Persistent Postural-Perceptual Dizziness
Description[edit | edit source]
Persistent Postural-Perceptual Dizziness (PPPD or 3PD) is a chronic disorder presenting with continual subjective dizziness or unsteadiness. Upright positions and environments with complex visual stimuli worsen symptoms and are perceived as a threat. These predominant symptoms may lead to incidental complications such as fear avoidance and functional gait abnormalities.[1]
Incidence and Prevalence[edit | edit source]
The World Health Organization (WHO) included PPPD in the 11th edition of the International Classification of Diseases as a new diagnosis to unify varied and overlapping predecessors such as phobic postural vertigo, space-motion discomfort, visual vertigo, chronic subjective dizziness, psychogenic gait disorders, etc. [1]
As this disorder has recently been redefined, valid data is difficult to obtain. Prospective studies have found that 25% of individuals developed PPPD 3-12 months after acute or episodic vestibular disorders (e.g. vestibular neuritis, benign paroxysmal positional vertigo (BPPV)). In 20% of cases, a vestibular migraine was a triggering event. Panic attacks or generalized anxiety preceded 15% of cases, and 7% were precipitated by an autonomic disorder. [1]
Diagnosis[edit | edit source]
All Barany Society Criteria must be met for a diagnosis of PPPD and thus is reliant on subjective history. PPPD symptom intensity can vary from distraction and energy levels but are overall chronic and persistent. This variability should not be mistaken for inauthenticity, as it is possible of the presentation.[1]
Barany Society Criteria for PPPD[2]: |
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A patient might also present with secondary psychiatric symptoms including fear of falling and avoidance behaviors, as well as functional gait abnormalities due to compensations such as body sway or hesitancy. Distracting motor tasks may be effective for the gait pattern to return to normal. This can demonstrate to the patient that it is possible to improve and return to normal gait patterns.
Pathophysiology[edit | edit source]
PPPD is theorized to develop by three main mechanisms:
- Stiffened postural control
- Favoring visual inputs rather than vestibular inputs to process spatial orientation information
- Failure to modulate the first two processes from higher cortical mechanisms
Outcome Measures[edit | edit source]
- Dizziness Handicap Inventory: measures a patient's perception of their disability related to their dizziness
Management / Interventions[edit | edit source]
- Patient Education
- Acknowledge the patient's symptoms are genuine and common
- Educate the patient that their symptoms can improve, and the nervous system is malfunctioning rather than permanently damaged
- Informing the patient on how various factors can trigger their symptoms including physical and emotional health
- Vestibular rehabilitation can be introduced as a tool to retrain the brain to improve movement and stability[3]
- Individualized Vestibular Rehabilitation
- The physical therapist should focus the goals of rehab on improving function and movement rather than the impairment [3]
- Habituation exercises are most appropriate to address the patients subjective dizziness. It is recommended to start slow and progress gently, as exercises that are too aggressive may aggravate their symptoms.
- Patients have shown to benefit from interventions to desensitize the patient to busy visual input[1]
- Medications
- Two classes of antidepressants may be effective in decreasing symptoms of dizziness: selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI)[1]
- Psychological Therapy
- Cognitive Behavioral Therapy (CBT) may be an effective intervention for PPPD to reframe beliefs, decrease fear and worries and improve overall psychological health as this can be effected by chronic subjective dizziness [1]
Differential Diagnosis[edit | edit source]
- Benign Paroxysmal Positional Vertigo (BPPV)
- Vestibular Neuritis and Labyrinthitis
- Neurologic Disorders (such as multiple sclerosis)
- Cerebral Vascular Accident
- Traumatic Brain Injury or Concussion
- Meniere's Disease
- Migraine (vestibular migraine)
Resources[edit | edit source]
A patient education resource can be found here for further information.
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018;18:5-13.
- ↑ Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, 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. J Vestib Res. 2017; 27:191–208.
- ↑ 3.0 3.1 Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015;86(10):1113-1119.