integrates these signals and interprets where we are in space.
Balance reactions are both static/staying still, and dynamic/moving. If someone trips or jumps, their dynamic balance reactions are what catch them. When someone stands still and something upsets their balance, static balance reactions are what prevent them from being pushed over.

HOW PD AFFECTS BALANCE

Bradykinesia can impair the small movements which help us correct our balance.

Decreased sense of proprioception, which is our sense of where someone is in space. Someone may not realize that they are leaning to one side, may not have a sense of whether the surface they’re standing on is stable, etc.

Decreased spatial awareness, often described as bumping into corners or furniture, especially when turning and stepping onto or off of curbs and steps. Someone may not know how much space they need to get around obstacles, especially in a tight space. Many people try to take shortcuts on the way to their goal, but run into the edges of objects instead.

Decreased awareness of posture. Someone may not realize they’re leaning or drifting to one side.

Slow reaction speed and rigidity each may make dynamic balance reactions too slow to catch someone, or inaccurate for what’s needed to catch someone.

Visual changes such as double vision reduce our ability to interpret our environment. The same muscles that control someone’s limbs control their eyes, affecting their ability to focus on one object, understand peripheral cues, understand depth, look at where they need to look in order to fix their balance, etc.

Impaired sense of center of gravity affects someone’s limits of stability. This is the maximum distance a person can intentionally shift their weight in any direction while maintaining their balance without needing support or to take a step.

Hesitancy and fear cause increased balance issues.

Freezing of gait, especially at thresholds, gait initiation as someone anticipates walking or begins to move forward, changes in flooring, and/or turning.

WHAT CONTRIBUTES TO FALLS

When falling becomes an issue, someone’s ability to travel and function is impacted. Their world can become very small, and quality of life is often affected.

Falls in those with PD are very common! Here’s some statistics:

48-63% of people with PD have at least one fall per year, which is three times higher than the general population, even controlling for age.
39% of people with PD are “recurring fallers” who average more than 20 falls per year. That’s a fall every couple of weeks!
1 in every 5 falls results in a serious injury for someone, such as a fracture or head injury.
Even if someone “learns how to fall,” they’re still at risk. The goal is to keep people on their feet.

Environmental hazards:

Crowded areas, whether with people or objects
Distracting environments and dual-tasking or task switching. Try to focus on your movement until you’re safely seated.
Dimly lit areas
Medication timing and “off-times.”

Most common reasons people fall, from an academic study by Drs. Chiba, Lidia, and Wlodzimierz in 2013:

31%: Sudden, unprovoked falls, such as when someone turns around quickly and can’t correct, or in a distracted environment.
20%: Freezing of gait and stuttering steps, especially impactful in small spaces and during transitions such as stepping on/off escalators or doorways.
12%: Neurological or sensory disturbances, such as vertigo.
12%: Environmental tripping hazards, such as tripping over sidewalks, tree roots, or objects left on the floor.
11%: Postural instability and loss of balance control.
4%: Orthostatic hypotension, a sudden blood pressure drop upon standing.
3.6%: Severe involuntary movements.

If you’d like to read more of this study, see: Causes and consequences of falls in Parkinson disease patients in a prospective study

WAYS TO IMPROVE BALANCE

Freezing of gait is best worked on with a physical therapist. This is a very individualized problem, and often requires one-on-one assessment and treatment.

A physical therapist can practice using visual prompts such as a laser pointer or tape on the floor, and internal prompts such as a countdown, to get out of a freeze or prevent one.
Reducing anxiety is an important part of preventing freezing. Feeling stuck and upset can make someone’s motions more jerky.
Try to reset yourself: don’t try to take a step all in one go. Shift your weight onto your heels so you’re stable and don’t fall forward. Then rock side to side to “unstick” yourself.

Shuffling gait, also called “festination.” This is usually a problem when people must cross small obstacles and uneven surfaces, such as rugs, roots, or cracked sidewalks. Physical therapists use “amplitude training” to help people practice making larger movements and steps. Practice larger steps in multiple directions, with the physical therapist providing guidance and encouragement.

With supervision and in a safe environment, practice exercising and moving while distracted, or while doing another task.

If you have orthostatic hypotension/blood pressure drops when standing up, go slowly! Give your body time to adjust when going from laying down to sitting, and from sitting to standing. Keep a hand on something to keep your balance, until you’re sure you’re steady, then begin walking. Stay hydrated throughout the day. Use compression garments to keep blood from pooling away from your head.

Start with establishing your ability to stand in one place, making static balance corrections.

Improve dynamic balance by practicing large movements.

