Chronic Dizziness: What is Persistent Postural-Perceptual Dizziness?

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Persistent Postural-Perceptual Dizziness. It’s a great name - it says it all (for short, call it 3PD). It’s not great to have, though - it’s a chronic sense of dizziness, unsteadiness, rocking, or swaying. 

It’s considered a chronic functional vestibular disorder - chronic because it may last for months or years, and functional because it is associated with dysfunction in how the vestibular and balance mechanisms operate. It’s not a psychiatric syndrome or a structural condition, and a patient with 3PD is not malingering or “faking it.” Just like we’re starting to understand that chronic pain is real, so is chronic dizziness. 

Other names that have been used in the past to describe what we now call 3PD include phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. These terms are slowly falling out of favour because, for the most part, they describe the symptoms but don’t capture the full scope of the disorder. 

Symptoms and Timing of Symptoms

Patients with 3PD report dizziness, unsteadiness, and/or non-spinning vertigo. These symptoms are present on most days, and in most patients, they occur every day or nearly every day. Patients usually report that symptoms increase as the day goes on. 

If a patient doesn’t have symptoms daily, a diagnosis of 3PD is still made if symptoms are present for more than 15 out of 30 days. 

Symptom Exacerbation

It’s in the name - 3PD occurs with persistent symptoms, meaning that they’re always or nearly always present, and don’t have specific triggers. But in patients with 3PD, symptoms get worse with:

  • Upright posture - standing or walking. In some patients, this may also include sitting unsupported

  • Active or passive movement regardless of the direction or position. Examples include walking, riding in a car, or being jostled in a group of people.

  • Moving visual stimuli or complex visual patterns. These can be things like a passing car, a busy carpet or wallpaper, or large screens. In some cases, a small object held up close, like a computer or phone screen, can have the same effect.

Onset and Clinical Presentation

Most often, 3PD develops as a patient recovers from another condition that disrupts balance or causes vertigo or dizziness. These can include peripheral or central vestibular disorders, vestibular migraine attacks, panic or anxiety attacks that include dizziness, concussion, whiplash, or other medical illnesses. 

Most conditions that precede 3PD are acute or episodic, and 3PD usually develops as the acute symptoms of the initial condition resolve. Patients usually don’t have a symptom-free period between the acute and chronic conditions, but as the acute vertigo symptoms fade, they develop the characteristic chronic symptoms of 3PD. This can vary, and less often some patients develop 3PD very gradually.

3PD may be present alone, or it may co-exist with other diseases or disorders. 


Pathophysiology

Prevalence: About 15-20% of patient presenting for evaluation of vestibular symptoms are estimated to have 3PD. This makes it one the most common vestibular diagnoses in adults. 

The reasons why some people develop 3PD are poorly understood. Hypotheses include changes in strategies used for postural control strategies, changes in multi sensory integration, and inefficiencies in the brain networks responsible for spatial orientation. As we often hear, more research is required. 

Risk Factors

There are certain factors that can be correlated with developing 3PD. As always, correlation is not causation - these things go together, but we can’t say what causes what. However, there is a higher risk of developing 3PD in people with:

  • Anxiety-related personality traits (neuroticism and introversion)

  • Family or personal histories of anxiety disorders

On the other hand, people with traits like resilience and optimism were less likely to develop persistent dizziness after an acute vestibular disorder. 

Management

I say this all the time, but rehab is not a DIY project. This is not a condition that a patient should try to self-manage, for a variety of reasons. 3PD should be managed by an experienced vestibular rehab therapist.


If you’re interested, here are the diagnostic criteria for 3PD (from Staab JP et al., 2017)

A) Primary symptom: Dizziness, unsteadiness, non-spinning vertigo

  • Present on most days for ≥ 3 months

  • Persistent but can wax and wane in severity (spontaneously or provoked)

    • Do not need to be present continuously for entire day

    • Tend to increase as day progresses

B) Exacerbating factors

  1. Upright posture

  2. Active or passive motion

  3. Moving visual stimuli or complex visual patterns

C) Onset: Precipitated by an acute vestibular event or other even that disrupts postural control

  • Vestibular disorders (25-30%)

  • Vestibular migraine (15-20%)

