Exercise Management for Persistent Postural Dizziness
Your balance system responds rapidly when an episode of true vertigo arises, receiving numerous signals about movement and space from different sensors and then combining these in the background so you can stand, move and turn without becoming dizzy.
When an ear infection causes vertigo, its usual process can become disrupted and symptoms remain for an extended period of time – this condition is known as Persistent Postural Perceptual Dizziness (PPPD).
Exercises for Persistent Postural Perceptual Dizziness
Persistent Postural Perceptual Dizziness (PPPD) is a condition whereby feelings of spinning, unsteadiness or vertigo associated with vestibular issues last more than three months after an initial vestibular insult has taken place. It is thought to result from long term maladaptation resulting from repeated vestibular exposures.
Many times the symptoms will improve when an ear infection clears up; however, neural signals which caused this initial episode continue to fire and lead to feelings of dizziness, making life unbearable for those living with it. A qualitative study found that PPPD can also negatively impact self-identity and make people feel like they are “going crazy.”
There are various treatments for PPPD available, including vestibular rehabilitation (VRT) and psychological interventions. Studies have demonstrated the efficacy of VRT in improving dizziness subjective experiences as well as posturography scores among those suffering from PPPD.
Psychological therapies may be effective at managing anxiety associated with vestibular dysfunctions associated with PPPD. Talking therapy and behavioral change strategies are two approaches which may be employed to assist individuals understand and cope with dizziness; oftentimes those living with this condition become so anxious they avoid head movements which trigger dizziness such as shopping centres or staring too long at computer screens, leading to neck stiffness and headaches as a result of avoidance behavior.
To counteract PPPD effectively, individuals needing treatment should engage with a physiotherapist experienced in managing this condition. Working together will allow individuals with PPPD to build confidence with exercises designed to gradually increase head movement exposure; some of these exercises may initially feel unfamiliar as your brain adjusts to new stimuli; however, over time this should lead to long term improvements in symptoms. MediVR KAGURA virtual reality system has proven very successful at increasing head movement tolerance – with patients reporting immediate relief after completion of training!
Habituation Exercises
A vestibular rehabilitation program is designed to teach you how to understand and interpret faulty signals coming from your inner ear balance sensors. Exercise-based vestibular rehabilitation programs involve stimulating your vestibular system in order to produce information for interpretation by your brain, which then adapts and learns how to cope with abnormal inputs to reduce dizziness and unsteadiness.
Habituation exercises have proven highly successful for treating PPPD in multiple studies. Habituation involves repeatedly exposing individuals to visual stimuli that cause their symptoms, gradually helping them desensitize over time – this may include head movement exercises or optokinetic stimuli such as rotating chairs or virtual grocery store screens7,8.
Eye movement exercises are another common habituation exercise that may help. Starting slowly, they progress gradually as speed and vertical movement increase over time. Finally, eye rotation may also involve shifting your eyes side to side – though initially uncomfortable this exercise should help alleviate dizziness over time.
Cawthorne-Cooksey exercises are home exercises initially developed to treat BPPV (benign paroxysmal positional vertigo) but may also help with PPPD. They are an excellent solution for people experiencing vestibular loss in one ear due to an acoustic neuroma or acoustic neuromi, labyrinthitis or advanced Meniere’s disease9. They will not, however, assist those suffering episodic vertigo or frequent attacks of BPPV9.
Postural Exercises
These exercises aim to alter how your brain interprets movement and space. At least three exercises should be completed three times daily for six-12 weeks until your dizziness has completely subsided; stopping before this has happened may cause symptoms to return.
Safety and motivation are top considerations when performing challenging exercises like these, so having someone present to support and guide is highly recommended. Exercise sessions require your full focus and may initially make you dizzy or queasy – that is normal, however – just get up and walk around while performing these movements, to relax your body and reduce any negative side effects.
Once you’ve been doing physical exercise for several weeks without feeling dizzy, increase the pace with which you perform each exercise. Use the timed exercise scoring test on page two to track how far you have come. Also keep a diary detailing when and how often your feel best so you can track improvement over time.
Vestibular rehabilitation therapy has been shown to increase both subjective and posturographic dizziness handicap scores for people living with PPPD, but its exact causes remain unknown. A variety of factors may contribute to its efficacy; such as failure of neural re-adaptation, cortical spatial integration issues or hypervigilance to vestibular input.
Virtual reality therapy (VRT) has also been shown to increase quality of life for those living with PPPD. One study used VRT as part of an integrated treatment package; patients received customized vestibular exercises and optokinetic stimulation using virtual reality systems with head mounted displays once every week for four weeks for comparison against standard vestibular rehabilitation therapy alone. Researchers concluded that VRT led to greater improvements in dizziness, balance and gait function than standard rehabilitation alone – concluding it should form part of any comprehensive therapy package plan for people living with PPPD.
Movement Exercises
Movement exercises are an integral component of treating PPPD. At first, they may worsen your dizziness symptoms; but over time this should subside. A vestibular therapist will assist you in setting treatment goals and designing an individualized program tailored specifically to you; they may recommend movement exercises combined with cognitive behavioral therapy (CBT) techniques to combat anxiety that exacerbates symptoms.
Movement exercises designed to retrain your balance system can help correct an adaptive change that results after an acute vestibular episode. When balance is disturbed, your brain responds by altering how it interprets signals from your inner ear – this leads to less reliance on inner ear information for balance maintenance, shifting towards visual cues instead – instead relying on inner ear information which may not provide as accurate results.
This can create a vicious cycle; as more you use your eyes for balance, the more sensitive they become to changes in their environment and you experience dizziness even without an internal vestibular signal being present. As more sensitive you become, your brain struggles more to retrain itself – leading to symptoms which linger long after an original vestibular condition has healed itself.
To address this, vestibular therapists use movement exercises to improve your ability to perceive your surroundings normally, including moving your head side-to-side and up and down. At first these movements will be slow but as time progresses the therapist will increase both speed and intensity based on how much dizziness increases on a number scale – until dizziness has returned back down into manageable levels – you should continue this practice until dizziness no longer presents as an issue.
As with PPPD treatment exercises, similar techniques can also be employed for BPPV; however, Brandt-Daroff exercises will likely be recommended instead of CRPs to manage dizziness symptoms and retrain your brain not to pay too much attention to dizzying signals. Your therapist may gradually increase intensity as you become used to them – similar to movement exercises.
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