Persistent Postural-Perceptual Dizziness: Precipitating Conditions, Co-morbidities and Treatment With Cognitive Behavioral Therapy

Transcranial magnetic stimulation use with chronic vestibular disorders: A scoping review

BackgroundTranscranial magnetic stimulation (TMS) is extensively studied as a neuromodulation tool in neurological disorders. However, its use with the central vestibular disorders is limited.ObjectiveTo evaluate the utility of TMS as an assessment and treatment of chronic vestibular disorders and propose recommendations for future work.MethodsA comprehensive search of four electronic databases (PubMed, CINAHL, PsycINFO, and Rehabilitation and Sports Medicine Source) identified 206 records of which 16 studies were included.ResultsOne study used TMS as a neurophysiological assessment tool and 15 used repetitive TMS (rTMS) as a neuromodulatory intervention. Mal de Debarquement syndrome was the most frequently explored diagnosis. Dorsolateral prefrontal cortex and the cerebellum were the most frequent sites for rTMS application. Statistically significant improvements were noted on the Dizziness Handicap Inventory (3/7 studies) but clinically significant improvements were not observed. Postural control (7/7 studies) showed improvements along with VOR gain (1/1 studies).ConclusionsTMS shows promise as both a neurophysiological assessment tool and a neuromodulatory intervention for chronic vestibular disorders. Methodological limitations of the studies warrant caution while interpreting the results. Larger sample sizes, control groups, optimal neuroanatomical targeting, and dosing along with active rehabilitation are required to determine effectiveness in chronic vestibular disorders.

Mental Health Education and Utilization Among Patients with Vestibular Disorders

To explore the receipt of mental health education, assessment, and referrals, and mental health service use among individuals with vestibular disorders. Patients with vestibular disorders living in the US, Australia, Canada, and the UK were surveyed through social media forums. Questionnaires assessed demographics, anxiety (Generalized Anxiety Disorder-7), depression (Center for Epidemiological Studies Depression-10), dizziness (Dizziness Handicap Inventory), and type of professional providing mental health education, assessment, referral, and treatment. The 226 participants were largely White (90%), educated (67% holding an associate's degree or higher) women (88%) with an average age of 45 who self-identified as having chronic vestibular symptoms (78%), as opposed to episodic ones (22%). Fifty-two percent reported never receiving verbal education, written education (69%), mental health assessment (54%), or referral (72%). Participants were more likely to receive mental health treatment in the past if they had received verbal resources and/or referrals from clinicians. The majority of patients with vestibular disorders report that medical professionals have not provided education, mental health assessment, or a mental health referral.

vHIT and fHIT in Patients With Migraine, Vestibular Migraine, and Persistent Postural-Perceptual Dizziness

OBJECTIVE

Impairment in the integration of different vestibular stimuli is the proposed mechanisms in vestibular migraine (VM). In this study, it was aimed to assess the vestibulo-ocular reflex (VOR) and dynamic visual acuity (DVA) in patients with VM and to compare the results with migraine without vestibular symptoms (MwoV), and persistent postural-perceptual dizziness (PPPD) to find out if there are discriminative differences and search for a correlation with the levels of anxiety.

METHODS

Twenty-two patients with MwoV, 23 patients with VM, 22 patients with PPPD, and 23 healthy controls (HC) were studied. Video head impulse test (vHIT) and functional head impulse test (fHIT) without and with an optokinetic background (OB) were performed. Percentage of correctly identified optotypes (CA%) was considered for the fHIT test. Beck anxiety inventory (BAI) was used to assess anxiety.

RESULTS

Lateral canal vHIT gain of the patient groups were not different from the healthy controls (p > 0.05). fHIT and fHIT/OB CA% results of all patient groups were lower than the HC (p < 0.005), and VM patients had the lowest scores for both tests. BAI scores of the PPPD patients were the highest and a correlation between anxiety levels, and fHIT results could not be identified (p > 0.05).

CONCLUSION

Prominent CA% drop by the use of an OB was the main finding in patients with VM. This discriminative feature was not correlated with anxiety scores. Difficulty in resolving the conflict between visual and vestibular inputs seem to be the underlying mechanism.

LEVEL OF EVIDENCE

3 Laryngoscope, 135:857-863, 2025.

Effect of benign paroxysmal positional vertigo course on residual symptoms after successful canalith repositioning procedures: A prospective controlled trial

BACKGROUND

Following successful canalith repositioning procedures (CRPs), some patients with benign paroxysmal positional vertigo (BPPV) may experience residual symptoms. There is currently no consensus on whether these residual symptoms are related to the disease duration.

OBJECTIVE

To examine the impact of BPPV duration on the persistence of residual symptoms following successful CRP.

METHODS

A total of 102 idiopathic BPPV patients were enrolled and categorized into short-course and long-course groups based on the duration of the disease. The course of disease in the short-course group was less than or equal to 7 days. The long course of disease was longer than 7 days. All patients underwent swivel-chair-assisted CRP and were followed up 7-10 days after successful CRP. The Dizziness Handicap Inventory (DHI) questionnaire was administered to all patients before and after CRP.

RESULTS

Before CRP, significant differences were observed between the two groups in total DHI score and its subdomains: Physical (DHI-P), Functional (DHI-F), and Emotional (DHI-E) (p < 0.05), indicating that long disease duration significantly affected all patient aspects. After CRP, significant differences remained in total DHI, DHI-P, DHI-F, and DHI-E scores (p < 0.05), with the long-course group consistently scoring higher. However, no significant differences were found in the changes in DHI scores across dimensions before and after CRP between the two groups.

CONCLUSION

The duration of BPPV did not influence CRP outcomes, but patients with a longer disease course were more likely to experience residual symptoms after successful CRP.

