The COVID-19 pandemic has left a lasting impact on the health of many individuals. A persistent set of symptoms, known as post-acute sequelae of COVID-19 (PASC) or Long COVID, affects millions. Among the most disruptive symptoms are issues related to balance and stability. People often experience unsteadiness, lightheadedness, or spinning that significantly interferes with daily life. Understanding the underlying science is the first step toward effective management and recovery.
The Spectrum of Balance-Related Symptoms
Balance problems after infection manifest in several distinct ways. One common complaint is vertigo, the sensation of spinning or whirling, linked to a malfunction within the inner ear or the brain’s processing of inner ear signals.
Another frequently reported symptom is dizziness or lightheadedness, described as feeling woozy, faint, or on the verge of passing out. Unlike vertigo, this sensation is often related to systemic issues, such as fluctuations in blood pressure or heart rate. The feeling of being unsteady on one’s feet, called gait instability or disequilibrium, is also common. This unsteadiness makes walking difficult and increases the risk of falling.
Underlying Causes of Post-COVID Instability
The complexity of post-COVID balance issues stems from the virus’s ability to affect multiple bodily systems. One major pathway involves the vestibular system, the body’s primary balance sensor located in the inner ear. The virus or the resulting inflammatory response can directly damage the inner ear structures or the vestibular nerve, known as labyrinthitis or vestibular neuronitis. This damage disrupts the signals sent to the brain about head position and movement, leading to vertigo and disequilibrium.
A second cause is autonomic dysfunction, often referred to as dysautonomia, which includes conditions like Postural Orthostatic Tachycardia Syndrome (POTS). The autonomic nervous system controls involuntary functions, such as heart rate, blood pressure, and digestion. In dysautonomia, this system is compromised, leading to orthostatic intolerance—a sudden drop in blood pressure or increase in heart rate upon standing. This failure to regulate blood flow to the brain is a direct cause of lightheadedness and dizziness.
The SARS-CoV-2 virus has neurotropic properties, meaning it can affect the Central Nervous System (CNS). This can result in neuroinflammation or direct viral entry into areas like the brainstem, which processes balance information. Dysfunction in these brain regions can cause central vertigo or persistent postural perceptual dizziness (PPPD), where patients feel chronic unsteadiness that worsens in visually complex environments. General deconditioning and fatigue also play a role in instability. Severe, prolonged illness and muscle weakness require the body to work harder to maintain posture and gait, which can compound the feeling of unsteadiness and increase the risk of falls.
Identifying the Source Through Medical Testing
Pinpointing the exact cause of post-COVID balance problems requires specialized diagnostic testing, often coordinated by neurologists or otolaryngologists. Vestibular testing, such as Videonystagmography (VNG), uses cameras to track eye movements during different maneuvers. VNG includes caloric testing, where warm and cool air or water are placed into the ear canal to stimulate the inner ear. Abnormal eye movements (nystagmus) or a reduced response during these tests can indicate damage to the inner ear or the vestibular nerve.
To diagnose autonomic dysfunction, clinicians perform tests like the Tilt Table Test (TTT) or an Active Standing Test. During a TTT, the patient lies flat on a table that is tilted upright while heart rate and blood pressure are continuously monitored. A significant increase in heart rate or a drop in blood pressure confirms a diagnosis of POTS or other forms of orthostatic intolerance. Imaging like MRI or CT scans are often performed as part of a standard neurological exam to rule out other serious conditions.
Targeted Rehabilitation and Recovery Approaches
Effective recovery relies on treatment approaches tailored to the specific underlying cause identified through testing. For those with confirmed inner ear or vestibular nerve damage, Vestibular Rehabilitation Therapy (VRT) is the standard of care. VRT involves specific, repetitive exercises, such as gaze stabilization drills and habituation exercises, designed to retrain the brain. The goal is to encourage the brain to compensate for faulty signals from the inner ear, improving balance and reducing vertigo symptoms.
When the problem is primarily due to autonomic dysfunction, the focus shifts to autonomic management strategies. These approaches often involve lifestyle changes to increase blood volume, such as increasing fluid and salt intake. Wearing compression garments can help prevent blood from pooling in the lower extremities, improving blood flow to the brain. Specific medications may also be prescribed to regulate blood pressure and heart rate.
For all patients, general physical therapy plays a role in recovery by addressing secondary issues. This therapy focuses on improving muscle strength, endurance, and confidence in movement. Physical therapy helps individuals improve gait stability, reduce the fear of falling, and regain their independence.