PPPD — persistent postural-perceptual dizziness

Persistent postural-perceptual dizziness (PPPD) is a chronic functional disorder of the balance system that causes dizziness, unsteadiness or a non-spinning sense of motion on most days for three months or more. Symptoms are typically worse when standing or walking, when moving, and in busy visual environments such as supermarkets or scrolling screens. PPPD often begins after another event that disrupts balance — such as an inner-ear problem, a concussion, a panic attack or an illness — and the brain stays stuck in a “high alert” balance strategy. It’s recognised by the Bárány Society and is treatable, most often with vestibular rehabilitation, sometimes combined with cognitive behavioural therapy (CBT) and medication prescribed by a physician.

What is PPPD?

Persistent postural-perceptual dizziness (PPPD) is a long-lasting form of dizziness. People describe feeling unsteady, swaying, light-headed or “not quite right” — usually without true spinning. The term PPPD was defined in 2017 by the Bárány Society, which brought together several older descriptions of the same problem, such as chronic subjective dizziness and phobic postural vertigo (Staab et al., 2017).

PPPD is diagnosed when dizziness, unsteadiness or non-spinning vertigo is present on most days for three months or more, and is made worse by:

• standing upright or walking
• your own movement, or being moved (for example, in a car)
• busy or moving visual environments, such as supermarkets, traffic or scrolling screens

PPPD can occur on its own or alongside other conditions — including the one that triggered it.

What causes PPPD?

PPPD usually begins after an event that disrupts balance. Common triggers include an inner-ear problem such as BPPV or vestibular neuritis, vestibular migraine, a concussion, another medical illness, or a panic attack or period of high anxiety.

During that initial event, it makes sense for the brain to switch into a cautious, high-alert balance strategy — stiffening posture, relying heavily on vision and constantly monitoring for movement. In PPPD, that strategy doesn’t switch back off once the original problem has settled. The result is a persistent sense of dizziness and unsteadiness that is real, but driven by how the brain is processing balance information rather than by ongoing damage.

What are the symptoms of PPPD?

• Dizziness, unsteadiness or a rocking or swaying sensation on most days
• Symptoms that build up through the day, especially when upright and active
• Discomfort in busy shops, crowds, traffic or when looking at moving screens
• A stiff, cautious walking pattern
• Fatigue, difficulty concentrating, and anxiety about symptoms
• Avoiding activities, places or travel because of dizziness

How is PPPD treated?

PPPD is treatable, and the most effective care usually combines several approaches (Popkirov et al., 2018):

• Vestibular rehabilitation — a physiotherapy program that uses gradual, repeated exposure to the movements and visual environments that provoke symptoms (habituation), along with balance and walking retraining, to help the brain turn down its high-alert response.
• Cognitive behavioural therapy (CBT) — delivered by a qualified mental health professional, CBT can help reduce the fear, avoidance and anxiety that often keep symptoms going.
• Medication — some people benefit from medication, such as certain antidepressants, prescribed and monitored by their physician.
• Clear explanation — understanding what PPPD is, and that it’s real and treatable, is an important part of recovery in its own right.

As vestibular physiotherapists, we focus on the rehabilitation side: a careful assessment, a clear explanation and a graded program. We’ll recommend involving your family doctor or a mental health professional when that’s likely to help.

1. 01

   Assess & explain

   A full vestibular assessment with infrared goggles to identify any co-existing conditions, followed by a clear explanation of how PPPD works.

2. 02

   Habituate

   Graded exposure to the movements, postures and visual environments that bring on your symptoms, paced so you can make steady progress.

3. 03

   Return to life

   Balance and walking retraining, and a plan for gradually returning to the places and activities you’ve been avoiding.

Why choose McKelvie Physiotherapy for PPPD?

• Vestibular specialists — our team is led by an Advanced Vestibular Physical Therapist (AVPT).
• Advanced diagnostic technology — we use infrared video goggles (video-oculography) to record eye movements the naked eye can’t see, so your diagnosis is based on evidence, not guesswork.
• We check for co-existing conditions — such as BPPV, which can trigger or sit alongside PPPD.
• Unhurried, one-on-one care in private rooms — a calm setting matters when busy environments are a trigger.
• Care that comes to you — in person in Pickering, at home across the GTA, or virtually anywhere in Ontario.
• Direct billing to many major insurers — and no referral needed.