Research Progress on the Potential Pathogenesis of Persistent Postural-Perceptual Dizziness

INTRODUCTION

Persistent postural-perceptual dizziness (PPPD) is the most prevalent chronic functional dizziness in the clinic. Unsteadiness, dizziness, or non-spinning vertigo are the main symptoms of PPPD, and they are typically aggravated by upright posture, active or passive movement, and visual stimulation. The pathogenesis of PPPD remains incompletely understood, and it cannot be attributed to any specific anatomical defect within the vestibular system. Consequently, there is no objective examination method for the disease, and the diagnosis primarily depends on the symptoms of the patient, which lack specificity.

METHODS

To better understand the pathogenesis of PPPD and to aid in the development of novel diagnostic strategies and therapies, we conducted a comprehensive narrative review of the relevant literature. We performed a search for literature in PubMed using the following search phrases: "persistent postural-perceptual dizziness" OR "PPPD" OR "chronic subjective dizziness" OR "functional dizziness" OR "space-motion discomfort" OR "visual vertigo" OR "phobic postural vertigo." The reference list of relevant studies was also screened. The search was limited to publications in English, and the final references were selected based on their relevance to the scope of this review.

RESULTS

This review summarizes recent studies that have investigated the pathogenesis of PPPD. It is traditionally assumed that PPPD may result from altered postural control strategies, cortical integration of threat assessment and spatial orientation, or abnormal integration of multi-sensory information. Recent studies have shown that the brain structure, activity, structural connectivity, and even cerebral perfusion of patients with PPPD differ from those of healthy individuals. Furthermore, PPPD patients are different from healthy individuals in spatial navigation ability, vestibular perception thresholds, central sensitization, and oxidative stress. These findings provide additional anatomical and behavioral insights into the pathogenesis of PPPD, suggesting that PPPD may arise from shifts in the interactions among emotional, visuo-vestibular, and sensorimotor networks.

CONCLUSION

Understanding the complex pathogenesis of PPPD is crucial for the development of novel therapeutics against PPPD. Following the existing findings, our review suggests directions for future research.

Repetitive transcranial magnetic stimulation as add-on the rapyin persistent postural-perceptual dizziness

Background

This study aims to evaluate the clinical effectiveness of repetitive transcranial magnetic stimulation (rTMS) when used as an add-on therapy for individuals with persistent postural-perceptual dizziness (PPPD).

Methods

In this randomized controlled, double-blind trial conducted at Shangluo Central Hospital, patients with PPPD diagnosed in the neurology departments were included. Participants were randomized into a rTMS treatment group and a control group in a 1:1 ratio by the randomized grouping method. Patients in both groups received conventional treatment, with the rTMS treatment group underwent daily rTMS sessions, whereas the control group received sham rTMS treatments following the same schedule. The effectiveness of the treatments was primarily assessed using the Dizziness Handicap Inventory (DHI), Hamilton Anxiety Rating Scale (HAMA), and Hamilton Depression Rating Scale (HAMD), which measured symptoms of vertigo, anxiety, and depression at baseline, after two weeks, and at the end of four weeks.

Findings

Of the 46 participants recruited, 2 were excluded due to contraindications, 22 were randomly assigned to the rTMS treatment group, and 22 were assigned to the control group. Ultimately, 2 withdrew for personal reasons, and data from 42 participants were included in the outcome analysis. HAMA, HAMD and DHI scores were significantly lower in the rTMS treatment group than in the control group after 4 weeks of treatment (p<0.05). A positive correlation was also observed between DHI scores and HAMA or HAMD scores.

Conclusions

This pilot study demonstrated that rTMS is a beneficial add-on therapy for patients with PPPD.

Self-reported dizziness, balance, and multisensory impairment following mild traumatic brain injury: an exploratory study

Dizziness following mild traumatic brain injury (mTBI), or concussion, is common and can encompass multiple sensations reflecting diverse aetiologies. This exploratory study investigated the types of dizzy sensations experienced, their evolution, and relationship with other post-concussion symptoms. Thirty New Zealanders (24 female) aged 49 ± 16 years who experienced dizziness or imbalance following their injury completed the Dizziness Handicap Inventory, Visual Vertigo Analogue Scale, and the Hospital Anxiety and Depression Scale. Additional custom questionnaires probed subjective experiences of dizziness and balance, headaches, and difficulties with auditory processing and vision. Just over half the participants (56.7%) experienced a single mTBI. The median time interval since the injury was 16 months (IQR = 24 months). Participants usually reported multiple dizzy symptoms which developed within a week of the injury, although delays of up to six months were reported. Most participants (70%) felt their symptoms improved over time, while lack of improvement was associated with a history of multiple mTBI (P = 0.020). Moderate to strong correlations between questionnaire scores representing dizziness handicap, visual vertigo severity, and auditory processing difficulties (P < 0.001) suggest that dizziness and sensory impairment following mTBI are multi-modal and likely to benefit from holistic, multidisciplinary treatment.

Addressing the Overlapping Challenges of Benign Paroxysmal Positional Vertigo (BPPV) and Persistent Postural-Perceptual Dizziness (PPPD): Impacts and Integrated Management

Benign paroxysmal positional vertigo (BPPV) and persistent postural-perceptual dizziness (PPPD) are challenging vestibular disorders with overlapping symptoms that complicate diagnosis and treatment. BPPV causes transient vertigo with head movements, while PPPD involves persistent dizziness and unsteadiness. Both significantly impact the quality of life, including emotional well-being. This review examines the relationship between BPPV and PPPD, stressing the need for comprehensive, multidisciplinary management. Effective treatment must address both physical and psychological aspects, using personalized care, technological innovations, and patient education to improve outcomes and enhance the quality of life for those affected.

