Treatment of Persistent Postural Perceptual Dizziness (PPPD)
Vestibular rehabilitation therapy (VRT) combined with cognitive behavioral therapy (CBT) is the first-line treatment for Persistent Postural Perceptual Dizziness (PPPD), with selective serotonin reuptake inhibitors (SSRIs) as adjunctive therapy for patients with significant anxiety or depression. 1
Understanding PPPD
PPPD is a chronic functional vestibular disorder characterized by:
- Persistent dizziness or unsteadiness occurring on most days for more than 3 months
- Symptoms typically exacerbated by upright posture, active or passive motion, and visual stimulation
- Often triggered by a vestibular disorder, such as BPPV, vestibular migraine, or other conditions
Treatment Algorithm
First-Line Treatment: Vestibular Rehabilitation Therapy (VRT)
VRT has been demonstrated to be highly effective for PPPD:
- Significantly improves quality of life, dizziness handicap, and anxiety levels within 3 months 2
- Should be customized to address the specific symptoms and triggers of each patient 3
- Can be delivered in both home-based and hospital-based settings with comparable effectiveness 2
Key components of VRT for PPPD include:
- Habituation exercises to reduce sensitivity to triggering movements
- Balance training to improve postural stability
- Gaze stabilization exercises
- Sensory integration training
Second-Line Treatment: Cognitive Behavioral Therapy (CBT)
CBT should be integrated with VRT for optimal outcomes:
- Addresses maladaptive thoughts and behaviors related to dizziness
- Helps patients manage anxiety and fear associated with symptoms
- Techniques from CBT should inform and augment physiotherapeutic approaches 1
Pharmacological Management
Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may be beneficial:
- Can facilitate rehabilitation, though the mechanism is not fully understood 1
- Particularly useful for patients with comorbid anxiety and depression 4
- Should not be used as monotherapy but as an adjunct to VRT and CBT
Important note: Vestibular suppressant medications such as antihistamines and benzodiazepines should NOT be routinely used for PPPD as they can interfere with central compensation and may lead to medication dependence 5, 6
Factors Affecting Treatment Response
Several factors may influence treatment outcomes:
- Duration of symptoms (longer duration associated with poorer outcomes) 3
- Presence of anxiety and depression (patients without these conditions show better improvement) 4
- Complexity of aggravating factors 3
- Severity of symptoms at baseline 3
Treatment Monitoring and Follow-up
- Patients should be reassessed within 1 month after initiating treatment 6
- Objective measures like Sensory Organization Test (SOT) and subjective measures like Dizziness Handicap Inventory (DHI) can be used to track progress 4
- Treatment may need to continue for several months in some cases
Special Considerations for Elderly Patients
Elderly patients with PPPD require special attention:
- Higher risk of falls and impairments in daily activities 6
- May require modified VRT techniques 6
- Balance between challenging exercises and safety is crucial
Pitfalls to Avoid
- Misdiagnosis: Ensure proper diagnosis of PPPD by excluding organic vestibular lesions before initiating treatment
- Overreliance on medications: Avoid long-term use of vestibular suppressants as they can hinder recovery
- Inadequate treatment duration: VRT may require at least 6-12 weeks to show significant improvement
- Ignoring psychological factors: Untreated anxiety or depression can significantly reduce treatment effectiveness 4
- One-size-fits-all approach: VRT must be tailored to the individual's specific symptoms and triggers 3
By following this comprehensive approach to PPPD management, clinicians can help patients break the cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in everyday life.