Seattle Dizzy Group

Persistent Postural-Perceptual Dizziness (PPPD)

by Morgan Kriz, DPT

Vestibular Physical Therapist

 (Presented to Seattle Dizzy Group on 11/16/19)

This presentation gives an overview of Persistent Postural-Perceptual Dizziness (PPPD) which is a newly defined diagnostic syndrome described as a common chronic dysfunction of the vestibular system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness.

Visual distracting environments (such as supermarkets, large crowds, or watching TV) can be overwhelming and cause significant distress for people with a Vestibular Disorder. Once recognized, PPPD can be managed.

3PD

Persistent: symptoms present > 50% of the time for more than 3 months; but wax and wane. Can get better with distractions, progress later in the day.

Postural: exacerbated with upright posture (standing/walking); sudden movements

Perceptual: active (self generated movement) or passive movement (elevator, car) with exposure to moving (traffic) or complex visual stimuli (wallpaper, phone)

Dizziness: false or distorted sensations of swaying, rocking, bobbing, or bouncing of oneself (internal non‐spinning vertigo) or the surroundings (external non‐spinning vertigo)

RD-D2 & C3PO

Not a “New” Diagnosis

• Persistent Postural Perceptual Dizziness (PPPD, 3PD) – Dietrich and Staab 2014
• Chronic Subjective Dizziness (CSD) – Staab and Ruckenstein2004
• Visual Vertigo/Visual dependence/Space Motion discomfort (SMD) – Staab 2003
• Phobic Postural Vertigo (PPV) – Brandt and Dieterich 1986
• Mimic Post-Traumatic Stress Disorder (PTSD)

Prevalence of PPPD

• About 5% of the population develops “vestibular” dizziness per year (Hain):
  • 0.05% = Mal Debarquement (0.5/1000 persons)
  • 50% = land sickness “LDS”
  • 1% = Vestibular Migraine
  • 0.2% = Meniere’s Disease
  • 10% = PPPD

How It Starts

Frequently at the beginning, there is an organic vestibular illness:

Medical Examination

• Normal eye exam
  • Visual strain may contribute

• MRI/imaging = negative

• NO ABNORMAL INNER EAR
  • * May start with an initial insult of inner ear years prior

“Normal” Vestibular System

Impaired Vestibular System

Poor Recovery from Vestibular Illness

Misunderstanding

• PPPD is in fact a series of normal misunderstandings between the ears, spinal chord, eyes and brain. The signals have been mislead and misfired.

• It is all reversible!

Research Shows

• Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and assessment

• Thus, PPPD is classified as a chronic functional vestibular disorder

• It is not a structural or psychiatric condition

Fight or Flight Initiated

• For this condition there is a strong link with anxiety and a subconscious underlying fear of the dizziness itself

• The body sensations are perceived with a ‘fright’

Fight or Flight Video

 

Anxiety and Fear

• THIS IS A NORMAL REACTION!
  • It is not a psychiatric condition
  • Neuro-otologic (vestibular-brain connection) condition with behavioral elements = not moving pattern
  • Co-morbidities would make a person more “aware” of symptoms

• If the pattern continues = problem

PPPD

• If left unmanaged, emotions can delay the natural recovery process as chronic anxiety inhibits neuroplasticity

• Over time this can lead to increased anxiety and avoidance behaviors that perpetuate the PPPD condition

• Not using body or inner ear, and instead only visual = PPPD

Treatment Options

• Vestibular Physical Therapy Protocol
  • Education on condition -> improve control -> reduce anxiety
  • Evaluate for non-compensated vestibular hypofunction
  • TRIGGERS (start journal)
  • Reduce stress/GET SLEEP!
  • Cervical spine contributions
  • VOR adaptation
  • Reduce visual dominance

• Cognitive and Behavioral Therapies

• Serotonergic Medications (serotonin = happiness, wellness, neurotransmitter) for sustained remission when applied systematically

• Non-Invasive Vagus Nerve Stimulation

Stimulate Vagus Nerve in Breath

Breathing Exercise

 

Take Home Message

• Not a “new’ diagnosis, but has changed over time

• Tell your brain “good job” and “you are safe”

• Increased visual dependency = less somatosensory reweighting

• Has central (brain) rewiring component

• Intervention: Vestibular Rehabilitation Therapy (VRT), Cognitive Behavioral Therapy (CBT) and medication

Resources

Brandt T. Vertigo. Its multisensory syndromes. Springer Verlag, New York, 1991.

Brandt T, Dieterich M, and Strupp M. Chapter 5: Psychogenic forms of vertigo and dizziness in “Vertigo And Dizziness: Common complaints: Springer, 1995

Breslau, N., L. R. Schultz, et al. (2000). “Headache and major depression: is the association specific to migraine?” Neurology 54(2): 308-313.

Clark DB, Hirsch BE, Smith MG, Furman JMR, Jacob RG. Panic in otolaryngology patients presenting with dizziness or hearing loss. Am J Psychiatry 1994; 151:1223 1225.

Clark, M. R. and K. L. Swartz (2001). “A conceptual structure and methodology for the systematic approach to the evaluation and treatment of patients with chronic dizziness.” J Anxiety Disord 15(1-2): 95-106.

More Information about PPPD

PPPD Explained article by The Dizzy Cook

PPPD Information from Vestibular Disorders Association (VeDA)

 

Morgan Kriz, DPT

Vestibular Physical Therapist