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by Giacomo Silvestri    MScPT   FCAMPT
Vestibular Physiotherapist
updated June 14, 2021


What is PPPD or Persistent Postural-Perceptual Dizziness?

Persistent Postural-Perceptual Dizziness (also known as PPPD and 3PD) is a condition which causes non-spinning dizziness and unsteadiness provoked by environmental or social factors.  For some individuals, PPPD can cause chronic dizziness following an acute bout of dizziness or vertigo.  Persistent Postural-Perceptual Dizziness is fairly rare, with a UK study showing that 15-20% of dizziness patients (4% of the general population) were experiencing symptoms consistent with 3PD.

Persistent Postural-Perceptual Dizziness was previously known as Chronic Subjective Dizziness (CSD) and was given as a diagnosis when a patient experienced dizziness symptoms without any positive objective tests for a condition.

It is now seen as the most common vestibular condition affecting people in the 30-50 age group and the second most common diagnosis for all vestibular patients.

 

What triggers or causes PPPD?

In most cases, PPPD starts after an acute event that causes dizziness, imbalance, vertigo etc.  It is commonly noted as ongoing dizziness symptoms that occur after an original dizziness issue has resolved. Some of these original precipitating events include:

  • BPPV
  • Vestibular neuritis
  • Meniere’s disease
  • Other peripheral or central vestibular disorders
  • Stroke
  • Vestibular migraine
  • Panic attacks with dizziness
  • Concussion/Whiplash (and other mild traumatic brain injuries)
  • Disease of the autonomic nervous system (e.g. orthostatic/postural hypotension)

Other medical conditions, like heart dysrhythmias and adverse drug reactions that occur along with acute episodes of dizziness, are less common triggers of PPPD.  

The underlying causes of PPPD are still under investigation. However at this time, it appears that there is a failure of the central postural control centres of the vestibular system to properly adapt once the acute issue has resolved. 

In plain English, let’s say you contracted a case of vestibular neuritis with the usual dizziness, imbalance, and motion sensitivity that comes with it. Then over several weeks, the neuritis improves and a physical evaluation shows that you have no positive tests. You don’t quite feel as bad as you did but you still have some symptoms of unsteadiness and difficulty in busy environments. And on top of this, you started to develop some anxiety that you had not experienced in the past. With PPPD, your brain was not able to completely adapt to the head movement and physical activity that normally allows you to calibrate your balance when you have a condition like a neuritis. In essence, you have healed from your vestibular neuritis, in an improper, asymmetrical manner.

 

What are the symptoms of PPPD?

PPPD is a complex/chronic vestibular condition that should be thoroughly examined and diagnosed by a medical professional.  The following list describes the required criteria to label a condition as Persistent-Postural Perceptual Dizziness.  

1.  One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo, present on most days for three or more months:

  • Symptoms last for prolonged periods of time, but may change throughout the day.
  • Symptoms do not need to be continuous throughout the day.

2.  Symptoms occur without specific aggravating factors, but are exacerbated by:

  • Upright posture
  • Active or passive movement regardless of direction and/or position
  • Looking at moving objects or viewing complex patterns

3.  PPPD symptoms causes the individual to experience significant distress or functional impairment.

 

How is PPPD Diagnosed?

There is no specific test or study that can diagnose PPPD. It does not show up on brain scans, blood work or laboratory balance tests. 

Rather, 3PD is is determined by a careful consideration of a patient’s medical history, current symptoms, the course of the condition over time and the elimination of other diagnoses (both vestibular and non-vestibular). 

All of the diagnostic criteria listed above for PPPD must be met in order to diagnose the condition.  3PD symptoms are very similar to those of other vestibular conditions, which can further complicate the diagnosis.  Be sure to talk to a trusted healthcare professional, like the Vestibular Physiotherapists at Cornerstone, to ensure the accuracy of your diagnosis.

A diagnosis of 3PD is only considered if symptoms are not better accounted for by another disease or disorder.

 

Does anxiety cause PPPD?

While anxiety is typically not a common event that causes PPPD, panic attacks or generalized anxiety disorders account for 15% of the triggers for the disorder.  Interestingly, panic attacks and generalized anxiety are two of the conditions that are most commonly associated with 3PD. 

