What is the recommended treatment for Persistent Postural Perceptive Dizziness (PPPD)?

Treatment of Persistent Postural Perceptive Dizziness (PPPD)

The most effective treatment for Persistent Postural Perceptive Dizziness (PPPD) is a combination of vestibular rehabilitation therapy (VRT) and cognitive-behavioral therapy (CBT), possibly augmented by selective serotonin reuptake inhibitors (SSRIs). 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 worsen with upright posture, active or passive motion, and exposure to complex visual environments
• Often develops following an episode of acute vertigo (e.g., vestibular neuritis, Meniere's disease)

Treatment Algorithm

First-Line Treatment: Vestibular Rehabilitation Therapy (VRT)

VRT is highly effective for PPPD and should be initiated as the primary treatment 2, 3:

• Home-based or hospital-based VRT programs show comparable effectiveness
• VRT significantly improves quality of life, dizziness handicap, and anxiety levels within 3 months
• Exercises should focus on:
  • Habituation to provocative movements
  • Balance retraining
  • Gaze stabilization
  • Sensory integration

Second-Line Treatment: Cognitive-Behavioral Therapy (CBT)

CBT should be integrated with VRT for optimal outcomes 1, 4:

• Addresses maladaptive thought patterns about dizziness
• Helps reduce anxiety and catastrophizing related to symptoms
• Teaches relaxation techniques
• Promotes gradual exposure to avoided situations

Medication Management

SSRIs may be beneficial as adjunctive therapy 1, 5:

• Sertraline has shown benefits in PPPD management
• Medication may facilitate rehabilitation by reducing anxiety and depression
• Important: Vestibular suppressant medications (antihistamines, benzodiazepines) should NOT be routinely prescribed for PPPD as they can interfere with central compensation 6, 7

Treatment Considerations

Factors Affecting Treatment Response

1. Psychiatric Comorbidities:

   • Patients with concomitant anxiety and depression show less improvement with VRT 3
   • Consider earlier introduction of SSRIs and more intensive CBT for these patients

2. Duration of Symptoms:

   • Earlier intervention typically leads to better outcomes
   • Chronic cases may require longer treatment duration

3. Precipitating Factors:

   • Vestibular migraine is a common precipitating condition (24.2% of cases) 3
   • Addressing any underlying conditions is essential

Monitoring and Follow-up

• Assess treatment response using validated tools:
  • Dizziness Handicap Inventory (DHI)
  • Hospital Anxiety and Depression Scale (HADS)
  • Sensory Organization Test (SOT) if available
• Re-evaluate after 4-6 weeks of therapy to assess progress and adjust treatment plan
• Continue therapy for at least 3 months for optimal results 2

Treatment Pitfalls to Avoid

1. Overreliance on vestibular suppressant medications:

   • These medications can delay central compensation and worsen long-term outcomes 6, 7
   • Should be limited to short-term use (<1 week) if used at all

2. Inadequate treatment duration:

   • Significant improvements may take 3 months or longer
   • Premature discontinuation of therapy often leads to symptom recurrence

3. Failure to address psychological factors:

   • Anxiety and depression significantly impact treatment outcomes 3
   • Multimodal approach addressing both physical and psychological aspects is essential

4. Neglecting patient education:

   • Patients need to understand the non-progressive nature of PPPD
   • Education about the condition reduces fear and improves compliance with therapy

Conclusion

PPPD requires a structured approach combining VRT and CBT, with medication support when needed. This multimodal treatment has demonstrated significant improvements in quality of life, dizziness handicap, and anxiety levels in patients with PPPD.