Vestibular Healing Insights

Persistent Postural Perceptual Dizziness (PPPD): Understanding Diagnosis, Pathology, and Treatment Options

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McKenzie DiStefano
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Persistent Postural Perceptual Dizziness (PPPD) is a chronic vestibular disorder characterized by non-rotational dizziness, unsteadiness, and hypersensitivity to visual stimuli. While not life-threatening, it significantly affects quality of life, making it crucial for clinicians and patients to understand its diagnosis, pathology, and treatment options.

History of PPPD and Its Previous Names

The journey to recognizing PPPD as a distinct clinical entity spans several decades. Previously, similar presentations were described under various terms, reflecting partial understandings of the condition:

  1. Phobic Postural Vertigo (PPV) (1986):
    • Introduced by Brandt and Dieterich, PPV described dizziness and unsteadiness exacerbated by visual or postural stimuli without identifiable structural vestibular damage.
    • Symptoms often overlapped with anxiety or phobic disorders, but it was not exclusively psychological.
    • Reference: Brandt, T., & Dieterich, M. (1986). “Phobic postural vertigo.” Neurology, 36(4), 476–478.
  2. Chronic Subjective Dizziness (CSD) (2004):
    • Coined by Staab and Ruckenstein, CSD captured chronic dizziness and hypersensitivity to motion or visual stimuli following an acute vestibular episode. Unlike PPV, it highlighted the role of central sensory processing dysfunction.
    • Reference: Staab, J. P., & Ruckenstein, M. J. (2004). “Chronic subjective dizziness.” Archives of Otolaryngology–Head & Neck Surgery, 130(8), 1048–1054.
  3. Visual Vertigo:
    • A term used for dizziness induced by visually complex environments, such as crowded spaces or fast-moving scenes. While not identical to PPPD, visual vertigo is a common symptom within the broader PPPD spectrum.
  4. Functional Dizziness:
    • This term broadly described dizziness driven by functional neurological changes rather than structural damage, often linked with anxiety or maladaptive sensory processing.

In 2017, these overlapping syndromes were unified under the name Persistent Postural Perceptual Dizziness (PPPD) by the Bárány Society. This consensus acknowledged the shared underlying mechanisms, focusing on chronic symptoms, central sensory reweighting, and the condition’s functional nature.

Diagnosis Criteria for PPPD

The Bárány Society provided the following diagnostic criteria for PPPD:

  1. Chronic Symptoms: Persistent, non-rotational dizziness, unsteadiness, or both, lasting at least three months. Symptoms are present most days and may wax and wane.
  2. Triggering Events: Symptoms often begin after an acute vestibular disorder (e.g., vestibular neuritis, BPPV, or vestibular migraine) or a psychological stressor (e.g., panic attack).
  3. Exacerbating Factors:
    • Upright posture.
    • Active or passive motion (e.g., walking or riding in a car).
    • Exposure to visually complex or busy environments.
  4. Absence of Structural or Progressive Disease: There is no active vestibular, neurological, or structural cause.
  5. Psychological Overlap: Anxiety and depression often co-occur but are not the primary cause of the symptoms.
  • Reference: Staab, J. P., Eckhardt-Henn, A., Horii, A., et al. (2017). “Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the Bárány Society.” Journal of Vestibular Research, 27(4), 191–208.

Pathology and Physiology of PPPD

PPPD is a functional neurological disorder, meaning the symptoms are driven by abnormalities in brain function rather than structural damage. Key mechanisms include:

  1. Central Sensory Reweighting:
    • Normally, the brain integrates vestibular, visual, and somatosensory inputs for balance and spatial orientation.
    • In PPPD, over-reliance on visual and somatosensory input disrupts this balance, causing persistent dizziness and sensitivity to motion or busy environments.
  2. Autonomic Dysregulation:
    • Heightened activity in the autonomic nervous system leads to exaggerated fight-or-flight responses, which perpetuate dizziness during stress or visual overload.
  3. Cognitive and Emotional Influences:
    • Anxiety and hypervigilance amplify symptom perception and disrupt normal sensory processing.
  • References:
    • Dieterich, M., & Staab, J. P. (2017). “Functional dizziness: From phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness.” Current Opinion in Neurology, 30(1), 107–113.

Treatment Options for PPPD

PPPD requires a multidisciplinary approach that combines physical, psychological, and pharmacological interventions.

1. Vestibular Rehabilitation Therapy (VRT)

  • Tailored exercises help recalibrate the brain’s sensory systems by promoting habituation, balance retraining, and desensitization to visual triggers.
  • Consistent engagement is essential, as improvement may take weeks to months.
  • Reference: Hall, C. D., & Herdman, S. J. (2020). “Vestibular rehabilitation: An advanced approach to dizziness and imbalance.” Journal of Neurologic Physical Therapy, 44(3), 190–199.

2. Cognitive Behavioral Therapy (CBT)

  • CBT addresses maladaptive thoughts and behaviors that perpetuate symptoms.
  • It is particularly effective for reducing anxiety, hypervigilance, and avoidance behaviors.
  • Reference: Godemann, F., Siefert, K., Hantschke-Brüggemann, M., et al. (2005). “What accounts for vertigo in anxiety disorders?” Journal of Psychosomatic Research, 59(5), 391–400.

