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

Treatment of Persistent Postural Perceptual Dizziness (PPPD)

Vestibular rehabilitation therapy (VRT) is the first-line treatment for PPPD, with significant improvements in quality of life, dizziness handicap, and anxiety levels within 3 months. 1

Primary Treatment Approach

Vestibular Rehabilitation Therapy

• VRT is highly effective for PPPD management and should be implemented as the cornerstone of treatment 1, 2
• Home-based VRT programs are as effective as hospital-based programs, making them an accessible option for patients 1
• Customized VRT exercises should be tailored to address specific symptoms and triggers 2
• VRT works by promoting habituation, adaptation, and central compensation mechanisms 3

Medication Options

• Antidepressant medications may facilitate rehabilitation, though evidence level is low 4
• Vestibular suppressants (antihistamines, benzodiazepines) should NOT be used routinely as they can:
  • Interfere with vestibular compensation
  • Cause adverse effects and medication interactions
  • Decrease diagnostic sensitivity 5, 3
• If medications are used, they should be limited to short-term use (<1 week) 3

Multimodal Treatment Components

Cognitive-Behavioral Therapy (CBT)

• CBT should be integrated with VRT for optimal outcomes 4
• CBT approaches should inform and augment physiotherapeutic techniques 4
• This combination helps patients escape the cycle of maladaptive balance control 4

Treatment Considerations

• Patients with longer duration of PPPD, complex aggravating factors, and higher initial DHI scores may have less favorable outcomes with VRT alone 2
• Concomitant anxiety and depression significantly impact treatment outcomes; patients without these conditions show greater improvement 6
• Regular follow-up is essential to document resolution or persistence of symptoms 3

Implementation Strategy

1. Initial Assessment:

   • Evaluate for anxiety and depression using standardized measures (DASS-21)
   • Assess dizziness handicap using DHI
   • Document specific triggers and aggravating factors

2. Treatment Plan:

   • Begin with customized VRT exercises
   • Consider CBT in parallel, especially for patients with anxiety/depression
   • Consider short-term medication only for severe symptoms

3. Monitoring:

   • Reassess within 4 weeks (early improvements should be evident) 1
   • Complete evaluation at 12 weeks 1
   • Maintain a daily symptom journal to track triggers and patterns 3

Important Caveats

• PPPD can develop following BPPV and may require different management strategies than the original condition 5
• Patients should be educated about the potential for recurrence and the importance of continuing exercises
• Fall prevention strategies should be emphasized, especially in elderly patients 3
• The most recent evidence shows that home-based VRT can be as effective as hospital-based programs, increasing accessibility of treatment 1
• Regular physical activity beyond specific VRT exercises is recommended to improve overall balance and coordination 3