1.
J Neurol. 2020 Mar 4. doi: 10.1007/s00415-020-09748-w. [Epub ahead of print]
Neurological update: dizziness.
Kaski D1,2.
Abstract
The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this 'update' I will review how our understanding of previously "unexplained" dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term 'persistent postural perceptual dizziness', and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.
KEYWORDS:
Dizziness; Persistent postural perceptual dizziness (PPPD); Small vessel disease cerebral; Vestibular; Vestibular migraine
2.
Neuroimage Clin. 2020 Feb 18;26:102216. doi: 10.1016/j.nicl.2020.102216. [Epub ahead of print]
Altered intra- and inter-network functional connectivity in patients with persistent postural-perceptual dizziness.
Abstract
BACKGROUND:
Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disorder characterized by persistent dizziness, unsteadiness, and non-spinning vertigo. It is the most common cause of chronic vestibular syndrome, but its pathogenesis is currently unclear. Recent studies have indicated that sensory integration may be altered in PPPD patients.
OBJECTIVE:
Using independent component analysis (ICA) combined with seed-based functional connectivity analysis, we aimed to analyze changes in brain network functional connectivity (FC) in PPPD patients during the resting state and to explore the underlying pathogenesis of PPPD, particularly the abnormal integration of multiple sensations.
METHODS:
Study subjects included 12 PPPD patients and 12 healthy controls and were recruited from January to August 2018. Detailed medical data were collected from all participants. Vestibular function, neurological and medical examinations were conducted to exclude other diseases associated with chronic dizziness. Functional MRI was performed on all subjects. ICA and seed-based functional connectivity analysis were performed to examine changes in intra- and inter-network FC in PPPD patients.
RESULTS:
In total, 13 independent components were identified using ICA. Compared with healthy controls, PPPD patients showed decreased intra-network FC in the right precuneus within the posterior default mode network. Moreover, seed-based functional connectivity analysis showed decreased intra-network FC between the right precuneus and the bilateral precuneus and left premotor cortex, and enhanced FC between the right precuneus and bilateral corpus callosum. With respect to the inter-network, FC in PPPD patients was increased between the occipital pole visual network and auditory, sensorimotor networks, as well as the lateral visual and auditory networks. Additional analyses showed that FC changes were negatively correlated with dizziness handicap inventory functional scores.
CONCLUSION:
In PPPD patients, dysfunction in the precuneus may cause abnormalities in external environment monitoring and in posture and movement regulation. Compensatory strategies may then be adopted to maintain balance. At the local level, information exchange between the two cerebral hemispheres is enhanced via the corpus callosum. At the whole brain level, through enhancement of functional activities of the visual network, the integration of multiple sensations and the regulation of posture and movement are primarily driven by visual information.
Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
Functional connectivity; Independent component analysis; Persistent postural-perceptual dizziness; Resting state functional magnetic resonance imaging; Visual network
3.
Front Neurol. 2020 Jan 9;10:1361. doi: 10.3389/fneur.2019.01361. eCollection 2019.
Spatial Navigation Is Distinctively Impaired in Persistent Postural Perceptual Dizziness.
Breinbauer HA1,2,3, Contreras MD3, Lira JP3, Guevara C3, Castillo L3, Ruëdlinger K3, Muñoz D1, Delano PH1,2.
Abstract
Objective: To determine whether performance in a virtual spatial navigational task is poorer in persistent postural perceptual dizziness (PPPD) patients than in healthy volunteers and patients suffering other vestibular disorders. Methods: Subjects were asked to perform three virtual Morris water maze spatial navigational tasks: (i) with a visible target, (ii) then with an invisible target and a fixed starting position, and finally (iii) with an invisible target and random initial position. Data were analyzed using the cumulative search error (CSE) index. Results: While all subjects performed equally well with a visible target, the patients with PPPD (n = 19) performed poorer (p < 0.004) in the invisible target/navigationally demanding tasks (CSE median of 8) than did the healthy controls (n = 18; CSE: 3) and vestibular controls (n = 19; CSE: 4). Navigational performance in the most challenging setting allowed us to discriminate PPPD patients from controls with an area under the receiver operating characteristic curve of 0.83 (sensitivity 78.1%; specificity 83.3%). PPPD patients manifested more chaotic and disorganized search strategies, with more dispersion in the navigational pool than those of the non-PPPD groups (standard distance deviation of 0.97 vs. 0.46 in vestibular controls and 0.20 in healthy controls; p < 0.001). Conclusions: While all patients suffering a vestibular disorder had poorer navigational abilities than healthy controls did, patients with PPPD showed the worst performance, to the point that this variable allowed the discrimination of PPPD from non-PPPD patients. This distinct impairment in spatial navigation abilities offers new insights into PPPD pathophysiology and may also represent a new biomarker for diagnosing this entity.