3. Medications

  • Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are commonly prescribed to manage central sensitization and comorbid anxiety.
  • Vestibular suppressants (e.g., meclizine) are generally avoided as they interfere with vestibular compensation.
  • Reference: Staab, J. P., & Ruckenstein, M. J. (2005). “Serotonin reuptake inhibitors for dizziness with psychiatric symptoms.” Archives of Otolaryngology–Head & Neck Surgery, 131(3), 219–225.

4. Lifestyle Modifications

  • Regular physical activity and gradual exposure to triggering environments promote neuroplasticity and symptom reduction.
  • Stress management techniques, such as mindfulness or yoga, reduce autonomic hyperarousal.

5. Patient Education and Support

  • Educating patients about their condition reduces fear and improves adherence to treatment.
  • Support groups and vestibular specialists can provide additional guidance.
  • Reference: Pavlou, M., & Davies, R. A. (2015). “The assessment and treatment of visual dependency.” Neuro-Otology Practice, 2(3), 109–116.

Conclusion

PPPD is a complex but treatable condition. Understanding its history, diagnostic criteria, and underlying mechanisms enables effective, individualized care. Combining vestibular therapy, cognitive strategies, and medication offers the best chance for recovery. Early intervention and consistent treatment can significantly improve outcomes.

If you or someone you know is navigating PPPD or a similar vestibular condition, reach out for support to regain your balance and quality of life.

References

  1. Brandt, T., & Dieterich, M. (1986). “Phobic postural vertigo.” Neurology, 36(4), 476–478.
  2. Staab, J. P., & Ruckenstein, M. J. (2004). “Chronic subjective dizziness.” Archives of Otolaryngology–Head & Neck Surgery, 130(8), 1048–1054.
  3. Staab, J. P., Eckhardt-Henn, A., Horii, A., et al. (2017). “Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the Bárány Society.” Journal of Vestibular Research, 27(4), 191–208.
  4. Dieterich, M., & Staab, J. P. (2017). “Functional dizziness: From phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness.” Current Opinion in Neurology, 30(1), 107–113.
  5. Hall, C. D., & Herdman, S. J. (2020). “Vestibular rehabilitation: An advanced approach to dizziness and imbalance.” Journal of Neurologic Physical Therapy, 44(3), 190–199.
  6. Godemann, F., Siefert, K., Hantschke-Brüggemann, M., et al. (2005). “What accounts for vertigo in anxiety disorders?” Journal of Psychosomatic Research, 59(5), 391–400.
  7. Pavlou, M., & Davies, R. A. (2015). “The assessment and treatment of visual dependency.” Neuro-Otology Practice, 2(3), 109–116.

Grounding Exercises for Vestibular Recovery and Symptom Management

Grounding exercises are an excellent way to help calm the nervous system, reduce dizziness, and improve balance by providing increased proprioceptive input to the body. These exercises are especially beneficial for individuals experiencing vestibular symptoms, as they help the brain recalibrate and better understand its position in space.

Exercise 1: Eyes Open, Feet Together with Weights

  1. Starting Position:
    • Stand with your feet together.
    • Hold small weights (or resistance bands) in your hands for added input.
  2. Breathing:
    • Focus on slow, deep breaths to calm your nervous system and reduce symptom intensity.
  3. Progression:
    • Step 1: Hold this position for 30 seconds, three times per session, a few times a day.
    • If your dizziness is above a 5/10, or this feels too challenging, stand with your back against a wall for added support and feedback.
    • Alternatively, place a weighted item (e.g., a microwaveable weighted beanbag) around your neck to provide additional proprioceptive input and grounding.
  4. Resistance Band Alternative:
    • Place a resistance band under your feet, holding the ends with your hands.
    • Ensure there is tension in the band to create feedback for your body.
    • Maintain the position with a focus on posture and controlled breathing.
  5. Progression Levels:
    • Gradually reduce external inputs (e.g., weights, wall support) until you can maintain the position without assistance.
    • Progress by standing with eyes closed.
    • Further advance by standing on a cushion or foam pad:
      • Eyes open → Eyes closed.
    • Add head turns (side to side, up and down) to increase difficulty.

Why This Exercise Works

  1. Increased Proprioceptive Input:
    • Using weights, resistance bands, or standing against a wall provides additional sensory input, helping your brain process where your body is in space. This can decrease symptoms of dizziness and perceived movement.
  2. Calming the Nervous System:
    • Focusing on deep breathing helps to regulate your autonomic nervous system, reducing the “fight-or-flight” response often associated with vestibular symptoms.
  3. Neuroplasticity and Symptom Reduction:
    • Gradually reducing inputs challenges your vestibular system, encouraging adaptation and improvement in balance and dizziness symptoms.

When and How to Use This Exercise

  • During Symptom Flares: This grounding technique can be particularly helpful on days when symptoms are heightened or when you first stand up in the morning.
  • Preventative Use: Performing this exercise regularly helps build resilience and improve overall vestibular function.

Have you tried this exercise? How does it work for you? Share your experience with me—I’d love to hear your feedback and answer any questions you have! Your insights help me continue refining tools to support you on your vestibular recovery journey. Let’s navigate this together!

McKenzie DiStefano PT/DPT

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