Persistent postural-perceptual dizziness: A functional neuro-otologic disorder

Persistent postural-perceptual dizziness (PPPD) is a functional neuro-otologic disorder that is the most frequent cause of chronic vestibular syndrome. The core vestibular symptoms include dizziness, unsteadiness, and non-spinning vertigo, which are exacerbated by an upright posture or walking, active or passive motion, and exposure to moving or complex visual stimuli. PPPD is mostly precipitated by acute or episodic vestibular diseases; however, its symptoms cannot be accounted for by its precipitants. PPPD is not a diagnosis of exclusion, but may coexist with other structural diseases. Thus, when diagnosing PPPD, the patient's symptoms must be explained by PPPD alone or by PPPD in combination with a structural illness. PPPD is most frequently observed at approximately 50 years of age, with a female predominance. Conventional vestibular tests do not reveal any specific signs of PPPD. However, the head roll-tilt subjective visual vertical test and gaze stability test after exposure to moving visual stimuli may detect the characteristic features of PPPD, that is, somatosensory- and visually-dependent spatial orientation, respectively. Therefore, these tests could be used as diagnostic tools for PPPD. Regarding the pathophysiology of PPPD, neuroimaging studies suggest shifts in interactions among visuo-vestibular, sensorimotor, and emotional networks, where visual inputs dominate over vestibular inputs. Postural control also shifts, leading to the stiffening of the lower body. To treat PPPD, selective serotonin reuptake inhibitors/serotonin noradrenaline reuptake inhibitors, vestibular rehabilitation, and cognitive behavioral therapy are used alone or in combination.

Functional Neurological Disorder Presenting After Concussion: A Retrospective Case Series

OBJECTIVE

Although a majority of individuals recover from a concussion within weeks of the index injury, a substantial minority of patients report persistent postconcussion symptoms. Some of these symptoms may reflect a diagnosis of functional neurological disorder (FND). The authors evaluated the relationship between persistent postconcussion symptoms and FND symptoms.

METHODS

In this retrospective chart review, the authors characterized demographic and clinical information from 50 patients with a confirmed diagnosis of FND whose functional neurological symptoms started after a concussion.

RESULTS

Patients who developed FND after a concussion had high rates of baseline risk factors for both persistent postconcussion symptoms and FND. After the concussive event, functional neurological symptoms presented abruptly or developed insidiously over time. Functional neurological symptoms ranged widely and included gait symptoms, seizures, speech and language symptoms, weakness, sensory symptoms, tremors, and vision and oculomotor symptoms.

CONCLUSIONS

Functional neurological symptoms can arise after a concussion. FND should be considered in the differential diagnosis of individuals presenting with neurological symptoms beginning after a concussion. By failing to recognize functional symptoms, clinicians may inadvertently reinforce negative health-related beliefs regarding a patient's injured brain.

Persistent Challenges: A Comprehensive Review of Persistent Postural-Perceptual Dizziness, Controversies, and Clinical Complexities

Persistent postural-perceptual dizziness (PPPD) is a chronic and disabling disorder characterized by persistent dizziness, unsteadiness, and imbalance. It often arises without an identifiable cause and is exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. This complex pathophysiology and the psychological dimensions of its symptomatology pose a significant challenge to clinicians. PPPD presents diagnostic challenges and a lack of standardized treatment options, underscoring the need for multidisciplinary approaches encompassing pharmacotherapy, vestibular rehabilitation, and psychological interventions for effective management. Bridging the gaps in understanding PPPD requires collaborative efforts across disciplines, emphasizing integrated research approaches and patient support networks to enhance care and improve outcomes. This review explores the challenges, controversies, and clinical complexities of PPPD, highlighting the importance of a patient-centered approach.

Age-related differences in the characteristics of persistent postural-perceptual dizziness

Objective

To investigate differences in the clinical characteristics of patients with persistent postural-perceptual dizziness (PPPD) according to age.

Methods

We retrospectively reviewed 143 patients diagnosed with PPPD. Patients were classified into three groups by age: young group (19 to 44 years, n = 60), middle-age group (45 to 64 years, n = 56), old group (65 to 85 years, n = 27). Demographic data, scores of the Dizziness Handicap Inventory (DHI), the Niigata PPPD Questionnaire (NPQ), the Hospital Anxiety and Depression Scale (HADS), precipitating conditions, and the results of vestibular function tests including caloric testing, video head impulse test (vHIT), cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs), and posturography, were compared among the three groups.

Results

While there were no significant differences in the scores of the DHI or NPQ, the total score and anxiety score in HADS in the young group were significantly higher than in the old group (p < 0.05, each). On the other hand, for precipitating conditions, the rate of peripheral vestibular diseases was significantly greater in the old group (77.8%) compared to the young group (41.7%, p < 0.01). There was no significant difference in the results of caloric testing, vHIT, cVEMPs, or oVEMPs among the three groups. For posturography, the velocity of the center of pressure with eyes-open as well as with eyes-closed was significantly greater in the old group compared to the young group and the middle-age group (p < 0.005, respectively).

Conclusion

The clinical characteristics of PPPD were different according to age. Young patients tended to have stronger anxiety than old patients whereas the old patients had a higher proportion of peripheral vestibular diseases among the precipitating conditions compared to young patients.

Habituation disorders in auditory middle latency response of persistent postural-perceptual dizziness patients

Objectives

To study habituation disorders in auditory middle latency response (AMLR) to repetitive stimuli of persistent postural-perceptual dizziness (PPPD) patients.

Subjects

Twenty-eight PPPD (10 men and 18 women, mean 59.5 years of age, 26-81 years of age) were enrolled. For comparison, data of 13 definite vestibular migraine (VM) patients (3 men, 10 women, mean age 45.5), 13 definite unilateral Meniere's disease (MD) patients (2 men, 11 women, mean age 50.6), and 8 healthy control (HC) subjects (2 men, 6 women, mean age 37.1) in the previous study were utilized.