Copyright © 2020 Breinbauer, Contreras, Lira, Guevara, Castillo, Ruëdlinger, Muñoz and Delano.
KEYWORDS:
dizziness; functional dizziness; morris water maze; persistent postural perceptual dizziness; spatial navigation
4.
J Clin Neurosci. 2020 Feb;72:26-30. doi: 10.1016/j.jocn.2020.01.043. Epub 2020 Jan 14.
Persistent postural-perceptual dizziness: Clinical and neurophysiological study.
Abstract
The aim of this study was to evaluate clinical and neurophysiological characteristics of Persistent postural-perceptual dizziness (PPPD) in a tertiary vertigo clinic. This was a cross-sectional study that included consecutive patients examined in the Vertigo clinic of the University Hospital Center Zagreb, Croatia. The following data were extracted from the electronic hospital records: age, sex, the duration of symptoms, initial trigger event, results of the caloric testing, video head impulse test (vHIT) for all six semicircular canals and ocular and cervical vestibular evoked myogenic potentials (oVEMP and cVEMP). During the study period 147 consecutive patients with dizziness were examined and 28 (19%) were diagnosed with PPPD, 68% of them were women and the mean age was 59.5 ± 15 years. The median duration of symptoms was 23 months. The most common initial event was vestibular neuritis in 39.3% of patients, followed by benign paroxysmal positional vertigo in 10.7% of patients. Caloric testing was performed in 25 patients. It revealed six cases of unilateral canal paresis. vHIT was performed in 24 patients. There were 13 pathological responses with three cases of lateral canal dysfunction, two cases of posterior, one case of anterior and seven cases of multiple canals affection. VEMP was performed in 23 patients. There were five isolated oVEMP pathologies, one isolated cVEMP pathology and 11 findings of a combined oVEMP and cVEMP pathology. This study provides clinical and neurophysiological data on PPPD and indicates the utility of complete neurophysiological assessment of vestibular function in this group of patients.
Copyright © 2020 Elsevier Ltd. All rights reserved.
KEYWORDS:
Neurophysiology; Persistent postural-perceptual dizziness; Vertigo
5.
Conf Proc IEEE Eng Med Biol Soc. 2019 Jul;2019:4342-4345. doi: 10.1109/EMBC.2019.8857332.
Reduced betweenness centrality of a sensory-motor vestibular network in subclinical agoraphobia.
Abstract
Agoraphobic patients feel dizzy in crowded open spaces and respond to this symptom with excessive fear and avoidance. These clinical features show great similitude with the newly defined syndrome of persistent postural perceptual dizziness (PPPD). Patients with PPPD show decreased activity and connectivity in regions of the vestibular cortex. Due to the great overlap between these two conditions, we hypothesized that individuals with sub-clinical agoraphobia would show reduction in the connectivity features of these regions. We selected a group of healthy individuals from the Human Connectome Project that self-reported agoraphobia episodes, and compared it with a control group. We accurately matched the two groups for psychological measures and personality traits in order to study the neural correlates of vestibular symptoms independently of possible psychiatric vulnerabilities. We found that the agoraphobia group showed reduced betweenness centrality of a network encompassing key regions of the vestibular cortex. Dysfunctions of the vestibular cortex may explain the dizziness symptom for a disorder previously labelled as psychogenic.
6.
Semin Neurol. 2020 Feb;40(1):130-137. doi: 10.1055/s-0039-3402736. Epub 2020 Jan 14.
Persistent Postural-Perceptual Dizziness.
Staab JP1,2.
Abstract
Persistent postural-perceptual dizziness (PPPD) was defined for the International Classification of Vestibular Disorders in 2017. It is a chronic vestibular disorder that manifests with waxing and waning symptoms of dizziness, unsteadiness, or nonspinning vertigo that last for 3 months or more and are exacerbated by upright posture, active or passive motion of self, and exposure to environments with complex or moving visual stimuli. Triggers of PPPD include a wide variety of conditions that may cause vestibular symptoms or disrupt balance functioning, including neuro-otologic and other medical conditions and psychological distress. The diagnosis is made by identifying key symptoms in patients' histories and conducting physical examinations and diagnostic testing of sufficient detail to establish PPPD as opposed to other illnesses. Ongoing research is providing insights into the pathophysiological mechanisms underlying PPPD and support for multimodality treatment plans incorporating specially adapted vestibular rehabilitation, serotonergic medications, and cognitive-behavior therapy.
