A woman wakes up one morning and out of nowhere she is dizzy. The room is spinning, she can’t move because of the dizziness so she is stuck in bed. She screams for her husband to which they rush to their local hospital. Her lab work is normal. Vital signs are normal. MRI/CT scan show no acute changes. EKG is normal. The neurologist at the hospital thinks the woman is simply anxious and recommends a prescription for Xanax, the emergency room physician says she has BPPV (Benign Paroxysmal Positional Vertigo) so they discharge the woman with a sheet demonstrating the Epley maneuver.
At home, she proceeds to attempt the Epley maneuver but is not sure which ear to do it for so she does it four times on each side. She no longer feels dizzy but feels like she is drunk. After this she goes to her primary care physician who prescribes her Meclizine and sends her to an ENT who gives her a hearing test which comes back normal, he can’t explain to her what is wrong however recommends that she get a procedure to fix her sinuses. She then goes to a physical therapist her friend recommends who received treatment for their shoulder and the physical therapist says she has BPPV (Benign Paroxysmal Positional Vertigo). She attends 12 treatment sessions and is taken through the epley maneuver followed by VOR (Vestibulo-ocular Reflex) exercises with her eyes and balance exercises. This unfortunately does not help her and now is dizzy all the time.
She goes back to see her primary care physician who says “the dizziness is all in your head” and prescribes her Xanax. She lives like this for months until she sees another ENT physician who recommends her see another physical therapist who does vestibular therapy (VRT). This physical therapist states that the woman has 3PD/PPPD or Persistent Postural-Perceptual Dizziness, previously known as CSD: Chronic Subjective Dizziness, also mentioned by some individuals as Visual Vertigo. The woman proceeds to get treatment with this PT and eventually is no longer constantly dizzy.
Unfortunately, these histories are similar to what I hear when I am evaluating someone for PPPD/3PD/Persistent Postural-Perceptual Dizziness or I am suspecting them to have this. They typically have been to numerous providers and either no one has been able to officially explain the diagnosis or the patient is deemed as anxious with the symptoms “being in their head.” While if we are being highly technical and analytical, yes the symptoms someone is experiencing is in their head simply because their brain is literally in their head(skull). This is not to insinuate that this phrase is acceptable to use with patients, it’s not and creates an improper understanding of the condition. There is always an underlying reason for 3PD to start as it is a pathology that does not start on its own.
A large percentage(15-20%) of people that end up being diagnosed with 3PD/PPPD have Vestibular Migraine as the inciting cause of their dizziness which ends up (with time) being the inciting cause of their 3PD, but it takes time because Vestibular Migraine can be difficult to understand and diagnose. Other common inciting causes of 3PD are Post-Concussive Syndrome, Panic attacks, and prolonged anxiety. Vestibular Migraine is the inciting cause of the woman’s dizziness above. No, it wasn’t Benign Paroxysmal Positional Vertigo (BPPV). How do I know? Because if it was BPPV, it would of been treated in 3 visits or less, more on this on a later post.
Anecdotally, you will have patients that will have both spinning and non-spinning vertiginous symptoms depending on how the Vestibular Migraines affect them. From my experience the first ever Vestibular Migraine someone gets tends to be have a strong sense of spinning vertigo symptoms. I will discuss Vestibular Migraine in a separate blog post.
So why did this person not get better with previous physical therapy? That is a great question! First off, what was being treated was incorrect and while VOR exercises can be a staple in vestibular rehab for the proper patient, VOR exercises are not suitable for this patient because you are not treating the underlying condition(s). Balance exercises are a great treatment in addition however you have to understand what you are treating in order to improve someones symptoms. This leads us to the million dollar question:
Persistent Postural-Perceptual Dizziness is a neuro-otologic disorder with behavioral components such as anxiety and/or depression that a patient will feel a near constant perception of movement(dizziness) greater than most days of the month that is provoked by upright posture and visual stimulation. Patients have to be experiencing symptoms for 3 months or greater as the 3 month timeline is part of the diagnostic criteria.
3PD is part of a collection of disorders of what are called Functional Neurological Disorders (FND). These disorders demonstrate a functional difficulty with brain inter-connectivity that leads to symptoms, such is the case of dizziness with 3PD. These findings can be with or without positive structural findings on imaging such as MRI(these findings either way do not establish a diagnosis of 3PD as it is a clinical diagnosis, there are positive findings in patients with 3PD despite no one test ruling it in). That does not mean there is nothing going on as it has been demonstrated in patients with these conditions have a higher amygdala activation in addition to other brain structures under fMRI(Functional MRI). What the functional MRI did was it measured blood flow so there are physiologic changes that are occurring but it is not resulting in a structural change in the brain which is what we commonly associate with conditions and symptoms.
So what is occurring is under a constant state of physiologic change (dizziness event(s)) with concordant stress causes the individuals brain with 3PD to rely less on the intact connections to their vestibular system and more on their visual system while creating hyper-vigilent responses in relation to their movement that further perpetuates their feeling of being dizzy and off-balanced. This is why patients with 3PD feel worse with busy environments such as grocery stores or the act of scrolling through a phone. These patients tend to feel best when laying flat on their back because they are getting the most somatosensory information. Somatosensation is the ability to sense touch, temperature, pain, and the position of your body parts.
The standard of care for treating someone with 3PD is a multi-disciplinary approach utilizing a combination of physical therapy(someone that understands and has an extensive understanding/experience with 3PD), medication, and CBT. From what I have seen in the patients that I have treated successfully for 3PD, some of those patients have gotten resolution of symptoms both with and without medications. That statement is not to insinuate that you do not need medication to treat 3PD and vice versa but it is a highly individualized treatment depending on the individual, some patients may or may not be medication sensitive. Additionally, while patients that are properly treated for 3PD have a good prognosis, there is no set time-line for resolution of symptoms. This condition cannot be compared to a muscular strain where the expectation is there will be significant relief in the span of 6-8 weeks based off of soft tissue healing. The brain is different however it is plastic which means that changes do occur. Typically patients that have been suffering with 3PD for a long period tend to have longer treatment duration’s compared to someone that is newly diagnosed.
If you, or someone you know has chronic unexplained dizziness or has a formal diagnosis of Persistent Postural-Perceptual Dizziness(3PD) and would like to get relief from their symptoms please call 610-679-9051 to schedule an appointment.