  • Panic/anxiety (15% each)

  • Concussion/whiplash (10-15%)

  • Autonomic disorders (7%) or other events which may produce dizziness (ex. cardiac dysrhythmia, adverse drug reactions)

D) Symptoms cause significant distress or functional impairment

E) Symptoms are not better accounted for by another disease or disorder

  • Although 3PD may co-exist with other diseases or disorders


Reference

Home Exercise Programs as Daily Goals: What You Need to Know

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When you prescribe a home exercise program, how much time do you spend thinking about how the patient or client interprets that program? I’m not talking about whether or not they enjoy it, or how it affects their symptoms. I’m talking about how it makes them feel about themselves. 

As therapists, we think of home exercise programs as a tool. When working with patients with persistent concussion symptoms, home exercises might include balance training, some specific movements to help neck dysfunction, vestibular habituation exercises, or aerobic exercise to improve exertion tolerance. We labour over how to help our patients get the most benefit from the exercises, but we acknowledge that with these exercises, patients risk exacerbating their symptoms. So we educate patients about how to handle that. If all goes well, they do the exercises, and they slowly begin to improve. 

The flip side

But think about it from the perspective of a patient. They feel rotten, and if symptoms are chronic, they’re likely struggling emotionally. Most patients with persistent symptoms are confronted with a lot of “can’t”s - they can’t do what they used to do, or as much, or as well, or for as long. There is a big emotional component to persistent concussion symptoms, regardless of what the symptoms actually are. This can be made worse if that patient is dealing with anxiety or depression, both of which are common and understandable. 

In this emotional landscape, a home exercise program can become a daily goal, and meeting or not meeting that goal can affect how a patient feels about themselves. Meeting a daily goal can feel like a big accomplishment, especially if it’s the only success they experience that day. Not meeting that goal can be one more “can’t” on the long list for that day. You didn’t mean for it to be a goal, but your patient made it one, and now meeting or not meeting that target can feed into a lot of emotions:

Am I doing enough = Am I good enough? 

Will this ever get easier = Will I ever get better? 

This makes me feel rotten = I feel so different from before. 

Think I’m exaggerating? Ask your patients with chronic, persistent, debilitating post-concussion symptoms. 

So what’s the solution?

Let’s acknowledge one thing: A home exercise is a patient goal. They want to complete the exercises, they want to succeed at the exercises. You might not like the emotional baggage that these programs can be saddled with, but for some patients, this will not change. How they feel after attempting their exercises will affect their emotional state, the rest of their day, and their overall symptom burden. 

As a therapist, you need to accept that. And you need to bear that in mind when you construct home exercise programs.

When you think of a home exercise program the way your patient does - as an outcome-focused goal - it can be performance-based or symptom-based.

Performance-based programs: “Stop after ____ minutes/metres/reps” 

This type of program becomes a goal focused on accomplishing something. How many reps of their neck exercises should they do? How many minutes of vestibular rehab? How many blocks or kilometres or steps should they walk? 

Symptom-focused programs: “Stop when your current symptoms worsen or when new symptoms develop”

This type of program disregards metrics other than how the patient feels. They monitor their symptoms, and make an individual decision about when to stop exercising. 


Both types of programs have pros and cons 


If a perfomance-based program has appropriate and achievable goals, the patient has a sense of being successful - which can be really valuable for patients who feel like they’re failing in other areas of life. The downside, though, is if the patient is not in touch with their symptoms, they aren’t learning self-awareness and not learning to respect their own limits. 

On the other hand, a symptom-based program can be essential in teaching a patient to self-monitor, and places the patient in control of his or her own care. It can also teach the patient that they can control their own symptoms, rather than feeling like their symptoms control them. But for patients who are already symptom-focused and anxious, this type of program can make them hyper-aware and even more anxious about exacerbating symptoms. It can also send the message that symptom-provocation is a bad thing (which is not always true). 

Neither type of program is always good or always bad, and both are better for some patients than for others

Sometimes one type of program is better early in the rehab program, but later you need to choose another strategy. Taking the time to understand your patient and their perspective will allow you to set up the best program at the best time - yet again, another reason why concussion rehab is not a DIY project!