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