Persistent postural perceptual dizziness (PPPD) is a condition where you feel constantly dizzy or unstable. Some people describe it as motion sickness, feeling lightheaded, off balance or swaying. Like walking on your “sea legs” on land, all the time. PPPD is now used to describe chronic subjective dizziness, space and motion discomfort, and visual vertigo. This unsteadiness is worse when upright, moving and in busy environments, while it mostly feels better when lying down in a dark, quiet space. People who suffer from PPPD often have trouble navigating busy shopping centres, watching 3D movies or attending concerts with big crowds. Vestibular rehabilitation targets the vestibular, visual and somatosensory systems to better integrate what you experience and keep you safe.

Balance is dependent on your eyes, body and ears, like a tripod. How the brain interprets the sensory information it receives from sight, proprioception and the vestibular apparatus determines if you can pirouette, land steady from a back flip or navigate the supermarket aisles without bumping into other customers.

Maintaining your balance is no easy task, just look at how clumsily a baby takes his/hers first steps. It involves the integration of sensory information. Messages from your ears, eyes, and body are processed by your brain to choose a strategy that keeps you standing. This all happens within milliseconds, as a reflex. The more options you have, the less likely you’ll fall.

The vestibular system in the inner ear detects head movements and changes in velocity, while the eyes provide visual cues and receptors in your joints and muscles send proprioceptive information. Your brainstem and cerebellum process this information and coordinate muscle activity to keep you upright and stable. If one of your sensory systems provides inaccurate information, the central nervous system will rely more heavily on the others to maintain stability.

Persistent postural perceptual dizziness is a physiological disorder, so you won’t find structural damage that explains all your symptoms on imaging/videonystagmography. This processing problem of your central nervous system, the brain and cerebellum, has psychological consequences. It is normal to feel scared when you experience an acute vestibular mismatch with vertigo, dizziness and nausea. If you are over anxious, avoiding movement because of fear and expect a negative outcome months after your symptoms started, you create the perfect storm for your brain to become hypervigilant, “I cannot trust balance information anymore, I’ll have to be on high alert all the time”. If your brain takes this strategy, any movement, busy environment, unstable surface or busy backgrounds can worsen your symptoms.

If you suffer from persistent postural perceptual dizziness you feel dizzy when moving, overwhelmed in busy environments, like shopping malls, motion sick on car journeys, avoid travel by boat or airplane, dread driving on the high way, feel unsafe when navigating rough terrain or walking in the dark. You probably decline invitations to concerts/games with big crowds, find excuses to not attend family gatherings or meeting friends. You are so afraid of falling that you are avoiding living.

PPPD is a functional vestibular disorder, meaning the dizziness comes from how the brain processes balance and motion signals, not from a structural problem that can be “fixed”, like a femur neck fracture can be repaired with an intramedullary nail.

The issue lies in maladaptive central integration between the visual, vestibular, and somatosensory systems. Your brain essentially becomes “over-alert” to motion and balance cues and interprets these cues as dangerous. Patients with PPPD fMRI shows overactivity in brain regions that process motion, balance, and threat, their vestibular nuclei, insular cortex, and limbic system light up more when exposed to balance and motion that someone without chronic dizziness.

This can happen after an acute vestibular event (like BPPV, neuritis, or even concussion) when some people’s brains fail to “reset” to normal sensory weighting. Your brain then remains hypervigilant to motion, leading to persistent dizziness, unsteadiness, and visual motion sensitivity. This hypervigilance is reinforced by anxiety pathways, keeping the brain in a state of high sensory gain and postural stiffness.

PPPD is usually precipitated by a distressing medical illness or neurological/vestibular disorder, like:

• vestibular neuritis
• BPPV
• vestibular migraine
• Meniere’s Disease
• transient ischemic attack

The problem is that the symptoms remain even if the initial causative problem is resolved, PPPD continues without structural pathology. Chronic dizziness can also be diagnosed concurrently with other vestibular, cardiac, autonomic or neurological condition, like:

• Postural Orthostatic Tachycardia Syndrome (POTS)
• cardiac arrhythmias
• cerebellar lesions
• concussion or other head trauma
• medication interaction
• anxiety disorder

PPPD is a chronic state that develops after these initial triggers have resolved/healed and typically does not include any asymptomatic periods.

