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Persistent Postural-Perceptual Dizziness (PPPD)

16 November, 2020


Persistent Postural-Perceptual Dizziness (PPPD)

Approximate reading time: 4 minutes

Persistent Postural-Perceptual Dizziness or PPPD is a common cause of dizziness in the middle aged. It significantly impacts day to day tasks - making everyday life very challenging.

PPPD Symptoms

  • More than three months of rocking, swaying unsteadiness and dizziness
  • Symptoms occur almost daily
  • Aggravated by movement, standing / sitting or complex visual environments
  • Relief with lying down
  • Frequently starts after an acute attack of:
    • Vestibular disorder such as BPPV or Ménière’s
    • Vestibular migraine
    • Panic attack with dizziness
    • Concussion or whiplash
    • Dysautonomia

PPPD Diagnosis

Diagnosis is made after excluding other causes - it's not a migraine, inner ear disease or anything else. This might include physical examination, blood tests and imaging.

These tests are all clear of pathology in PPPD patients.

PPPD Treatment Options

Medication for PPPD

Serotonin based drugs are frequently effective in reducing dizziness. They also help with the anxiety & depression experienced by up to 75% of PPPD patients.

Medication is generally required for at least a year.

Vestibular Rehabilitation for PPPD

The vestibular system is the inner ears. Responsible for balance and stability.

Training the vestibular system can reduce dizziness symptoms as well as associated anxiety & depression. Not only does it help with balance, but also moving about.

Vestibular Rehabilitation should be continued for 3 - 6 months.

Counselling for PPPD

Counselling is helpful for reducing the likelihood of developing ongoing issues when a balance disorder first starts.

If you’ve had PPPD for a while, it’s helpful for any anxiety and depression associated with it but not as much the dizziness.

Mechanisms of PPPD

It’s not known exactly what’s happening - yet. It’s believed to involve a number of functional factors:

  • Psychological components - with anxiety or depression affecting up to 75%
  • Altered sensory perception
    • Postural control
    • Visual processing
    • Vestibular processing
    • Pain perception

Functional disorders, such as PPPD, means that the structure of the brain, vestibular system and other balance areas are all intact. They just are a bit wonky in the way they work.

This is like a software glitch on a computer. The computer hardware (aka the keyboard, screen and processing unit) are all working. It’s just the software that needs an update or reboot.

Vestibular rehabilitation aims to update and reboot the vestibular system.


Summary

  • Persistent Postural-Perceptual Dizziness (PPPD) is a mismatch of sensory information
  • PPPD occurs almost daily for more than 3 months
  • Vestibular rehabilitation, medication and, in the early phases, counselling may help with the dizziness & associated anxiety / depression 

About the author:

Dr Cassie is a Chiropractor trained in neurological rehabilitation, vestibular rehabilitation, neurofeedback and functional brain scans. She’s suffered concussions as well as a vestibular disorder called Labyrinthitis. During this time, she would hold on to tables to avoid falling over. Those around her just saw her holding the table as she wasn’t moving at all!


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References

  • Holle D et al. (2015). Persistent Postural-Perceptual Dizziness: A Matter of Higher, Central Dysfunction? PLoS One. 2015; 10(11): e0142468. Published online 2015 Nov 16. doi: 10.1371/journal.pone.0142468
  • Staab JP. (2012). Chronic Subjective Dizziness. Continuum (Mineapp.Minn.). 2012 Oct; 18(5 Neuro-otology):1118-41.
  • Staab JP et al. (2017). Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research, vol. 27, no. 4, pp. 191-208, 2017. DOI: 10.3233/VES-170622
  • Persistent Postural-Perceptual Dizziness. World Health Organization, International Classification of Diseases (ICD-11). Accessed via http://id.who.int/icd/entity/2005792829