Georgia Chiropractic Neurology Center

Brain Based Treatment for the 21st Century!

Written by Sophie Hose, DC, MS, CCSP

Persistent Postural-Perceptual Dizziness, or PPPD, is a chronic, often debilitating condition that has garnered increasing attention in recent years. Characterized by persistent dizziness, unsteadiness, and heightened sensitivity to motion, PPPD significantly impacts daily life and is notoriously difficult to manage. Unlike episodic vertigo or acute dizziness, which are often short-lived and linked to specific triggers, PPPD is persistent and can be provoked by seemingly innocuous activities like walking in a busy environment or turning the head quickly. This blog post will explore PPPD from a chiropractic neurology standpoint, highlighting the unique approaches that can help manage this condition effectively.

The Neurological Basis of PPPD

PPPD is considered a disorder of sensory processing within the brain, particularly related to balance and spatial orientation. The human brain integrates sensory input from three primary systems to maintain balance: the vestibular system (inner ear), the visual system (eyes), and the somatosensory system (proprioceptive input from muscles and joints – your ability to perceive your own body and know where it is at in space and in relationship to other objects or bodies). Under normal circumstances, these systems work together seamlessly to provide the brain with a comprehensive understanding of the body’s position in space.

In individuals with PPPD, however, this integration process becomes maladaptive. Following an initial vestibular event—such as vestibular neuritis, benign paroxysmal positional vertigo (BPPV), or even a mild concussion—the brain may shift its reliance away from the vestibular system and towards visual and proprioceptive cues to maintain balance. While this compensatory mechanism is helpful in the short term, it can become problematic if the brain fails to recalibrate properly.

Over time, this maladaptive sensory integration leads to the persistent symptoms characteristic of PPPD.

A seminal study by Staab et al. (2017) laid the groundwork for understanding the pathophysiology of PPPD, outlining how chronic dizziness develops from an initial vestibular insult and is maintained by dysfunctional sensory processing. The authors highlight that individuals with PPPD often exhibit heightened sensitivity to motion, complex visual environments (like busy streets or shopping malls), and even their own movements, all of which can exacerbate symptoms.

In addition to an initial event that involves direct injury or damage to the vestibular system, some healthcare providers and researchers have also hypothesized that a highly emotional event or trauma can elicit feelings of vertigo that can develop into PPPD. This is likely due to the intricate relationship both anatomically and functionally between our emotional brains (the limbic system) and the areas of the brain that process information about the environment relayed to it by the vestibular system, the eyes and the receptors throughout our bodies that relay proprioception. These brain areas mainly live in the brainstem, the parietal and occipital lobes and the cerebellum.

The Role of Chiropractic Neurology

Chiropractic neurology, also known as functional neurology, is a field dedicated to optimizing the function and performance of the nervous system through non-invasive, drug-free therapies. In the context of PPPD, chiropractic neurologists focus on re-establishing proper sensory integration, improving the brain’s ability to process vestibular, visual, and proprioceptive information, and addressing any underlying dysfunctions that contribute to the persistence of symptoms.

Comprehensive Assessment

The first step in managing PPPD from a chiropractic neurology perspective is a thorough neurological examination. This assessment includes evaluating the function of the vestibular system, eye movements, postural control, and proprioception. Additionally, a detailed patient history is essential, as PPPD often coexists with other conditions like anxiety, depression, or migraine, which can exacerbate symptoms and complicate treatment.

Popkirov et al. (2018) emphasize the importance of a comprehensive assessment, noting that PPPD is not merely a disorder of dizziness but a multifaceted condition that involves sensory, cognitive, and emotional components. A holistic approach that considers all these aspects is crucial for effective management.

Treatment Approaches

  1. Vestibular Rehabilitation Therapy (VRT): Vestibular rehabilitation is a cornerstone of PPPD treatment. VRT involves exercises designed to recalibrate the brain’s interaction with the vestibular, visual, and proprioceptive systems. These exercises may include gaze stabilization (which trains the brain to maintain focus during head movements), balance training (which improves postural control), and habituation exercises (which gradually expose the patient to motion stimuli that provoke symptoms).

Research by Cousins et al. (2014) demonstrated that VRT significantly improves symptoms in patients with PPPD. The study found that patients who underwent VRT reported reduced dizziness, improved balance, and increased confidence in their ability to perform daily activities. The success of VRT in managing PPPD underscores the importance of targeted rehabilitation exercises in restoring normal sensory integration.

  1. Proprioceptive Training: Proprioception refers to the body’s ability to sense its position and movement in space, and it plays a crucial role in maintaining balance. In individuals with PPPD, proprioceptive feedback may become distorted, leading to increased reliance on visual cues, which can exacerbate symptoms. Proprioceptive training involves exercises and therapies designed to improve the accuracy of proprioceptive input from the muscles and joints, particularly in the neck and spine.

Chiropractic adjustments and soft tissue therapies can enhance joint position sense, thereby improving proprioceptive feedback and reducing dizziness. Studies on proprioceptive training in patients with dizziness have shown that improving proprioception can significantly reduce symptoms and enhance overall balance and coordination. Furthermore, chiropractic neurologists use different sensory stimuli to retrain proprioception all throughout the body. This can include differentiating between sharp and dull stimuli, locating light and deep touch, recognizing shapes and lines drawn onto the skin (such as letters and numbers for example) and many more.