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
7.
Ear Hear. 2019 Dec 13. doi: 10.1097/AUD.0000000000000825. [Epub ahead of print]
Cross-Sectional Analysis of Cognitive Dysfunction in Patients With Vestibular Disorders.
Abstract
OBJECTIVE:
The relationship of cognitive dysfunction and vestibular dysfunction has been established by various studies. However, the available Patient-Reported Outcome Measures questionnaires that address the main vestibular complaint fail to highlight this domain of dysfunction in this patient population. The objective of this study was to quantify and compare cognitive impairment using a validated cognitive questionnaire across several vestibular diagnoses.
STUDY DESIGN:
Cross-sectional study of 186 patients presenting to a tertiary care vestibular clinic with a diagnosis of vestibular migraine, Meniere's disease (MD), benign positional paroxysmal vertigo, or persistent postural-perceptual dizziness (PPPD). Patients completed the Cognitive Failures Questionnaire (CFQ) and the Dizziness Handicap Inventory (DHI).
RESULTS:
Mean CFQ scores for this cohort were significantly higher than similarly aged published controls (34.9/100 versus 31.3/100; p < 0.01; mean age, 45 years) as well as published controls between 65 and 74 years of age (34.9/100 versus 31.2/100; p < 0.05). Patients with PPPD or combined vestibular migraine and MD scored the highest on the CFQ and significantly higher than controls (45.1/100, p = 0.001; and 44.1/100, p = 0.006, respectively). Patients with benign positional paroxysmal vertigo had lower scores than normal controls. There is a weak but significant correlation between CFQ and DHI (r = 0.31; p < 0.001). Multivariate linear regression shows that CFQ scores were largely driven by the duration of symptoms (p < 0.001), type of diagnosis (notably PPPD; p = 0.026), and DHI (p < 0.001).
CONCLUSIONS:
Our results indicate that cognitive impairment is prevalent with chronic vestibular disorders, even in peripheral disorders such as MD. The duration of vestibular symptoms before diagnosis (and management), as well as certain etiologies, may play a bigger role in cognitive disability than age. This is not currently well-addressed in Patient-Reported Outcome Measures questionnaires and may be overlooked at the time of the diagnosis. Appropriate identification may help tailor treatment, namely rehabilitation programs, to individual patients.
8.
Zh Nevrol Psikhiatr Im S S Korsakova. 2019;119(9. Vyp. 2):5-9. doi: 10.17116/jnevro20191190925.
[Persistent postural perceptual dizziness of the elderly].
[Article in Russian; Abstract available in Russian from the publisher]
Abstract
Persistent postural perceptual dizziness (PPPD) is a common cause of complaints to dizziness and unitability among patients of all-ages. The disease is characterized by a permanent feeling of non-rotatory dizziness or unsteadiness that at first can be caused by an acute vestibular dizziness, somatic disturbance that causes sudden unsteadiness and loss of balance or, for example, by a panic attack. Despite the permanent feeling of unsteadiness and dizziness, a regular instrumental examination cannot reveal important changes that can explain personal feeling. The diagnosis can be made according to the diagnostic criteria developed by the International Barani Society. Treatment consists of psychotherapy, drug therapy and vestibular rehabilitation.
KEYWORDS:
chronic subjective dizziness; dizziness; persistent postural perceptual dizziness; postural phobic instability
9.
Curr Treat Options Neurol. 2019 Dec 5;21(12):66. doi: 10.1007/s11940-019-0606-x.
Benign Positional Paroxysmal Vertigo Treatment: a Practical Update.
Abstract
PURPOSE OF THE REVIEW:
To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV).
RECENT FINDINGS:
Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.
KEYWORDS:
BPPV; Liberatory; Positional vertigo; Repositioning maneuvers; Vertigo; Vestibular
10.
Ugeskr Laeger. 2019 Nov 11;181(46). pii: V04190245.
[Diagnostics and treatment of functional dizziness in accordance with the new ICD-11 criteria].
[Article in Danish]
Abstract
Persistent postural-perceptual dizziness (PPPD) is a new diagnosis for functional chronic dizziness and included in the new International Classification of Diseases (ICD)-11. The new criteria are positive, specific and make it easier to identify and study functional chronic dizziness. PPPD is a condition triggered by vestibular-, neurological- or psychological conditions. This review examines the symptoms, pathophysiology and treatment of PPPD.
