What is Persistent Postural Perceptual Dizziness (PPPD)?
Persistent postural perceptual dizziness (PPPD or 3PD) is a common cause of chronic vertigo and dizziness. Patients diagnosed with this condition often complain of ongoing vertigo, unsteadiness and/or brain fog which is present for most days for at 3 months or more. Affected individuals feel worse when upright, exposed to complex or moving visual stimuli and during active or passive head movements. In most cases, PPPD is usually triggered after an acute episode of vertigo which can be caused by:
- BPPV
- Vestibular migraine
- Vestibular neuritis
- Menieres Disease
- Head trauma
- Anxiety/depression
- Panic attacks
Patients often report ongoing vertigo and dizziness for months even after the original triggering event has resolved.
Diagnosis/Symptoms
PPPD is a chronic and complex vestibular condition. Symptoms experienced often vary person to person. The following is a widely accepted diagnostic criteria for PPPD by the Barany Society. All criteria need to be fulfilled for a diagnosis to be provided. To diagnose PPPD, it is often a process of elimination where assessments are performed to rule out any other vestibular conditions.
Adapted from Bárány Society diagnostic criteria for persistent postural-perceptual dizziness
- One or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for at least 3 months
- Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity
- Symptoms need not be present continuously throughout the entire day
- Persistent symptoms occur without specific aggravator factors. Symptoms are exacerbated by 3 factors: upright posture, active or passive motion without regard to direction or position and exposure to moving stimuli or complex visual patterns (i.e busy shopping centres/aisles)
- The disorder is triggered by events that cause vertigo, unsteadiness, dizziness or problems with balance, including acute, episodic or chronic vestibular conditions, other neurological or medical illnesses and psychological distress.
- Symptoms cause significant distress or functional impairment
- Symptoms are not better accounted for by another disease or disorder
Why did I develop PPPD
Patients often develop PPPD following an alarming or distressing event. These can involve injury to the balance system (such as vestibular neuritis, vestibular migraine, or BPPV), physical (head trauma) or psychological trauma (anxiety, panic attack).
It is hypothesised that during the first initial event, your brain becomes more sensitive to stimulus and causes the brain to sense the surroundings abnormally. Your brain normally processes information from your inner ear (vestibular) system, your somatosensory (what you feel through your feet, body) and your vision. Your brain goes into this “crisis mode” and becomes hypervigilant in detecting self and environment motion. Often people become more visually dependent for their balance and rely less on the two other systems (vestibular, somatosensory).
In patients with PPPD, even after the initial event is over, their brains fail to return back to normal processing and remains in this “hypervigilant mode” which results in symptoms of vertigo, light headedness and unsteadiness to last longer. It is uncertain what the cause of this is, however, it is found that people who have anxiety and/or depression are more likely in developing PPPD.
PPPD suffers then start to avoid activities/motion that they know will make their symptoms worse. This is often detrimental and can make your symptoms. Balance is a skill. If you do not USE IT you will LOSE it. For example, if you know turning your head quickly to look left and right make you dizzy, you start to avoid it. You are now no longer challenging your balance when your head moves, and over time these skills decrease. The next time your try turnsyour head quickly, your body and brain becomes more sensitive to it, and the symptoms are worse so you continue to avoid it. Then this vicious cycle continues and causes your symptoms to worsen over time.
Treatment
Often the most important aspect to treatment is having the diagnosis of PPPD. There are no scans that can diagnose PPPD. It is often done by a qualified vestibular clinician through a detailed history and balance and oculomotor assessment. From there a individualised exercise program will be provided to perform aimed to improve your vestibular system and start desensitising your brain and nervous system to movement.
With PPPD, the best evidence is for a multi-disciplinary approach meaning you may be required to see specialists and psychologist to assist with rehabilitation. This may be the cause if your brain is extremely motion sensitive or there is a large psychological aspect to your symptoms. Some patients may require medications once vestibular rehabilitation has commenced, if they are slower or not progressing. Often rehabilitation progresses at a slower rate (may take a few months of rehab) compared to other conditions but people do get better!
If you have had any of these symptoms mentioned above or you tick quite a few boxes whilst reading this,we recommend you book in with a vestibular physiotherapist to get down to the root cause of your conditions and return you living life.
John Ma
Vestibular Physiotherapist
