Balance Beyond Dopamine: Let’s Deep Dive

Every person with Parkinson’s presents a unique set of challenges—what we refer to as impairments—that include freezing of gait, dizziness, poor posture, fatigue, falls, and most commonly: imbalance And here’s something many don’t realize: imbalance in Parkinson's is not only because of dopamine deficiency

Let’s try and understand this

The basal ganglia, a dopamine-dependent brain structure, helps generate vigorous, coordinated movements—especially automatic postural responses. When dopamine is low, those responses become slower and weaker. Picture this: you’re bent over pulling weeds in your garden. As you stand up, your body wobbles and you feel like you might fall forward. Normally, your brain would trigger a quick postural response to help you stabilize. In Parkinson’s, that response is delayed. The anticipatory postural adjustment is impacted which triggers imbalance. But there’s more to the story.

Balance is supported by more than just dopamine. Multiple areas of the brain and other neurotransmitters are involved:

• Brainstem pathways activate spinal muscles that keep us stable against gravity.

• The pedunculopontine nucleus (PPN), a brainstem structure, sends cholinergic signals essential for posture and gait. When this area degenerates (as it does in PD), transitions like rising from a chair or turning in bed become difficult.

• Other neurotransmitter systems—GABA, glutamate, serotonin, norepinephrine—also decline in PD. These influence attention, arousal, memory, coordination, and trunk control.

The Braak staging image above shows how Parkinson’s disease progresses through the brain. By Stage 3, the dopaminergic system is already affected. But other systems are too—which explains why balance issues persist even when dopamine medications seem to be working.

What’s the takeaway?

Train your balance—and keep training it.

Balance training not only helps improve strength and confidence, it also stimulates the non-dopaminergic systems that affect posture, coordination, and stability. This can be especially beneficial during periods when medication isn’t working optimally.

At Congruence Physical Therapy & Wellness, we view balance as a complex process. That’s why our strategies are highly individualized—designed to support your unique neural systems, movement patterns, and lifestyle goals.

Want to move more confidently with better balance and feel safer doing what you love?

Contact us to schedule a free consultation to learn more about our neurologically informed balance and vestibular rehab programs. References:

• Mancini, M., Horak, F. B., & Nutt, J. G. (2019). Balance dysfunction in Parkinson's disease: Basic mechanisms to clinical management. Elsevier. https://doi.org/10.1016/C2017-0-00054-X

• O’Gorman Tuura, R. L., Baumann, C. R., & Baumann-Vogel, H. (2018). Beyond Dopamine: GABA, Glutamate, and the Axial Symptoms of Parkinson Disease. Frontiers in Neurology, 9. https://doi.org/10.3389/fneur.2018.00806

• Bohnen NI, Albin RL. The cholinergic system and Parkinson disease. Behav Brain Res. 2011 Aug 10;221(2):564-73. doi: 10.1016/j.bbr.2009.12.048. PMID: 20060022; PMCID: PMC2888997.