Methods

The electrodes were placed on the vertex and the spinal process of the fifth cervical vertebra. Clicks (0.1 msec, 70 dB nHL) were binaurally presented and averaged (800 times). Averaged responses were divided into 4 sets (S1 to S4) according to the temporal order. As peaks, Na, and Pa were identified, and relative Na-Pa amplitudes in S2-S4 to S1 were analyzed.

Results

The mean relative amplitude of PPPD patients showed lack of habituation (potentiation) as shown in VM patients, although the extent of potentiation was weaker than VM. Comparison of relative S4 amplitudes showed significant differences among the 4 groups (p = 0.0013 one-way ANOVA), Multiple comparison revealed significant differences between PPPD and MD (p = 0.0337 Dunnet's test).

Conclusion

PPPD patients showed lack of habituation (potentiation) of Na-Pa amplitude in AMLR to repetitive stimuli. Lack of habituation (potentiation) might be associated with sensory processing disorders in PPPD.

Clinical characteristics of persistent postural-perceptual dizziness and its visual subtype in Korean patients: A multicenter cross-sectional study

OBJECTIVES

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder for which the Bárány Society has established diagnostic criteria. This nationwide multicenter study aims to investigate the clinical features of individuals with definite PPPD and clinical variant PPPD who do not fully meet the diagnostic criteria, with a particular focus on visual exaggeration.

METHODS

Between September 2020 and September 2021, a total of 76 individuals with definite PPPD and 109 individuals with clinical variant PPPD who did not meet all three exacerbating factors outlined in Criterion B were recruited from 18 medical centers in South Korea. The study gathered information on demographic factors, clinical manifestations, balance scales, and personality assessments.

RESULTS

Comparative analysis between groups with definite PPPD and clinical variant with visual exacerbation revealed no significant differences in sociodemographic characteristics, clinical course, dizziness impact, and specific precipitants. Only disease duration was significantly longer in definite PPPD compared with variant with visual exacerbation. However, the variant without visual exacerbation displayed significantly reduced rates of panic disorder, diminished space-motion discomfort, lesser impact of dizziness, and decreased prevalence of depression when compared with the definitive PPPD.

CONCLUSION

This is the first comprehensive nationwide study examining clinical features of both definite PPPD patients and its clinical variants, considering visual exacerbating factors. Differences in dizziness and personality traits emerged between definite PPPD and its potential variant without visual issues. Our results highlight the possibility of a distinct clinical variant of PPPD influenced by visual dependency.

Cognition in vestibular disorders: state of the field, challenges, and priorities for the future

Vestibular disorders are prevalent and debilitating conditions of the inner ear and brain which affect balance, coordination, and the integration of multisensory inputs. A growing body of research has linked vestibular disorders to cognitive problems, most notably attention, visuospatial perception, spatial memory, and executive function. However, the mechanistic bases of these cognitive sequelae remain poorly defined, and there is a gap between our theoretical understanding of vestibular cognitive dysfunction, and how best to identify and manage this within clinical practice. This article takes stock of these shortcomings and provides recommendations and priorities for healthcare professionals who assess and treat vestibular disorders, and for researchers developing cognitive models and rehabilitation interventions. We highlight the importance of multidisciplinary collaboration for developing and evaluating clinically relevant theoretical models of vestibular cognition, to advance research and treatment.

Characterization of Vestibular Perception in Patients with Persistent Postural-Perceptual Dizziness

OBJECTIVE

To assess vestibular (i.e., passive self-motion) perception in patients diagnosed with persistent postural-perceptual dizziness (PPPD).

STUDY DESIGN

Case-controlled, cross-sectional, observational investigation.

SETTING

Single-center laboratory-based study.

PATIENTS

Thirteen patients with PPPD, 13 age-matched healthy control volunteers. Of those with PPPD, eight had co-occurring vestibular migraine (VM).

INTERVENTIONS

All participants completed a vestibular threshold test battery reflecting perception with predominant inputs from ( a ) the otoliths (1-Hz interaural y -axis translation, 1-Hz superior-inferior z -axis translation), ( b ) the semicircular canals (2-Hz yaw rotation, 2-Hz tilts in the planes of the vertical canal pairs), and ( c ) and canal-otolith integration (0.5-Hz roll tilt).

MAIN OUTCOME MEASURES

Direction-recognition thresholds for each vestibular threshold test condition.

RESULTS

Across all patients with PPPD, higher thresholds for superior-inferior z -translations thresholds in comparison to age-matched healthy control participants were identified ( p < 0.001). Those patients with co-occurring VM and PPPD (PPPD/+VM) displayed significantly higher z -translation thresholds ( p = 0.006), whereas patients with PPPD without VM (PPPD/-VM) displayed significantly higher roll tilt thresholds ( p = 0.029).

CONCLUSIONS

Patients with PPPD did not display a global worsening of passive self-motion perception as quantified by vestibular perceptual thresholds. Instead, patients with PPPD displayed elevated thresholds for only roll tilt and z -translation thresholds, with the relative change in each threshold impacted by the co-occurrence of VM. Because both z -translation and roll tilt motions are reliant on accurate gravity perception, our data suggest that patients with PPPD may exhibit impaired processing of graviceptive cues.

Effect of public square dancing combined with serotonin reuptake inhibitors on persistent postural-perceptual dizziness (PPPD) in middle-aged and older women

BACKGROUND

Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disorder that causes chronic dizziness and limits daily activities. Although pharmacology, vestibular rehabilitation, and cognitive behavioral therapy have been proposed to have some efficacy, they have certain limitations. Some patients with PPPD report that public square dancing can effectively relieve the symptoms of dizziness and instability, and their mood improves.