11.
Otol Neurotol. 2020 Jan;41(1):e70-e75. doi: 10.1097/MAO.0000000000002446.
Functional Head Impulse Test With and Without Optokinetic Stimulation in Subjects With Persistent Postural Perceptual Dizziness (PPPD): Preliminary Report.
Abstract
OBJECTIVE:
Persistent postural perceptual dizziness (PPPD) is a clinical condition characterized by unsteadiness present on most days for a period of at least 3 months. The aim of our work was to assess vestibular function, the role of anxiety, and possible interactions between visual and vestibular systems in patients with PPPD.
STUDY DESIGN:
Cross-sectional prospective study.
SETTING:
Tertiary referral center.
PATIENTS:
Twenty-five PPPD patients.
INTERVENTIONS:
Clinical history was collected before examination; vestibular function was assessed through bedside examination, video and functional head impulse test (video-HIT, f-HIT). The latter test was based on having the patient identify an optotype displayed on a computer screen during passive head rotations. The test was repeated while optokinetic stimulation (OKS) was given on the screen. Results were compared with those of 25 controls. State and trait anxiety levels were measured with the State-Trait Anxiety Inventory (STAI) questionnaire. Anxiety before and after vestibular examination was assessed using a VAS scale.
MAIN OUTCOME MEASURE:
Results of video and functional HIT with and without OKS.
RESULTS:
Video-HIT and f-HIT showed normal values in all subjects. f-HIT with OKS provoked more reading errors in patients than in controls. The interaction of group per time detected different decreasing trends between the two groups (p = 0.0002).Patients presented a reduction in anxiety levels after examination. Nine patients fulfilled diagnostic criteria for vestibular migraine, eight of whom presented nystagmus either to positional tests or vibration test. Only anxiety levels before testing were predictive of worsening of f-HIT with optokinetic stimulation (p = 0.0007).
CONCLUSIONS:
Our data support the hypothesis that increased anxiety may play a role in visuo-vestibular interactions; moreover, they are not inconsistent with the hypothesis that OKS might provoke a "threatening effect," leading to gaze bias during examination.
12.
J Vestib Res. 2019 Sep 17. doi: 10.3233/VES-190679. [Epub ahead of print]
Persistent-postural perceptual dizziness (PPPD)-Yes, it is a psychosomatic condition!
Abstract
The Barany society published recently the consensus document for the diagnostic criteria of persistent postural perceptual dizziness (PPPD). In this commentary we highlight the benefits of this new diagnosis and possible problems that can arise during the use of the criteria in day to day clinical practice at a University Clinic for Psychosomatic Medicine. The diagnostic criteria of PPPD are compared to those of somatic symptom disorder and bodily distress disorder. We think that a discussion from a psychosomatic point of view is important to improve the understanding between different specialties and how PPPD fits into the broader framework of psychosomatic medicine.
13.
BMJ. 2019 Sep 12;366:l5435. doi: 10.1136/bmj.l5435.
Vestibular migraine and persistent postural-perceptual dizziness.
Comment on
- Vestibular migraine. [BMJ. 2019]
14.
Front Neurol. 2019 Aug 13;10:874. doi: 10.3389/fneur.2019.00874. eCollection 2019.
Lower Functional Connectivity in Vestibular-Limbic Networks in Individuals With Subclinical Agoraphobia.
Abstract
Background: Agoraphobia was described in 1871 as a condition of fear-related alterations in spatial orientation and locomotor control triggered by places or situations that might cause a patient to panic and feel trapped. In contemporary nosology, however, this original concept of agoraphobia was split into two diagnostic entities, i.e., the modern anxiety disorder of agoraphobia, consisting solely of phobic/avoidant symptoms in public spaces, and the recently defined vestibular disorder of persistent postural perceptual dizziness (PPPD), characterized by dizziness, and unsteadiness exacerbated by visual motion stimuli. Previous neuroimaging studies found altered brain activity and connectivity in visual-vestibular networks of patients with PPPD vs. healthy controls. Neuroticism and introversion, which pre-dispose to both agoraphobia and PPPD, influenced brain responses to vestibular and visual motion stimuli in patients with PPPD. Similar neuroimaging studies have not been undertaken in patients with agoraphobia in its current definition. Given their shared history and pre-disposing factors, we sought to test the hypotheses that individuals with agoraphobic symptoms have alterations in visual-vestibular networks similar to those of patients with PPPD, and that these alterations are influenced by neuroticism and introversion. Methods: Drawing from the Human Connectome Project (HCP) database, we matched 52 participants with sub-clinical agoraphobia and 52 control subjects without agoraphobic symptoms on 19 demographic and psychological/psychiatric variables. We then employed a graph-theoretical framework to compare resting-state functional magnetic resonance images between groups and evaluated the interactive effects of neuroticism and introversion on the brain signatures of agoraphobia. Results: Individuals with subclinical agoraphobia had lower global clustering, efficiency and transitivity relative to controls. They also had lower connectivity metrics in two brain networks, one positioned to process incoming visual space-motion information, assess threat, and initiate/inhibit behavioral responses (visuospatial-emotional network) and one positioned to control and monitor locomotion (vestibular-navigational network). Introversion interacted with agoraphobic symptoms to lower the connectivity of the visuospatial-emotional network. This contrasted with previous findings describing neuroticism-associated higher connectivity in a narrower visual-spatial-frontal network in patients with PPPD. Conclusion: Functional connectivity was lower in two brain networks in subclinical agoraphobia as compared to healthy controls. These networks integrate visual vestibular and emotional response to guide movement in space.