Increasing strength with daily training and exercise.

Simulate the real world with your physical therapist, such as the tight spaces in a kitchen.

BEST EXERCISES AT HOME TO IMPROVE BALANCE

Strength training for hips, core and abdominals, and ankles:

Hip abductions: keeping your leg straight, lift it away from your center. This can be done laying on your side, or standing with something to hold onto for balance. If you want a greater challenge, loop a resistance band around your ankles.
Bird dogs: start on your hands and knees. Lift one arm, and the opposite leg. Repeat with the other pair of arm/leg.

Static balance practice:

With your back to a corner or next to a chair for safety, practice moving your feet together and apart. Practice putting one foot directly in front of the other.
With your feet in different positions, add nods and turns of your head and eyes. This challenges your visual system.

Dynamic balance practice:

With your back to a corner or next to a chair for safety, practice stepping with one foot, in any direction. Practice taking large steps with one foot that turns your body.
Practice standing from a sitting position, with repetitions.

Dual task training, either cognitive or manual:

Count your repetitions, or count your steps. Count by twos or fives, whatever is challenging for you.
Do your exercises while doing “word searches,” such as naming different fruits and vegetables, or pairing one word with left and one with right.
For a manual exercise, hold an object while you’re moving. Move a ball or pillow from one side of your body to the other. Practice holding a safe but heavy object, like a plastic jug with water inside, close to your body, and then extending your arms.
Challenge yourself to keep the same pace while distracted.
“Clock Yourself App” with lunges. The app helps you imagine a clock on the floor, and prompts you to step on different numbers (such as “3 o’clock” directly to someone’s right).

DO I NEED AN ASSISTIVE DEVICE?

That depends! It takes training with the patient and with their family, and knowledge of their home space, to make a decision. Some people are helped by a mobility aid, but some people are more at risk with the wrong one.

For example, if someone has poor spatial awareness and tries to use walking poles or a cane, they may trip over it. If someone has trouble slowing their steps down, and uses a four-wheeled walker, it might pull them farther forward or faster, increasing their risk.

QUESTIONS AND ANSWERS

Question: Do changes brought on by PD affect someone’s ability to drive?

Answer: Yes, especially slowed reaction speeds and decreased eye movement. Some patients first notice their symptoms when driving, especially backing into parking spaces. Driving evaluations should be done to make sure someone’s driving is still safe.

Question: My husband specifically falls backwards, sometimes multiple times per month. What can be done to help?

Answer: Limits of stability are affected with PD. Many people drift or lean in one direction more than any others. Physical therapy can provide one-on-one support.

Question: How does balance affect dizziness, and vice versa?

Answer: Vestibular system dysfunction can cause dizziness. Please talk to your doctor, and/or a vestibular specialist, if you’re regularly feeling dizzy, so they can investigate underlying issues.

Question: Does flooring color matter, or just a change in texture of the floor?

Answer: Both color and texture changes can have an impact! Some people may have challenges crossing color changes, whether they’re subtle shades or high-contrast. This may be made worse with increased anxiety; usually self-cueing helps, though it can take time to make it a habit.

Question: My loved one can “walk big” with the physical therapist and occupational therapist, but still struggles at home.

Answer: Sustained attention is another challenge. Being able to remember strategies you learned in therapy can be difficult. Ongoing therapy sessions are important, because carryover of practice and habits does reduce over time. It’s not the same as physical therapy post injury; PD doesn’t stop developing and changing.

Question: Once someone starts falling, are they more prone to falling?

Answer: Often, yes. If left unattended, falls do tend to get worse and more frequent. A fall is a sign that someone needs support to manage their mobility. Impaired confidence and reduced movement can further impair someone’s mobility.

Question: Could a U-Step be right for me?

Answer: The U-Step walker is a very stable and heavy walker, which shines a laser on the floor to act as a visible prompt for someone to move their feet and step over the lines. It’s designed to provide stability and help for shuffling and freezing of gait. They’re expensive, and may be too heavy for some people to use, or for their care partners to move around. One alternative may be trekking poles made for those with PD, with a very stable base and a special handle that provides leverage; one brand is Urban Poling. Another option may be shoes that vibrate to help prompt people to move.

Question: What advice do you have for those with neuropathy in the feet?

Answer: Avoid shoes with very thick soles, as these can make people feel more unsteady and less aware of the ground. Neuropathy takes away proprioceptive feedback that would usually come from the feet and ankles. Practice being aware of your surroundings, and use visual cues to help compensate.

“Balance and Parkinson’s with Dr. Nate Coomer” – Webinar Notes