OBJECTIVE

To evaluate the effects of combining public square dancing with serotonin reuptake inhibitors (SSRIs/SNRIs) on the subjective sensations of dizziness, balance enhancement, anxiety, and depressive symptom regulation in middle-aged and older women with PPPD.

MATERIALS AND METHODS

In this trial, 124 patients diagnosed with PPPD were enrolled. Among them, 64 patients were randomly assigned to the experimental group (EG), where they received square dance training combined with serotonin reuptake inhibitors. The remaining 60 cases were randomly assigned to the control group (CG), where they received only serotonin reuptake inhibitors and did not participate in organized sports activities, allowing them freedom in their daily lives. Data from the Dizziness Handicap Inventory (DHI), Hospital Anxiety and Depression Scale (HADS), Active-specific Balance Confidence Scale (ABC), and Vestibular Disorder Activities of Daily Living Scale (VADL) were collected and compared at the beginning, 3 months, and 6 months of the trial to evaluate the effect of public square dancing on middle-aged and older women with PPPD.

RESULTS

There were no significant differences between the EG and CG before the trial. Compared with baseline measures, DHI, HADS, ABC, and VADL scores improved as the experiment progressed, and the improvements were more pronounced in the EG.

CONCLUSION

Public square dancing combined with serotonin reuptake inhibitors has a positive impact on the subjective sensations of dizziness, balance enhancement, anxiety, and depressive symptom regulation in middle-aged and older women with PPPD.

What's in a Name? Chronic Vestibular Migraine or Persistent Postural Perceptual Dizziness?

Current consensus diagnostic criteria for vestibular migraine (VM) describes this as an episodic disorder. However, a minority of patients report prolonged (>72 h duration) or even persistent VM symptoms, prompting whether a chronic variant of vestibular migraine (CVM) should be introduced to the current classification and how best to define it. Here we summarize current evidence of such a potential chronic variant of VM and critically review proposed definitions for CVM. Potential approaches to establish a diagnostic framework for CVM include (a) following the distinction between episodic and chronic migraine headaches, namely, frequent and/or prolonged episodes of VM (but not persistent vertigo or dizziness) in the context of chronic migraine headaches or (b) daily dizzy spells over more than 6 months that responded well to prophylactic anti-migraine therapy. A key challenge when defining diagnostic criteria for CVM is how to distinguish it from other chronic vestibular syndromes such as motion sickness, persistent postural-perceptual dizziness (PPPD), and mal de débarquement syndrome. Indeed, more than 50% of patients with PPPD and up to 46% with mal de débarquement syndrome fulfil diagnostic criteria for episodic migraine headaches, suggesting these disorders may all lie along a spectrum. We propose that when VM becomes persistent, it is best classified as PPPD but that VM and PPPD are not mutually exclusive, such that patients with PPPD need not have features of VM, and the triggering event for persistent dizziness may be independent of migraine. However, further research is needed to better characterize the spectrum of clinical phenotypes in patients with chronic dizziness, migraine headaches and anxiety, to define whether a chronic variant of VM sufficiently differs from current persistent dizziness definitions.

Preceding Benign Paroxysmal Positional Vertigo as a Trigger for Persistent Postural-Perceptual Dizziness: Which Clinical Predictors?

OBJECTIVE

Persistent postural-perceptual dizziness (PPPD) is a syndrome described as secondary, when it is the consequence of an organic disorder (s-PPPD), or primary, when no somatic triggers can be identified. We evaluated a group of patients diagnosed as s-PPPD, with Benign Positional Paroxysmal Vertigo (BPPV) as the main somatic trigger, with the aim of identifying the predictive clinical elements of evolution towards PPPD.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

We evaluated 126 patients diagnosed with PPPD; 54 patients were classified as p-PPPD (43%) and 72 as s-PPPD (57%). Of these, 51 patients had BPPV as a somatic trigger of PPPD, and in this group, we evaluated the prevalence of some clinical features (age, sex, latency between the onset of BPPV and the final diagnosis, recurrence of BPPV and the presence of migraine headache) for comparison with a group of patients who suffered from BPPV without an evolution towards PPPD (control group).

RESULTS

In the group with PPPD secondary to BPPV, we found a significantly higher mean age and a longer latency between the onset of BPPV and the final diagnosis compared to the control group. No difference between the two groups was found regarding sex, recurrence rate and the presence of migraine headache.

CONCLUSIONS

The parameters most involved as potential precipitants of PPPD after BPPV were the age of the patients and a long latency between the onset of BPPV and the final diagnosis; the mean age of the subjects who developed PPPD following BPPV was significantly higher. These findings lead us to emphasize the importance of the early identification and treatment of BPPV, especially in older patients.

Persistent Postural-Perceptual Dizziness: Review and Update on Key Mechanisms of the Most Common Functional Neuro-otologic Disorder

Persistent postural-perceptual dizziness (PPPD) is a functional neuro-otologic (vestibular) disorder manifesting dizziness, unsteadiness, or nonspinning vertigo lasting 3 months or more and exacerbated by upright posture, active or passive motion, and complex visual stimuli. PPPD is the most common cause of chronic vestibular symptoms. Early pathophysiologic models of PPPD emphasized the adverse effects of anxiety on postural control and spatial orientation. More recent concepts added predictive processing of sensory inputs and alterations in motion perception. Herein, a third-generation model incorporates prioritization of postural stability over fluid locomotion to explain symptoms, physiologic and neuroimaging data, and effects of current treatments.

