Understanding Persistent Postural-Perceptual Dizziness (PPPD)

Do you experience frequent dizziness without the spinning sensation of vertigo? Do you feel unsteady when standing or walking, especially in visually complex environments like shopping malls or busy streets? These could be signs of Persistent Postural-Perceptual Dizziness (PPPD), a chronic vestibular disorder that affects many individuals but often goes undiagnosed.

As we continue our commitment to community education at Willow Grove Physical Therapy, we want to shed light on common but often misunderstood conditions—we understand how it can affect your confidence, independence, and overall quality of life. PPPD is actually the most common cause of chronic dizziness, particularly affecting adults between 30-50 years old, with women experiencing it more frequently than men.

What Exactly is PPPD?

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic vestibular disorder that causes dizziness without vertigo and unsteadiness provoked by environmental or social stimuli, which can not be explained by any other neuro-otologic disorder. PPPD commonly starts after an event that causes acute vertigo, unsteadiness, dizziness, or disruption of balance, but may occur for unknown reasons. There is a disruption between the visual and postural control mechanisms. People with PPPD have lower thresholds for perceiving motion and often overestimate how much they’re actually moving.

Key Facts About PPPD:

Most common cause of chronic dizziness: If you’ve been experiencing persistent dizziness, you’re not alone.

Typically affects adults 30-50 years old: More common in females than males.

Makes up 15-20% of diagnoses in vestibular clinics.

Symptoms must be present most days for 3+ months and typically include:

• Unsteadiness
• Dizziness
• Non-spinning vertigo

Symptoms get worse with:

• Upright positions like sitting up, standing, or walking
• Movement of your head or body
• Exposure to visually complex places (like grocery store aisles or patterns)

How is PPPD Diagnosed?

Getting to the bottom of dizziness can be challenging, but our team knows what to look for. Based on your subjective report, we begin a thorough exam to rule out other possible causes of your symptoms. We’ll test your balance and assess how you walk.

For a PPPD diagnosis, these 5 criteria must be met:

1. Persistent symptoms: Experienced for more than half the days for 3+ months – typically present for hours
2. Specific triggers: While symptoms can occur without provocation, they get worse with upright posture, motion, and exposure to moving or complex visual environments
3. Triggering event: PPPD typically follows a condition that caused balance or dizziness problems (like BPPV, concussion, or vestibular neuritis)
4. Impact on daily life: Symptoms must significantly affect your quality of life
5. No other explanation: Symptoms can’t be better explained by another medical condition

Who Is More Likely to Develop PPPD?

Research has shown that those with pre-existing behavioral factors may have an increased risk of developing PPPD:

• People with anxious personalities or a pre-existing anxiety disorder are predisposed to PPPD after the event
  • Up to 60% of patients with PPPD had clinically significant anxiety
• Those with a higher tendency to experience negative emotions (neuroticism) are at higher risk to developing PPPD
• “Body vigilance” – paying very close attention to bodily sensations and changes – has been shown to be a predictive factor for PPPD

What are the Treatment Options for PPPD?

Currently the treatment for PPPD involves a combination of approaches all of which have been shown to reduce dizziness related handicap, including:

Patient Education:

• Understanding your condition is the first step to recovery
• Early psychotherapy can reduce chances of developing chronic PPPD

Pharmacotherapy:

• Selective Serotonin Reuptake Inhibitors (SSRIs) may help, though evidence is limited
• Important note: Vestibular suppressants (like Meclizine) are NOT effective for PPPD

Vestibular Rehabilitation: This is where we at Willow Grove PT truly shine! We take an individualized approach for each patient, focusing on:

• Postural stability exercises
• Balance training
• Habituation therapy – gradually retraining your brain to respond appropriately to movement

Psychological Interventions:

• Cognitive Behavioral Therapy, involving exposure therapy with psychotherapists or in group sessions
• Relaxation techniques including meditation and mindfulness
• Recognition and appraisal of symptoms through acceptance and commitment therapy

Finding Balance with Willow Grove Physical Therapy

Living with persistent dizziness can be incredibly frustrating and limiting. At Willow Grove Physical Therapy, we understand the significant impact PPPD can have on your daily life and overall wellbeing. Our team of specialized physical therapists has extensive experience in vestibular rehabilitation and treating conditions like PPPD.

We take a comprehensive, individualized approach to help you:

• Understand your condition
• Manage your symptoms effectively
• Develop strategies to handle challenging environments
• Regain confidence in your daily activities
• Return to the activities you love

Don’t let dizziness dictate your life. Early intervention often leads to better outcomes when managing PPPD, so if you’re experiencing persistent dizziness or unsteadiness that’s affecting your quality of life, don’t wait to seek help.

Take the first step toward feeling balanced again – schedule an appointment with us today!

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Written By:

Kayla Mastrocola, SPT

References:

1. Knight B, Bermudez F, Shermetaro C. Persistent Postural-Perceptual Dizziness. [Updated 2023 Apr 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. https://www.ncbi.nlm.nih.gov/books/NBK578198/
2. Trinidade, A., Harman, P., Stone, J., Staab, J. P., & Goebel, J. A. (2021, January 21). Assessment of potential risk factors for the development of persistent postural-perceptual dizziness: A case-control pilot study. Frontiers in neurology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859446/
3. Trinidade, A., Cabreira, V., Kaski, D., Goebel, J., Staab, J., Popkirov, S., Stone, J. (2023, August 21). Treatment of Persistent Postural-Perceptual Dizziness (PPPD). Curr Treat Options Neuro. DOI 10.1007/s11940-023-00761-8
4. Oka M, Ichijo K, Koda K, Kamogashira T, Kinoshita M, Igarashi K, Kawahara T, Takashima I, Yamasoba T, Fujimoto C. Preceding Balance Disorders Affect Vestibular Function in Persistent Postural-Perceptual Dizziness. J Clin Med. 2023 Mar 29;12(7):2589. doi: 10.3390/jcm12072589. PMID: 37048672; PMCID: PMC10095344.
5. Ivan Adamec, Snježana Juren Meaški, Magdalena Krbot Skorić, Katharina Jažić, Luka Crnošija, Iva Milivojević, Mario Habek, Persistent postural-perceptual dizziness: Clinical and neurophysiological study, Journal of Clinical Neuroscience, Volume 72, 2020, Pages 26-30, ISSN 0967-5868, https://doi.org/10.1016/j.jocn.2020.01.043.