What makes some people develop PPPD and others not?

The severity of the initial vestibular damage does not predict the development of PPPD. What does influence your risk profile is high anxiety after the event, dependant personality traits, autonomic dysfunction, increased body vigilance and visual dependence. Hypertension and carotid artery atherosclerosis also increases your risk of developing chronic dizziness.

This makes early intervention after any vestibular insult very important, so that maladaptive behaviours are completely avoided.

Answering yes to the following questions may be an indication that your symptoms are caused by chronic postural dizziness:

• Have your symptoms been present for more than 3 months?
• Do your symptoms include dizziness, unsteadiness and non spinning vertigo?
• Is your dizziness present most of the time?
• Is your symptoms worsened by being upright, in motion, or during exposure to visual motion/complex visual patterns?
• Are your symptoms relieved by lying down or less visually busy environments?
• Does your dizziness last hours to days after being exposed to a triggering event?
• Are you very worried about your symptoms?
• Does your symptoms cause limitation in your everyday life?

Because of the nature of persistent postural perceptual dizziness being a functional problem, no quantifiable evidence will be found on imaging were the severity of what you are experiencing can be graded. We therefor work with how badly your symptoms are influencing your ability to work, participate in your hobbies or care for your family. We make use of the Dizziness Handicap Inventory to determine how much disability you are experiencing because of your symptoms. As a general guide, a score of 16-34 indicates mild handicap, 36-52 moderate handicap and a score above 54 severe handicap. Your treatment program and frequency of visits will be influenced by this score.

PPPD may co-exist with other vestibular pathology, like Meniere’s Disease or Uncompensated Vestibulopathy, in these cases you may experience other types of dizziness and vertigo attacks that will make your chronic dizziness worse.

We make use of a bedside evaluation at the practice, which means all the balance and movement tests will be done by you in the treatment room. This, with your history will guide us in determining where in your balance trio (eyes, ears or proprioception) you are experiencing the most trouble. Our physiotherapists understand how these different systems work together and how one influences the other. We will then be able to guide you during your PPPD treatment journey.

Symptoms present for at least 3 months, including:

• dizziness
• unsteadiness
• non spinning vertigo

Dizziness is present most of the time

Worsened by being upright, in motion, or during exposure to visual motion/complex visual patterns

Relieved by lying down or less visually busy environments

Symptoms may last hours to days after exposure

Characterised by significant distress and functional impairment caused by dizziness

Symptoms are not better accounted for by any other disease, but can co-exist with the disease that initially caused vertigo.

An audiogram, or hearing test, may be done to rule out hearing loss accompanying your dizziness. Videonystagmography (VNG) can be performed by specialist audiologist to compare left and right vestibular function. With PPPD these studies are normal if not accompanied by other co-existing pathology.

An MRI/CT scan can view all of the structures around your inner ear and brain. These are expensive studies that can only be ordered by your specialist. It may be done to rule out any other pathology that may be causing your dizziness, but is not necessary to get before starting your chronic dizziness rehabilitation. If your physiotherapist suspects anything else to be the cause of your symptoms, you will be referred to the right specialist.

Capacity vs load

This idea of how much load a tendon/muscle can manage is similar when we consider your chronic postural dizziness. The less you do to avoid your symptoms, the less you’ll be able to do next week, next month, next year. If you don’t use is, you’ll definitely lose it! By gradual exposure we aim to get your brain’s amazing neural plasticity to reframe your idea of possible triggering events and recreate pathways that you can trust. This is where the experience of your rehab team is of the essence, without causing some delayed onset of muscle stiffness, you won’t get stronger muscles. Without touching the barrier of your dizziness and attempting some things you have avoided, we won’t increase your capacity. Always be honest with what you fear can happen, so that we can address this during your treatment.

