COMMON VESTIBULAR ISSUES
Persistent Postural Perceptual Dizziness PPPD Treatment Melbourne
The Vertigo Co will assess your symptoms and provide tailored treatment options.
The Vertigo Co
What is Persistent Postural Perceptual Dizziness (PPPD)?
Persistent Postural Perceptual Dizziness (PPPD), also known as Chronic Subjective Dizziness (CSD), is a type of chronic, non-vertiginous dizziness which cannot be explained by any particular neurological or otological (inner ear) disorder.
PPPD can be an incredibly frustrating condition. For a detailed assessment and treatment options, get in touch today.
PPPD Symptoms
The primary symptoms of PPPD are persistent sensations of dizziness without vertigo and/or unsteadiness, including rocking or swaying.
To qualify as PPPD, the symptoms have to last 3 months or more and be present on more days than not, i.e. at least 15 of every 30 days. Most patients will have daily symptoms.
Symptoms may intensify as the day progresses, and are typically worse with:
Upright posture (standing or sitting upright) compared to lying down
Head or body motion/movement, whether self generated or by external forces (i.e. being in a moving vehicle)
Exposure to complex or motion-rich environments (i.e. busy, crowded places, traffic, complex patterns or visual stimuli)
PERSISTENT POSTURAL-PERCEPTUAL DIZZINESS (PPD)
What Causes It?
PPPD typically starts shortly after an event that causes acute vertigo, unsteadiness, dizziness, or disruption of balance such as:
- A peripheral or central vestibular disorder (e.g., BPPV, Vestibular Neuritis, Meniere’s Disease, Stroke)
- Vestibular Migraine
- Panic attacks with Dizziness
- Mild Traumatic Brain Injury (mTBI) – concussion or whiplash
- Dysautonomia (disease of the autonomic nervous system)
Usually, when a stressful event like this happens, the body will first react then settle down. With PPPD, the body is stuck in the reaction phase.
PPD involves a misalignment between the balance systems in the body, including the visual system, proprioception and vestibular system. This leads the brain to perceive that the body is unsteady or in motion, even when still. The result is feelings of dizziness, rocking and swaying.
PPPD, Anxiety and Depression
PPPD rarely starts slowly and gradually without a triggering event, although it is not always possible to sort out the cause. However, we know it is a physiological disorder that can have psychological consequences, including anxiety and depression. These two conditions also increase a person’s likelihood of developing PPPD. 60% of patients with PPPD had clinically significant anxiety and 45% had clinically significant depression. 25% of patients reported neither in association with their symptoms.
PERSISTENT POSTURAL-PERCEPTUAL DIZZINESS (PPD)
How is PPPD Diagnosed?
A diagnosis of PPPD is based on a patient’s symptoms and their complete medical history.
They may also be asked to undertake laboratory tests such as MRIs or Vestibular Function Testing, unless there is another neurological or otological disorder which preceded the onset of PPPD.
If you have symptoms of PPPD, we can perform a full physical assessment of your symptoms and guide you through potential causes and treatment options. Book an appointment with our team to get started.
the Vertigo Co
PPPD Treatment
PPPD is treated using a range of methods, from physiotherapy and medication to cognitive behavioural therapy. We focus on delivering Vestibular Rehabilitation Therapy.
Vestibular Rehabilitation Therapy (VRT)
This form of physiotherapy exposes clients to complex patterns or busy environments as a way of retraining their nervous system to ignore or grow accustomed to situations that may provoke dizziness. VRT has been shown to reduce the severity of PPPD symptoms by up to 60 – 80% in some cases, although may be required for between 3 to 6 months for optimal benefit. Your physiotherapist will help prescribe these exercises.
Medication
Selective Serotonin Reuptake Inhibitors (SSRIs) are commonly used for depression and are also useful for PPPD. They are usually prescribed by a Neuro-Otologist who understands PPPD in great detail. Clinical trials have shown 70% of patients experienced a reduction in their symptoms by at least half when trialling an SSRI, but in some cases more than one medication may need to be trialled. Treatment often needs to be maintained for at least one year or more to reduce the risk of relapse.
Cognitive Behavioural Therapy (CBT)
Counselling is often used to help clients cope with their dizziness sensations. A qualified Vestibular Psychologist can be recommended by your physiotherapist. CBT is quite effective for early PPPD and has been shown to have good benefit within just 3 sessions.
Resources
- Vestibular Disorders Association (VEDA) Website: https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/persistent-postural-perceptual-dizziness/
- Dr. Timothy Hain (Vestibular neurologist, University of Chicago) offers extensive educational information https://dizziness-and-balance.com/disorders/psych/pppd.html
Frequently Asked Questions
PPPD symptoms like dizziness and unsteadiness may worsen in a range of situations, including when you stand or sit upright, walk forward, ride in a moving vehicle, absorb complex partners and visual stimuli (e.g. a colourful carpet or wallpaper), or engage with busy, motion-rich environments like supermarkets, shopping malls or roads with lots of traffic.
Your first goal should be seeking a professional diagnosis from a trusted Vestibular Physiotherapist. If you book an Initial Vestibular Physiotherapy Consultation with us, we can undertake an assessment and refer you to a trained specialist doctor called a Neuro-Otologist for a diagnosis. Your doctor or specialist will also likely recommend treatment options. Your treatment plan may include Vestibular Rehabilitation Therapy (available at The Vertigo Co), medication, and a form of psychology such as Cognitive Behavioural Therapy (CBT).
We recommend a multi-disciplinary approach that includes Vestibular Rehabilitation Therapy, medication, and Cognitive Behavioural Therapy. Vestibular rehabilitation therapy typically involves a range of exercises, includes habituation exercises and balance retraining exercises targeted specifically for your symptoms. It helps people with PPPD by provoking symptoms or stimuli, including situations or environments with a dizzying effect, in ways that retrain your body’s vestibular system without allowing your symptoms to overwhelm you.
We do not require a referral from a GP or other medical practitioner for private patients. If you are a Workcover or TAC patient, we require a referral, and request that you please contact the clinic before booking your appointment. If you have been given a referral, please bring it along to your appointment along with any other relevant test results or reports.
An Initial Vestibular Physiotherapy Assessment is $180, or if conducted via Telehealth, $160. Please view our FAQs page for further fee information and our policies regarding private health insurance claims, Enhanced Primary Care Plan (EPC)/Chronic Disease Management Plans, and Medicare claims.
The Vertigo Co
Book a PPPD Assessment
If you think you might have PPPD, there is support available. Our highly experienced and friendly physiotherapists can assess your symptoms and suggest potential next steps, including Vestibular Rehabilitation Therapy.
For more information or to book an appointment, contact us today.
the Vertigo Co
References:
- 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(4):191-208. https://pubmed.ncbi.nlm.nih.gov/29036855