  1. Oculomotor Therapy: Since visual processing is heavily implicated in PPPD, oculomotor therapy is a critical component of treatment. This therapy involves exercises that improve eye movements, visual-vestibular interaction, and the brain’s ability to process complex visual environments. For example, exercises may focus on improving pursuits (smooth following of moving objects), saccades (quick eye movements between two points), and visual fixation (maintaining focus on a single object despite head movement). A review by Shaikh et al. (2018) on the rehabilitation of oculomotor disorders and vertigo highlights the effectiveness of oculomotor therapy in improving visual-vestibular integration and reducing symptoms in patients with chronic dizziness, including those with PPPD.
  2. Cognitive Behavioral Therapy (CBT): While not directly a chiropractic intervention, CBT is often a valuable adjunct to chiropractic care for patients with PPPD. CBT helps address the anxiety, fear, and hypervigilance that often accompany chronic dizziness. By challenging and reframing negative thought patterns, CBT can reduce the psychological impact of PPPD and help patients engage more fully in their physical rehabilitation.  A study by Probst et al. (2019) found that CBT, when combined with vestibular rehabilitation, significantly improved outcomes for patients with chronic dizziness, including PPPD. Patients who participated in CBT reported lower levels of anxiety and dizziness-related disability, suggesting that addressing the psychological aspects of PPPD is crucial for comprehensive treatment. Instead of doing CBT, there are other techniques that address the emotional component of PPPD. This can include chiropractic techniques, such as NeuroEmotional Technique (NET), craniosacral techniques, homeopathy targeting emotional components and many more.
  1. Postural Adjustments: Chiropractic care often involves spinal adjustments, particularly in the cervical spine, to restore proper alignment and function. Misalignments or dysfunctions in the cervical spine can contribute to proprioceptive disturbances and exacerbate dizziness. By correcting these issues, chiropractic adjustments can improve proprioceptive input, reduce dizziness, and enhance overall balance. Postural adjustments also play a role in reducing muscle tension and improving blood flow, which can have a positive impact on overall neurological function. Although more research is needed to fully understand the role of chiropractic adjustments in managing PPPD, clinical evidence suggests that improving spinal alignment can have beneficial effects on proprioception and balance. Another way to address proprioceptive influences of the spine on the vestibular system is to use myofascial therapies or rehabilitation exercises that integrate spinal movements with visual feedback. A good example for a therapy like that is a tool called MotionGuidance, which allows the patient to see the smoothness of their neck movements thanks to a laser that is attached to a headband they are wearing. Moving the head then integrates vestibular (inner ear) information with proprioception from the neck and visual information perceived from the eyes.

Patient Education and Self-Management

Educating patients about the nature of PPPD is a critical aspect of treatment. Many individuals with PPPD experience significant anxiety and fear related to their symptoms, which can exacerbate the condition and create a vicious cycle of dizziness and avoidance behavior. Understanding that PPPD is a result of maladaptive neurological processes, rather than structural damage, can help alleviate some of the anxiety associated with the disorder.

Patients should be encouraged to engage in gentle, graded exposure to stimuli that provoke their symptoms. Avoidance of these stimuli can reinforce maladaptive patterns and prolong recovery. Instead, gradual, controlled exposure can help desensitize the brain and promote more adaptive sensory processing.

Conclusion

Persistent Postural-Perceptual Dizziness is a complex condition with a strong neurological basis. Chiropractic neurology offers a multifaceted approach to managing PPPD by addressing the underlying sensory integration issues through vestibular rehabilitation, proprioceptive training, oculomotor therapy, and more. By improving the brain’s ability to process and integrate sensory information, chiropractic neurologists can help patients regain their balance, reduce dizziness, and improve their overall quality of life.

If you or someone you love is suffering from PPPD or another form of vertigo and you would like to learn how chiropractic neurology can help, contact the team at Georgia Chiropractic Neurology Center today. We look forward to hearing from you.

Sources

  1. Staab, J. P., Eckhardt-Henn, A., Horii, A., Jacob, R., Strupp, M., Brandt, T., & Bronstein, A. (2017). Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research, 27(4), 191-208. doi:10.3233/VES-170622
  2. Popkirov, S., Staab, J. P., & Stone, J. (2018). Persistent postural-perceptual dizziness (PPPD): A common, characteristic and treatable cause of chronic dizziness. Practical Neurology, 18(1), 5-13. doi:10.1136/practneurol-2017-001809
  3. Cousins, S., Kaski, D., Cutfield, N., Arshad, Q., Ahmad, H., Gresty, M. A., Seemungal, B. M., Golding, J. F., & Bronstein, A. M. (2014). Vestibular perceptual thresholds to angular rotation: Reduced thresholds in vestibular migraine and PPPD. Frontiers in Neurology, 5, 243. doi:10.3389/fneur.2014.00243
  4. Shaikh, A. G., Pacheco, K., Ghasia, F. F., Gallemore, G., & Thurtell, M. J. (2018). Rehabilitation of oculom