Persistent
PPPD symptoms tend last for most of the day (though may change throughout the day) and occurs often daily. It must persist for at least three months.
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Understanding PPPD
Persistent Postural-Perceptual Dizziness (PPPD) is a term used to describe a chronic and persistent form of dizziness or unsteadiness that is typically triggered or exacerbated by changes in body position, especially when standing or moving.
The name helps to describe the condition:
Postural
Changes in body position, such as standing up or moving the head, can trigger or worsen symptoms.
Perceptual
There may be abnormalities in perception, such as feeling like the ground is moving, or a sense of swaying or rocking when stationary.
Dizziness
Individuals with PPPD experience a sense of dizziness (without vertigo), light-headedness or unsteadiness often provoked by complex or motion-rich environments.
Persistent Postural-Perceptual Dizziness (PPPD) has undergone changes in name and diagnostic criteria over the years. The condition was previously known as Chronic Subjective Dizziness (CSD). The evolution in terminology reflects a better understanding of the underlying mechanisms and the need for more precise diagnostic criteria.
In 1991 the term "chronic subjective dizziness" (CSD) was introduced by Dr. Michael Baloh and colleagues to describe patients with chronic dizziness who did not fit neatly into existing diagnostic categories. It wasn’t until 2014 that the International Classification of Vestibular Disorders (ICVD-3) recognized and defined Persistent Postural-Perceptual Dizziness (PPPD) as a distinct diagnostic entity. The new term was introduced to encompass the characteristic features of chronic dizziness, particularly the postural and perceptual components.
PPPD Symptoms
The symptoms often involve a combination of physical and perceptual disturbances. Here are the key symptoms associated with PPPD:
Chronic Dizziness or Unsteadiness: Individuals with PPPD experience a continuous or near-continuous sense of dizziness or unsteadiness. This sensation persists for most of the day, and symptoms may be present daily.
Postural Triggers: Changes in body position, especially when moving from a lying or sitting position to a standing position, can trigger or worsen symptoms. The dizziness may be more pronounced when standing or walking.
Perceptual Disturbances: Abnormalities in perception are common in PPPD. This may include a feeling of swaying, rocking, floating, or being on uneven ground even when stationary. Visual disturbances, such as difficulty focusing or sensitivity to visual stimuli, may also be present.
Symptoms Worsened by Upright Posture: Symptoms tend to be exacerbated when the individual is in an upright position and may improve or resolve when lying down.
Associated Symptoms: Individuals with PPPD may experience other symptoms such as headaches, fatigue, and difficulties with concentration. There may be a heightened sensitivity to motion, visual stimuli, or busy environments.
Persistent Nature: PPPD symptoms persist for at least three months, contributing to the chronic nature of the condition.
Impact on Daily Functioning: The symptoms of PPPD can significantly impact daily activities and may lead to avoidance of certain situations or activities due to fear of exacerbating symptoms.
What Causes PPPD?
PPPD often occurs after an acute vestibular or balance disorder. Typically, the acute dizziness will resolve, but ongoing dizzy symptoms will persist, leading to PPPD. The original vestibular disorder can include:
Labyrinthitis
Vestibular neuritis
Meniere’s disease
Stroke
POTS (postural orthostatic tachycardia syndrome) or other autonomic nervous system dysregulation
After an initial vestibular event takes place, the brain will develop compensation strategies to address dysfunction or vestibular loss. There are three major systems that help us with balance: our vestibular, vision and proprioception systems. It is suspected with PPPD that there is a disruption in the sensory integration of these three systems, often resulting in vision being more heavily relied on. The consequence is over utilization of this system which can result in sensory conflict when exposed to visually complex and motion-rich environments.
Psychological factors, such as anxiety or stress, may also play a role in the development and maintenance of PPPD. Emotional distress can heighten sensitivity to symptoms and affect an individual's ability to cope. In addition, central sensitization can occur, which refers to an increased responsiveness of the central nervous system to stimuli. In the context of PPPD, this heightened sensitivity results in early alarm bells within our brain, resulting in dizziness being experienced more often and with less triggers. The interplay between vestibular and psychological factors in PPPD is very complex, and both aspects may contribute to the chronicity of symptoms.
How is PPPD Diagnosed?
Diagnosis is typically made based on clinical criteria, as there is no specific test for PPPD; for example it will not be present on imaging or bloodwork. Rather, PPPD is determined during an initial examination with careful consideration of a patient’s medical history, evolution of symptoms, current symptoms, physical examination findings, and the elimination of other diagnoses. That being said, PPPD can present alone or co-exist with other conditions, so working with a qualified healthcare provider familiar with PPPD is important.
How is PPPD Treated?
The management of PPPD typically involves a multidisciplinary approach:
Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy (VRT) is designed to promote central nervous system compensation for inner ear deficits and improve balance and stability. If PPPD is caused by an acute vestibular disorder which resulted in a vestibular loss, VRT first works to address this vestibular dysfunction and utilize specialized exercises to promote recovery of the vestibular apparatus.
From here, individualized exercises will be prescribed based on the presentation of PPPD in that individual. It may work on habituation, where the brain becomes accustomed to certain movements or positions that trigger dizziness. It may also involve sensory reweighting, where we work to increase utilization of the vestibular and proprioception systems and reduce over-reliance on the vision system. VRT also works to reduce sensitivity to visual motion using specialized exercises adapted for each individual based on tolerance. Overall, PPPD presents in different ways for everyone, and thus a customized program with proper dosing and progression is essential for good recovery.
Medication
SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) have been use successfully in patient with PPPD. Clinical trials show reduced symptoms in 80% of patients over a 12-week period, however a full year of medication use is recommended to avoid relapses. Patients who did not respond to one SSRI tended to respond to the other, making the overall success of these two medications high. If the PPPD exists in conjunction with another disorder, such as vestibular migraines, migraine medications may also be helpful.
Counseling, Cognitive-Behavioural Therapy (CBT)
Counseling, particularly CBT, can be an essential component of the multidisciplinary approach to treating PPPD. Anxiety is commonly associated with PPPD, and individuals may develop fear and avoidance behaviors related to activities or situations that trigger dizziness. CBT can help individuals identify and challenge maladaptive thought patterns and fears, promoting more adaptive coping strategies. Counseling may involve exposure therapy, where individuals gradually and safely expose themselves to activities or situations that trigger symptoms. This helps in desensitizing the individual to these triggers over time. Counselors can also work with individuals to develop effective coping strategies to manage symptoms and reduce the impact of PPPD on daily life. This may include relaxation techniques, mindfulness, and stress management.
Individuals with PPPD should work closely with their healthcare professionals to determine the most appropriate treatment plan for their specific situation. The physiotherapists at Healing Vertigo have treated PPPD successfully and we welcome you to reach out with questions you may have about treatment. Book a free 15-minute consultation to get started today!
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Disclaimer: This advice is not meant to be a substitute for advice from a medical professional regarding diagnosis, prognosis, or treatment. Always seek advice from your physician, physiotherapist, or other qualified healthcare provider with questions you may have regarding a healthcare condition. The information of this website and email, including but not limiting to text, graphics, videos, images, and other materials are for informational purposes only. Reliance on the information on this website and email is soley at your own risk.