Persistent Postural-Perceptual Dizziness (PPPD)

PPPD is one of the most common causes of chronic dizziness. It is a functional disorder, meaning the balance system itself is structurally intact, but the way the brain processes balance and visual information has become oversensitive. PPPD often develops after another vestibular event (such as BPPV, vestibular neuritis, or vestibular migraine) and responds well to targeted vestibular rehabilitation.

Understanding PPPD

After an initial trigger, the brain can stay in a “high alert” mode for balance, over-relying on visual and postural cues. This creates persistent symptoms even after the original problem has resolved.

Signs and Symptoms

Symptoms are present on most days for three months or more and typically include:

• Persistent unsteadiness or a “rocking/swaying” sensation
• Dizziness that is worse when upright and moving
• Sensitivity to busy visual environments (supermarkets, screens, traffic)
• Worsening with motion and complex surroundings
• Symptoms that improve when lying down or distracted

Common Triggers

• A previous episode of vertigo (BPPV, neuritis)
• Vestibular migraine
• A panic or anxiety episode with dizziness
• Medical illness or a period of inactivity

Assessment

Our vestibular physiotherapists complete a comprehensive assessment to:

• Confirm the pattern: Identifying the features typical of PPPD
• Rule out active causes: Screening for BPPV and other vestibular conditions
• Assess balance and gaze: Measuring how you respond to movement and visual load
• Identify triggers: Understanding the situations that provoke symptoms

Physiotherapy Treatment

Vestibular Rehabilitation

• Graded exposure to provoking movements and environments
• Habituation exercises to reduce sensitivity over time
• Gaze stability and balance retraining
• Gradual return to activities and environments you’ve been avoiding

Education and Self-Management

• Understanding why symptoms persist (and why they are not dangerous)
• Strategies to reduce visual and motion sensitivity
• Pacing and confidence-building
• Coordination with GPs and ENT/neurology where appropriate

Why a Structured Approach Helps

Avoiding movement and busy environments tends to make PPPD worse over time. A carefully graded program retrains the brain to tolerate movement and visual input again, steadily reducing symptoms.

Expected Outcomes

With consistent vestibular rehabilitation, most people experience significant improvement in dizziness, steadiness, and confidence, and return to the activities and environments they had been avoiding.