Assessing the efficacy of perilymphatic fistula repair surgery in alleviating vestibular symptoms and associated auditory impairments

Perilymph Fistula (PLF), abnormal communication between the fluid-filled space of the inner ear and the air-filled space of the middle ear, is a significant cause of vestibular and auditory symptoms. This is a retrospective study of 22 cases treated with PLF repair surgery, selected based on our surgical indication. We analyzed the characteristics of these 22 cases and evaluated the efficacy of PLF repair surgery in treating vestibular and auditory symptoms. Cases with antecedent events had significantly shorter intervals before surgery. The postoperative recovery from vestibular symptoms following PLF repair surgery was strikingly rapid, with 82% of cases demonstrating marked improvement within a week, even in chronic cases. Despite the notable absence of a control group in the study, the marked improvements in vestibular symptoms and substantial reductions in Dizziness Handicap Inventory (DHI) scores suggest that the observed benefits are attributable to the surgical intervention. Further, timely surgery showed improvements in hearing, with some benefits also seen in late-stage surgeries. Using the perilymph-specific protein Cochlin-tomoprotein (CTP) as a diagnostic biomarker, we could prove that PLF could be responsible for disequilibrium and related auditory disturbances in these patients. A new hypothesis is proposed that the chronic disequilibrium experienced by many PLF patients is due to enhanced mobility of the utricle and not to endolymphatic hydrops. Further research is needed to fully elucidate PLF's symptoms and treatment efficacy using the surgical indication we developed.

Treating Psychiatric Symptoms in Persistent Postural Perceptual Dizziness

Persistent postural perceptual dizziness (PPPD) is a functional neurological disorder characterized by troublesome feelings of dizziness and might be precipitated by vestibular events, postural changes, psychopathologies, and/or a person's perceptual experiences. The diagnosis is confirmed by assessing a patient's history. A variety of psychiatric symptoms are associated with PPPD; anxiety and depression are the most common. Psychotherapy and pharmacotherapy can be clinically helpful in reducing psychiatric symptoms and dizziness. Early intervention improves prognosis.

Management of Migraine-Associated Vestibulocochlear Disorders

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

[Expert consensus on the diagnosis of isolated otolith dysfunction]

Isolated otolith dysfunction(iOD) involves a group of unexplained vestibular syndromes that manifest clinically as a sense of translation, tilting or floating, and blurred vision with head movement, with normal semicircular canal function but abnormal otolith function on laboratory vestibular testing. As vestibular medicine has gained widespread popularity in recent years, increasing attention has also been paid to iOD and case reports, clinical studies and diagnostic criteria have been published. However, there is no consensus document to guide the diagnosis of this disease in China. In this context, the Special Committee on Vertigo of China Medical Education Association organized a group of domestic experts in vestibular medicine and formulated this diagnostic consensus after thorough discussion based on the latest evidence in China and abroad, in order to promote the best clinical practice for iOD.

Balance Rehabilitation with Peripheral Visual Stimulation in Patients with Panic Disorder and Agoraphobia: An Open-Pilot Intervention Study

Given the involvement of balance system abnormalities in the pathophysiology of panic disorder and agoraphobia (PD-AG), we evaluated initial evidence for feasibility, acceptability, and potential clinical usefulness of 10 sessions of balance rehabilitation with peripheral visual stimulation (BR-PVS) in an open-pilot 5-week intervention study including six outpatients with PD-AG who presented residual agoraphobia after selective serotonin reuptake inhibitor (SSRI) treatment and cognitive-behavioral therapy, dizziness in daily life, and peripheral visual hypersensitivity measured by posturography. Before and after BR-PVS, patients underwent posturography, otovestibular examination (no patients presented peripheral vestibular abnormalities), and panic-agoraphobic symptom and dizziness evaluation with psychometric tools. After BR-PVS, four patients achieved postural control normalization measured by posturography, and one patient exhibited a favorable trend of improvement. Overall, panic-agoraphobic symptoms and dizziness decreased, even though to a lesser extent in one patient who had not completed the rehabilitation sessions. The study presented reasonable levels of feasibility and acceptability. These findings suggest that balance evaluation should be considered in patients with PD-AGO presenting residual agoraphobia and that BR-PVS might be an adjunctive therapeutic option worth being tested in larger randomized controlled studies.

Clinical features of persistent postural-perceptual dizziness with isolated otolith dysfunction as revealed by VEMP and vHIT findings

Background

Persistent postural-perceptual dizziness (PPPD) is a relatively new disease entity, with diagnostic criteria published by the Bárány Society. PPPD is often preceded by a peripheral or central vestibular disorder. It is not clear how coexisting deficits due to preceding vestibular disorders affect PPPD symptoms.

Objective

This study aimed to characterize the clinical features of PPPD with or without isolated otolith dysfunction using vestibular function tests.

Methods

The study included 43 patients (12 males and 31 females) who were diagnosed with PPPD and completed oculomotor-vestibular function tests. The Dizziness Handicap Inventory (DHI), Hospital Anxiety and Depression Scale (HADS), Niigata PPPD Questionnaire (NPQ), and Romberg test for stabilometry were examined. The 43 patients with PPPD were classified into four categories based on vestibular evoked myogenic potential (VEMP) and video head impulse test (vHIT) results: normal function for both semicircular canals and otoliths (normal), isolated otolith dysfunction (iOtoDys), isolated semicircular canal dysfunction (iCanalDys), and dysfunction of both otoliths and semicircular canals (OtoCanalDys).

Results

Among the 43 patients with PPPD, the iOtoDys group was the largest (44.2%), followed by the normal group (37.2%), iCanalDys group (9.3%), and OtoCanalDys group (9.3%). Eight of the 19 iOtoDys patients showed both abnormal cVEMP and oVEMP responses unilaterally or bilaterally (both sacculus and utriculus damage type), whereas 11 showed either an abnormal cVEMP or an abnormal oVEMP response (either sacculus or utriculus damage type). In a three-group comparison of the both sacculus and utriculus damage type, the either sacculus or utriculus damage type, and the normal group, the mean total, functional, and emotional DHI scores were significantly higher for the both sacculus and utriculus damage type than for the either sacculus or utriculus damage type. The Romberg ratio, a measure of stabilometry, was significantly higher for the normal group than for the both sacculus and utriculus damage type and the sacculus or utriculus damage type in the iOtoDys group.

