What is PPPD?

Persistent Postural-Perceptual Dizziness (PPPD) is one of the most common causes of long-term
dizziness.

PPPD is described as symptoms of dizziness and unsteadiness which are present on most days for
three months or more and are made worse by movement or by certain visual challenges such as a
supermarket or scrolling on your phone.

PPPD stands for:

Persistent – symptoms are there most of the day, most days of the week.

Postural – symptoms are usually worse when standing up and moving around, and better
when resting.

Perceptual – something that is felt by you, but not necessarily obvious to others.

Dizziness – the symptom that most people experience.

It usually begins following something which affects the balance system in the inner ear such as an ear infection, BPPV, head injury or migraine. But can also be caused by a medical issue which results in dizziness (i.e. heart problems) as well as dizziness from anxiety. Rather than the symptoms gradually improving once the initial cause resolves they continue and begin to impact more and more on daily life.

The symptoms are usually not as extreme as the initial onset but are there more often than not. This sensation of ongoing dizziness begins to occur as our brains start to become more and more aware of the feelings of dizziness and motion and don’t ignore it as it usually would. The brain becomes hypervigilant to the sensation of dizziness and motion making the experience of dizziness increase, this leads to a vicious circle of increased sensations and increased awareness of symptoms. This is sometimes described like malfunctioning computer software as the brain begins to change how it processes information related to motion.

How might it affect me?

People suffering from PPPD often report the following symptoms (although these can be different
for every one):

• A sensation of rocking/swaying as if on a boat
• Feeling like head is in a goldfish bowl
• Feeling like brain moves slower than head when turning head
• Mismatch between head and eye movement
• Feeling drunk
• Feelings of dissociation/de-realisation
• Veering when walking or bumping in to things in narrow spaces

These symptoms can make many daily activities challenging to do, in particular people with PPPD often (but not always) report the following difficulties in daily life:

• Struggling in busy environments such as the supermarket or train station
• Visual patterns being difficult to look at – chequred tiles, highly patterned carpets
• Symptoms when scrolling through phone or when using the computer
• Difficulty using escalators
• Increased symptoms when traveling on a bus/train or whilst being a passenger in a car
• Repeat movements such as hanging out washing increase symptoms
• Veering into others when walking next to someone

All of this can make it very challenging for people to manage all things taken for granted in daily life such as traveling into work, using a computer, going shopping, visiting restaurants and can result in people becoming less and less able to do all the things they need to.

Another big challenge with PPPD is how it can be perceived by those around you, although having PPPD can make you feel very unwell you will generally look well to people around you and this can make it very difficult for them to understand the challenges you are facing and why you can’t tolerate certain situations. PPPD is often misdiagnosed as anxiety and, although this can be part of the issue, it is not the sole feature of the condition and some people with PPPD do not experience any anxiety.

How can physiotherapy help me manage it?

PPPD can take a long time to improve and there is no quick fix, however with the right input the symptoms can improve significantly.

One of the key things is understanding what is going on so explaining PPPD is a key part of the physiotherapy role.

Vestibular physiotherapy is key in helping to decrease the sensitivity of your brain to motion. We use specific exercises to help improve your tolerance to visual stimulation and to improve your balance. We know with PPPD that starting an exercise programme too intensely can lead to an increase in symptoms so we always start exercises carefully and steadily and make sure they are specific to each individual.

What other treatment is available?

For some people who are struggling to make improvements with exercises alone there is some research to show that low dose SSRI medication can help. These are thought to work by improving communication between different areas of the brain helping to improve processing of balance information. These have been shown to help even in people with out anxiety or depression.

There is also some evidence to show that when PPPD is accompanied by anxiety then CBT (Cognitive Behavioral Therapy) can be helpful. CBT can help to decrease a person’s fear around movement induced dizziness and help them to gain confidence in returning to environments that trigger dizziness.

However, all these are additional supports for PPPD and they require physiotherapy to work alongside them, they are not alternatives to physiotherapy.

If you think we may be able to help you in the management of PPPD, then please call us on 01306888171 or email [email protected]

Ramsey Hunt Syndrome has been in the news recently with the singer Justin Beiber being diagnosed with it in June 2022. Knowing a few patients with the debilitating condition it seemed like a good time to write a blog about what it is and how neuro physiotherapy can help anyone suffering from it.