Anxiety is a risk for factor for getting PPPD, as well as depression and those with introverted personalities. Those with higher levels of anxiety also have higher risks of longer recovery times, usually due to poorer brain compensation and reliance on avoidance strategies to manage symptoms. A recent study showed:

  • 60% of patients with PPPD had clinically significant anxiety
  • 45% of patients with PPPD had clinically significant depression
  • only 25% of patients had neither.

 

PPPD Treatment

Since 3PD is complex and is influenced by many different factors, treatment must be tailored to the individual and typically requires several different interventions to make meaningful, long lasting change.

Vestibular Rehabilitation Therapy

In the treatment of PPPD, Vestibular Rehabilitation Therapy (VRT) aims to desensitize patients to motion stimulation which produce symptoms.  As with all vestibular conditions, treatment for PPPD must be individualised and there is no “one-size-fits-all” approach.

The most recent research has show that VRT:

  • Reduces the severity of symptoms by 60%-80%
  • Increased mobility and daily functioning
  • May be effective in reducing anxiety and depression in PPPD patients

The evidence suggests that patients should continue VRT for a minimum of 3 to 6 months to achieve the maximum benefit.  A VRT treatment program should be started and progressed slowly under the supervision of a vestibular therapist to control symptom flare-ups.

Medication

SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) have been used with success for patients with PPPD.  While good clinical trials are few in number, smaller studies have shown a 50% reduction in symptoms in 80% of patients who used these medications for at least 8-12 weeks.  Treatment using SSRIs and SNRIs usually needs to continue for one year to minimize relapses.  Research has also shown that Benzodiazepines and vestibular suppressants (such as Serc or Betahistine) are not effective as a primary treatment for PPPD.  

It’s important to remember that starting or modifying the dose of medication should be performed under the supervision of a licensed medical professional like a Physician, Nurse Practitioner or Pharmacist.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) has been shown to have an additional positive effect when used as part of a multidisciplinary approach that included Vestibular Rehabilitation and medication.  One study showed that 3/4 of patients noticed a 6-month improvement in symptoms after just three sessions of CBT.  Another small study showed that CBT led to an improvement in postural behaviours (balance) in patients experiencing 3PD symptoms.  Furthermore, CBT has been shown to help patients reduce the fear and anxiety associated with the loss of balance experienced with PPPD.

Overall, the research shows us that a combination of treatments will lead to the best results for patients experiencing symptoms of  Persistent Postural-Perceptual Dizziness.  Be sure to consult a qualified vestibular rehabilitation professional to better understand which approach is right for you.

 

Will PPPD go away?

As we mentioned earlier, Persistent Postural-Perceptual Dizziness is an incredibly variable condition, and therefore its course of recovery will be different for every individual.  Those experiencing 3PD often wait several years before receiving a diagnosis.  Scientific evidence suggests that patients with PPPD will continue to be symptomatic for a significant period of time even after the start of treatment.  This same research indicates that symptom control of 3PD is likely for most and complete improvement for some is possible.

Persistent Postural-Perceptual Dizziness is a complex and evolving condition, which requires the expertise of a multidisciplinary healthcare team.  While complete symptom resolution may not be possible for all, vestibular rehabilitation coupled with counselling and a pharmacological approach has been shown to improve symptoms for most people with the condition.


The vestibular physiotherapists at Cornerstone Physiotherapy have successfully treated Persistent Postural-Perceptual Dizziness since 2008. Our clinics are located in Toronto, North York and Burlington. Contact us for a free consultation to see if our treatment program is right for you.

 

REFERENCES:

  1. The most common form of dizziness in middle age: phobic postural vertigo]. Strupp M, Glaser M, Karch C, Rettinger N, Dieterich M, Brandt TNervenarzt. 2003 Oct; 74(10):911-4. 
  2. Popkirov S, Staab JP, Stone J.  Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizzinessPractical Neurology 2018;18:5-13. 
  3. Staab, Jeffrey P. et al. ‘Diagnostic Criteria for Persistent Postural-perceptual Dizziness (PPPD): Consensus Document of the Committee for the Classification of Vestibular Disorders of the Bárány Society’. 1 Jan. 2017 : 191 – 208. 
  4. Persistent Postural-Perceptual Dizziness 
About the author

Giacomo Silvestri

Physiotherapist Learn More about Giacomo Silvestri

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