Conclusions

The coexistence of sacculus and utriculus damage may exacerbate dizziness symptoms in patients with PPPD. Determining the presence and extent of otolith damage in PPPD may provide useful information on the pathophysiology and treatment strategies of PPPD.

Vestibular dysfunction amongst adolescents: what do we know? A review

BACKGROUND

Vestibular dysfunction in children is a debilitating condition that results in countless pernicious effects, such as motor development delay, poor academic performance and psychosocial impairment. Yet, research pertaining to vestibular and balance disorders amongst adolescents is still lacking and remains an enigma.

METHODS

This paper outlines novel emerging aetiological factors contributing to vestibular dysfunction amongst adolescents by appraising published articles through a narrative review.

RESULTS

Underlying aetiological factors of vestibular dysfunction can be identified among adolescents with thorough evaluation. Proper diagnostic evaluation of vestibular dysfunction is imperative in providing optimal care and guiding appropriate treatment strategies. The available literature demonstrated multifactorial aetiological factors that contribute to vestibular dysfunction in adolescents.

CONCLUSION

Outlining the underlying aetiological factors of vestibular dysfunction is vital to ensure that patients receive appropriate care and treatment.

Oxytocin Disturbs Vestibular Compensation and Modifies Behavioral Strategies in a Rodent Model of Acute Vestibulopathy

Unilateral inner ear injury is followed by behavioral recovery due to central vestibular compensation. The therapeutic effect of oxytocin (OT) on vestibular compensation was investigated by behavioral testing in a rat model of unilateral vestibular neurectomy (UVN). Animals in the oxytocin group (UVN-OT) exhibited delayed vestibular compensation on the qualitative scale of vestibular deficits and aggravated static postural deficits (bearing surface) compared to animals in the NaCl group (UVN-NaCl). Surprisingly, oxytocin-treated animals adopt a different postural strategy than untreated animals. Instead of shifting their weight to the ipsilesional paws (left front and hind paws), they shift their weight to the front paws (right and left) without modification along the lateral axis. Furthermore, some locomotor strategies of the animals to compensate for the vestibular loss are also altered by oxytocin treatment. UVN-OT animals do not induce an increase in the distance traveled, their mean velocity is lower than that in the control group, and the ipsilesional body rotations do not increase from 7 to 30 days after UVN. This study reveals that oxytocin treatment hinders the restoration of some postural and locomotor deficits while improving others following vestibular lesions. The mechanisms of the action of oxytocin that support these behavioral changes remain to be elucidated.

Persistent Postural Perceptual Dizziness in Episodic Vestibular Disorders

Benign Paroxysmal Positional Vertigo (BPPV), Vestibular Migraine (VM), and Meniere Disease (MD) are among the most common episodic vestibulopathies. Persistent Postural Perceptual Dizziness (PPPD) is a chronic functional vestibular disorder that can arise in patients suffering from one or more of these conditions. We analyzed the role of these vestibular disorders as single or multiple associated comorbidities and as a precipitating condition for PPPD. A total of 376 patients suffering from dizziness with a known history of single or multiple vestibular disorders were preliminarily evaluated. We conducted a careful anamnesis to determine whether the reported dizziness could meet the diagnostic criteria for PPPD. PPPD was diagnosed in 24 cases; its incidence in patients with history of a single comorbidity or multiple vestibular comorbidities was 3.9% and 22.4%, respectively. BPPV, VM, and MD were identified as a precipitating condition in 2.34%, 16.45%, and 3.92%, respectively. BPPV constituted a precipitating condition mainly at the first episode. We observed that the presence of multiple vestibular comorbidities (BPPV, VM, and MD) in patients' clinical history increased the risk of PPPD. VM plays a significant role in representing a precipitating condition for PPPD, both when present individually or in association with the other vestibular disorders.

Persistent Postural Perceptual Dizziness Induced by Caloric Testing: A Case Report

BACKGROUND

 The condition of persistent postural perceptual dizziness (PPPD) is a common chronic vestibular disorder that is thought to be due to a central vestibular maladaptation. The condition is frequently encountered in those with a history of migraine, anxiety, or panic attacks. Many cases of PPPD are preceded by vestibular disorders, with vestibular migraine thought to precede at least 20% of cases.

PURPOSE

 Those with a history of migraine have been shown to have difficulties with sensory integration, habituation, and intolerance to stimuli. This often leads to discomfort associated with some vestibular test procedures, specifically caloric irrigations. At this time there has been little investigation into any prolonged symptoms associated with undergoing vestibular test procedures in this population.

CONCLUSIONS

 We pose a case report of a patient with a history of migraine that developed new-onset PPPD following caloric irrigations.

Vestibular Migraine

PURPOSE OF REVIEW

To explore recent developments in vestibular migraine (VM).

RECENT FINDINGS

This review discusses the current diagnostic criteria for VM in the adult and pediatric populations, as proposed by the International Headache Society and Bárány Society. Recent VM studies confirm the prior findings and reveal new insights, including the wide range of vestibular symptoms, symptoms in the attack-free period, and triggers. Many patients experience persistent vestibular symptoms, even in the absence of acute attacks, which often significantly impact patients' quality of life. The syndrome of benign recurrent vertigo and its relationship to migraine, VM, and Meniere's disease is also discussed. There is a dearth of randomized controlled trials in VM treatment. Prospective and retrospective studies support the benefit of many migraine treatments are effective in VM, including neuromodulation, and calcitonin gene-related peptide monoclonal antibodies. VM affects almost 3% of the population, but remains under-diagnosed. Recent diagnostic criteria can help clinicians diagnose VM in adults and children.