Ramsey Hunt is a neurological condition that affects adults (commonly those over the age of 60). It is caused by the same virus that causes chicken pox in children and shingles in adults, Varicella Zoster Virus. Following chicken pox in childhood the virus can lay dormant until it is reactivated causing shingles, if it affects the facial nerve then it is called Ramsey Hunt Syndrome. The virus can become reactivated when your immunity is low and less able to fight off infection, stress can often be a cause of weakened immunity and therefore Shingles and Ramsey Hunt can be triggered by a period of significant stress. In Ramsey Hunt the reactivated virus causes irritation and swelling to the facial nerve leading to facial weakness. Due to the close proximity of the facial nerve to the nerves of balance and hearing it is also possible to experience loss of hearing and balance/dizziness problems associated with Ramsey Hunt Syndrome.

You can’t catch Ramsey Hunt Syndrome from anyone, however if you have no immunity to chicken pox (no childhood exposure or vaccination) then you can catch chicken pox from someone with Ramsey Hunt Syndrome if in contact with an open blister.

Ramsey Hunt typically presents with a rash or blisters around the ear and scalp on the affected side and can cause blisters inside the mouth. Weakness in the face can lead to difficulty closing your eye and blinking, smiling, and eating and sometimes causes changes in taste. You might also lose hearing on the affected side and experience problems with getting dizzy and being off balance. Although it doesn’t directly affect your ability to speech the weakness in the lips and cheek muscles can make forming some sounds difficult.

Urgent treatment at onset of symptoms can be critical to improving the outcome of your facial palsy ideally early diagnosis and starting anti-viral medication and steroids with-in 72 hours can help limit the extent of the facial weakness. It is also very important to get urgent advice on eye care to avoid damage to the eyeball due to limited blinking.

The outcome depends on the severity of the facial weakness and speed of recovery. Once you’ve accessed urgent medical care for diagnosis and timely management of the condition then it’s time to start physiotherapy to learn what is best to do in the management of facial palsy and how to help ensure you make steady progress with exercises to maximise your recovery and limit complications.

Physiotherapy can also help if you have issues with dizziness and poor balance by providing an individual exercise programme to help improve the function of your balance systems.

Useful info:

Ramsay Hunt Syndrome – NORD (National Organization for Rare Disorders) (rarediseases.org)
Ramsay Hunt Syndrome – Facial Palsy UK

If you think we may be able to help you in the management Facial Palsy and Balance problems, then
please call us on 01306 888171 or email [email protected]

What is Huntington’s Disease?

It is a progressive brain disorder that leads to uncontrolled movements, changes in how you think
and emotional problems. Symptoms most commonly appear between the ages of 30 to 40 years
old.

What causes Huntington’s Disease?

It is a genetic condition caused by inheriting a defect in a single gene from one of your parents

What are the symptoms?

Huntington’s Disease has a wide range of signs and symptoms, which appears first varies from person to person and symptoms can change throughout the progression of the disease.

Changes in activity and movement :

• Involuntary movements such as jerking or writhing movements which can travel around the
• body
• Stiffness or contractures in the muscles
• Difficulties with walking and balance
• Changes in eye movements
• Difficulties with speech and swallow
• Changes in how you think (cognitive function)
• Difficulty focusing/organising/prioritising a task
• Tendency to get stuck on a certain thought, action or behavior – inflexibility/perseverance
• Difficulty in controlling impulses ‘acting without thinking’
• Lack of awareness of behaviours
• Slow to process thoughts, difficult to find the right word
• Challenging to learn new information
• Changes in emotions (caused by the damage to the brain and not as a response to the diagnosis)
• Feeling irritable, sad or apathetic
• Withdrawing socially
• Insomnia
• Decreased energy levels
• Frequent thoughts of death or self-harm

Can physiotherapy help?

YES!!! Research shows that increased levels of physical activity has several benefits in Huntington’s
Disease:

• Increased quality of life and confidence
• Improved balance
• Able to walk further and faster
• Prevention of stress and aggression
• Decreased symptoms of anxiety and depression

Have a look at http://eurohuntington.org/active-huntingtons/ and https://www.hda.org.uk/media/1602/move-to-exercise.pdf for advice on how to get active with Huntington

Where can I find further information about Huntington’s Disease?

https://www.hda.org.uk

http://eurohuntington.org/

If you think physiotherapy will help you to increase your activity levels then please contact us on 01306
888171 or email [email protected]