Decompensation

This phenomenon can occur whenever your body is under more strain than it can handle that affects your bio-rhythms. Fighting a cold, bad night’s sleep, eating unhealthy, having a few too many drinks can all cause a relapse in symptoms that will make anyone feel demotivated. But this effect is reversed whenever one these basic bio-rhythms are restored. No need to fear that you are back where you started from.

Misdiagnosis

Most general practitioners treat vertigo as a diagnosis, and not the symptom it is. For many healthcare practitioners, any positional vertigo is diagnosed as BPPV. This may lead to patients not getting the right intervention early on during their treatment.

Misconceptions about treatment

Chronic postural dizziness is there most of the time. Treatment is aimed at understanding your diagnosis, managing your symptoms and broadening your capacity so that you can participate in life. Don’t expect a switch to flip and you symptoms disappear, practice makes progress.

Complications from oral medication

Long term use of vestibular suppressants to decrease your dizziness won’t allow your brain to recalibrate and trust the messages from your balance apparatus. This increases your chance of developing persistent postural perceptual dizziness.

Persistent Postural Perceptual Dizziness doesn’t mean there’s permanent damage to your balance system. Instead, your brain has stayed in “high alert” after an earlier episode of dizziness or illness, and it now needs time and practice to settle back into normal balance patterns. Your recovery will be gradual, think of it as retraining your brain rather than healing an injury.

The key to improvement is consistency. You have to commit to your vestibular exercises, stay active, and gradually engage in daily activities instead of avoiding movement or busy environments. With time and practice your brain learns to trust the messages from your balance system again, and your confidence and steadiness returns step by step.

It is important to remember that PPPD is not a structural injury, like an ankle sprain, but more similar to what happens with chronic pain. Your balance system gets stuck in high alert/danger mode. Recovery means that you need to teach your brain to trust normal balance messages again. This can take 3 weeks to 6 months to achieve. How long your symptoms have been present, your predisposition to anxiety and avoidance strategies, help of medication and consistency with the correct vestibular exposure during your rehabilitation will influence your recovery time.

• Your doctor (ENT/neurologist) will probably prescribe serotonergic antidepressants, not for depression, but because of the modulatory effects this medication has on sensory integration and threat processing. It is usually prescribed at lower doses than for depression.
• The long term use of vestibular suppressants (like stugeron/stemetil) are not recommended as they delay central compensation necessary to get better after an acute vestibular episode, like BPPV or vestibular neuritis.
• Cognitive behavioural therapy (CBT) is not prescribed because PPPD is thought to be psychological or “in your head”, but because of the cognitive-emotional and behavioural factors that neurophysiologicaly controls your balance and motion perception.

No, there are no surgical interventions for Persistent Postural Perceptual Dizziness. PPPD is a functional problem, therefor nothing can be surgically fixed or removed like with other peripheral vestibular disorders. With a vestibular schwannoma, a benign tumor on the vestibular nerve, the tumor can be removed. With PPPD rehabilitation, cognitive behavioural therapy and medication is the choice of treatment.

• Uncompensated vestibulopathy

Any discrepancy between your left and right vestibular symptoms, like vestibular neuritis or a traumatic injury, can cause dizziness when confronted with complex or moving targets and tasks.

• Pharmacological interaction

Many medications can cause dizziness due to the effect on your blood pressure or heart rate, make sure to have your list of chronic medications for your health care provider.

• Labyrinthine concussion

Vertigo caused by a traumatic injury, like a fall or accident, can last hours to days

• Postural Orthostatic Tachycardia Syndrome (POTS)

An increase in resting heart rate of 30 beats per minute on standing can cause dizziness, fatigue, lightheadedness and palpitations.

• Meniere’s disease

This condition causes vertigo, intense attacks that last for minutes to hours, hearing loss, ear fullness and tinnitus.

• PPPD/3PD
• chronic subjective dizziness
• space and motion discomfort
• visual induced vertigo
• postural dizziness
• constant dizziness