Improving self-motion perception and balance through roll tilt perceptual training

The present study aimed to determine if a vestibular perceptual learning intervention could improve roll tilt self-motion perception and balance performance. Two intervention groups (n = 10 each) performed 1,300 trials of roll tilt at either 0.5 Hz (2 s/motion) or 0.2 Hz (5 s/motion) distributed over 5 days; each intervention group was provided feedback (correct/incorrect) after each trial. Roll tilt perceptual thresholds, measured using 0.2-, 0.5-, and 1-Hz stimuli, as well as quiet stance postural sway, were measured on day 1 and day 6 of the study. The control group (n = 10) who performed no perceptual training, showed stable 0.2-Hz (+1.48%, P > 0.99), 0.5-Hz (-4.0%, P > 0.99), and 1-Hz (-17.48%, P = 0.20) roll tilt thresholds. The 0.2-Hz training group demonstrated significant improvements in both 0.2-Hz (-23.77%, P = 0.003) and 0.5-Hz (-22.2%, P = 0.03) thresholds. The 0.5-Hz training group showed a significant improvement in 0.2-Hz thresholds (-19.13%, P = 0.029), but not 0.5-Hz thresholds (-17.68%, P = 0.052). Neither training group improved significantly at the untrained 1-Hz frequency (P > 0.05). In addition to improvements in perceptual precision, the 0.5-Hz training group showed a decrease in sway when measured during "eyes open, on foam" (dz = 0.57, P = 0.032) and "eyes closed, on foam" (dz = 2.05, P < 0.001) quiet stance balance tasks. These initial data suggest that roll tilt perception can be improved with less than 5 h of training and that vestibular perceptual training may contribute to a reduction in subclinical postural instability.NEW & NOTEWORTHY Roll tilt vestibular perceptual thresholds, an assay of vestibular noise, were recently found to correlate with postural sway. We therefore hypothesized that roll tilt perceptual training would yield improvements in both perceptual precision and balance. Our data show that roll tilt perceptual thresholds and quiet stance postural sway can be significantly improved after less than 5 h of roll tilt perceptual training, supporting the hypothesis that vestibular noise contributes to increased postural sway.

Infra-low frequency neurofeedback in persistent postural-perceptual dizziness—Case report

Persistent Postural-Perceptual Dizziness, also known as PPPD or 3PD, is a chronic functional vestibular disorder characterized by persistent sensation of rocking or swaying unsteadiness and/ or non-spinning dizziness without vertigo lasting at least 3 months. Symptoms typically worsen with upright posture (like standing or sitting upright), head or body motion and exposure to busy or visually rich environments. The article describes the application of Infra-Low Frequency Neurofeedback (ILF NF) over 32 sessions on an unmedicated individual with symptoms related to PPPD that were still present 3 years after the initial diagnosis. Along with significant reduction in those symptoms, other accompanying symptoms (like anxiety, intrusive violent thoughts, suicidal thoughts) were markedly improved with ILF NFB. Consistent symptom tracking from session to session, as well as before and after CPT data were used to document reported changes with ILF NF.

Effects of Occlusal Splints on Spinal Posture in Patients with Temporomandibular Disorders: A Systematic Review

There is still a gap in the scientific knowledge on the linkage between craniofacial structure and spinal postural control in temporomandibular disorder (TMD) patients. This systematic review aimed to assess the role of occlusal splints on spinal posture of TMD patients. PubMed, Web of Science, and Scopus were systematically searched from inception until 5 January 2022 to identify observational studies with a longitudinal study design presenting: patients with diagnosis of TMD according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD); occlusal splint therapy as intervention; postural assessment as outcome. Out of 133 records identified, 104 were suitable for data screening, and only 7 articles were included satisfying the eligibility criteria. We found that occlusal splints might have a positive effect on posture in TMD patients, albeit there is little evidence of appropriate investigation for postural assessment. This systematic review suggested that the occlusal splint might be considered a non-invasive therapeutic approach for patients with TMD. However, the low number of studies with high-quality methodology in these patients showed an urgent need for further research using combined force platform stabilometry and kinematic evaluation of the spine to investigate the impact of occlusal splints on posture.

Isolated Otolith Dysfunction in Persistent Postural-Perceptual Dizziness

The aims of this study were to investigate otolith dysfunction, especially isolated otolith dysfunction (with preserved semicircular canal function) in persistent postural-perceptual dizziness (PPPD) patients. Twenty-one patients who had been diagnosed with PPPD were enrolled in this study. The subjects filled out questionnaires [the Dizziness Handicap Inventory (DHI) and the Niigata PPPD Questionnaire (NPQ)] and underwent vestibular evoked myogenic potential (VEMP) tests, video head-impulse tests (vHIT), and stabilometry. Among the 21 subjects with PPPD, 9 showed isolated otolith dysfunction, 4 exhibited both otolith dysfunction and semicircular canal dysfunction, and 2 demonstrated isolated semicircular canal dysfunction. Six subjects exhibited normal VEMP and vHIT results. Concerning the subjects' questionnaire scores and stabilometric parameters, there were no significant differences among subgroups when the subjects were classified according to their VEMP and vHIT results while stabilometric parameters obtained in PPPD subjects were significantly increased than published data of healthy subjects. As precipitating conditions for PPPD, vestibular neuritis was the most frequent and the second most was idiopathic otolithic vertigo. In conclusion, the majority of PPPD patients had otolith dysfunction, and most of them showed isolated otolith dysfunction. Idiopathic otolithic vertigo can be a precipitating factor of PPPD. While otolith dysfunction may be associated with initiation of PPPD symptoms, PPPD symptoms are also considered to be associated with other dysfunctions of the sensory processing system.