Persistent Postural Perceptual Dizziness

Persistent Postural Perceptual Dizziness, known as PPPD or 3PD is a chronic vestibular condition with an array of frustrating symptoms, most often with normal medical test results. Brain MRI, VNG, hearing tests and standard blood work usually come back negative. It is characterized by a sense of dizziness, unsteadiness, and a swaying or rocking sensation that is worsened when upright, with movement, or with visual stimulation such as scrolling or riding in a car. Dizziness in busy environments like grocery stores, shopping malls, theatres and crowds can be debilitating, and lead to a sense of anxiety and fear from the disorienting sensations. The nervous system can then become dysregulated, adding symptoms such as startle, generalized anxiety, tension, headache, sensitivity to all stimuli, racing heart, digestive distress, and sweating.

There is typically a triggering event prior to developing PPPD, such as previous BPPV, inner ear dysfunction, head injury, or viral infections. It is often coexisting with vestibular migraine and can then include additional symptoms of ringing in the ears, mood irritability, neck tension, visual snow, visual afterimages known as palinopsia, and headaches.

Explore our services in Castle Rock:

Concussion Physical Therapy Castle Rock
Vertigo Physical Therapy Castle Rock
Vestibular Physical Therapy Castle Rock

PPPD involves a maladaptation of the central nervous system, where the brain continues to struggle to process balance information correctly, becoming over reliant on vision and less reliant on vestibular networks for orientation, leading to chronic perception of threat to balance and orientation, even after the initial trigger has been resolved. This can lead to a heightened awareness of balance and postural adjustments, and increased reliance on stationery visual cues, which can further exacerbate symptoms. These symptoms are present on most days and can vary in degree of intensity, greatly impacting quality of life. Additional symptoms may include difficulty with concentration, problems with memory, impaired spatial awareness, and brain fog. Many individuals are forced to avoid triggering environments and movement, which can greatly impact your quality of life and increase symptoms of anxiety.

Five criteria related to your symptoms define the diagnosis of PPPD. You meet the criteria if:

• You feel dizzy or unsteady (without room spinning vertigo) for most days, for at least three months.
• You experience worsening symptoms without specific provocation such as specific positions, but the dizziness is more intense when you’re upright, in motion or processing lots of visual information.
• You experienced a triggering event, either a temporary episode or a chronic condition, that caused dizziness.
• Your symptoms negatively impact your quality of life.
• Your symptoms aren’t because of another condition.

Treatment options at NeuroBalance Physical Therapy: We take a complete inventory of your symptoms and medical history, along with individualized assessment of your body systems including vision, vestibular physical therapy in Castle Rock, sensory, motor, cervical and autonomic systems. Initial treatments will address any impairments noted in this exam with a plan customized to your specific symptoms. Commonly utilized strategies include vestibular rehabilitation, balance training, qEEG brain mapping to evaluate cortical brain networks with specific recommendations for neurofeedback training as indicated, dry needling to reduce neurogenic inflammation and common secondary impairments such as cervical dysfunction, as well as autonomic regulation. Transcranial photobiomodulation to improve cerebral blood flow and brain energy, and vagus nerve stimulation to help regulate the nervous system are often included. Your physical therapist will discuss your exam findings with you and create the most effective treatment plan. Due to the chronicity of this condition, it is important to be patient with yourself as neurological therapies and neuroplasticity within the brain are very effective yet may take several months to recognize significant changes.

Certain medications may help alleviate symptoms, particularly in cases where vestibular migraine is co-existing with PPPD. We will work closely with your medical provider to discuss your care and optimize your recovery.

References:
Popkirov, Stoyan, Jeffrey P. Staab, and Jon Stone. “Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness.” Practical neurology 18.1 (2018): 5-13.
Yagi, Chihiro, Akira Kimura, and Arata Horii. “Persistent postural-perceptual dizziness: a functional neuro-otologic disorder.” Auris Nasus Larynx 51.3 (2024): 588-598.