KEYWORDS:
agoraphobia; functional connectivity; graphs theory; persistent postural perceptual dizziness; resting state fMRI; vestibular network
15.
J Vestib Res. 2019;29(2-3):131-136. doi: 10.3233/VES-190669.
Association between dopamine receptor D2 Taq IA gene polymorphism and persistent postural-perceptual dizziness.
Abstract
BACKGROUND:
Persistent postural-perceptual dizziness (PPPD) is a chronic dizziness, its pathogenesis is unknown by now.
OBJECTIVE:
To study the relationship between the DRD2 gene TaqIA polymorphisms and PPPD, and further to explore the molecular mechanism underlying this disease.
METHODS:
43 patients diagnosed with PPPD and 45 randomly selected cases (matched by age and sex) were included in the study and control group, respectively. DRD2 gene TaqIA polymorphisms were detected in all participants by polymerase chain reaction (PCR)combined with the restriction fragment length polymorphism (RFLP) method.
RESULTS:
In the study group, frequencies of the A1 and A2 TaqIA alleles (65.1% and 34.9%, respectively) were significantly different to those in the control group (46.7% and 53.3%, respectively; P < 0.05). The allele frequency in the study group for the A1/A1 genotype was 34.9%, for A1/A2 was 60.5%, and for A2/A2 was 4.6%, all of which were significantly higher than the control group (24.4%, 44.5%. and 31.1%, respectively; P < 0.01).
CONCLUSIONS:
Our findings indicate that the DRD2 TaqIA A1 allele is possibly the susceptibility polymorphism for PPPD, and that the A2/A2 genotype has a potentially protective role for PPPD. However, larger independent studies are required for further validation.
KEYWORDS:
Persistent postural-perceptual dizziness; TaqIA polymorphism; dopamine receptor D2; neuroticism
16.
Brain Imaging Behav. 2019 Jul 16. doi: 10.1007/s11682-019-00168-7. [Epub ahead of print]
Altered spontaneous functional activity of the right precuneus and cuneus in patients with persistent postural-perceptual dizziness.
Abstract
Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disorder, and is the most common cause of chronic vestibular syndrome. However, the pathogenesis of PPPD is currently unclear. This study aimed to analyze the changes of brain spontaneous functional activities in PPPD patients during the resting state, and to explore the underlying pathogenesis of PPPD, particularly the abnormal integration of visual and vestibular information. Ten PPPD patients and 10 healthy controls were enrolled from January to June 2018, and baseline data were collected from all subjects. Videonystagmography (VNG), the vestibular caloric test, the video head impulse test (vHIT) and vestibular evoked myogenic potentials (VEMPs) were measured to exclude peripheral vestibular lesions. Functional MRI (fMRI) was conducted in PPPD patients and healthy controls. The amplitude of low frequency fluctuation (ALFF) and regional homogeneity (ReHo), and functional connectivity were calculated to explore changes in brain spontaneous functional activity during the resting state. Compared with healthy controls, ALFF and ReHo values in the right precuneus and cuneus were significantly lower in PPPD patients (both P < 0.05). Further seed-based functional connectivity analysis showed decreased functional connectivity between precuneus, cuneus and left precentral gyrus (P < 0.05). Our findings suggest that the spontaneous functional activity of cuneus and precuneus in PPPD patients were altered, potentially leading to abnormal integration of visual and vestibular information. Weakened functional connectivity between the precuneus and the precentral gyrus may be associated with aggravated symptoms during upright posture, active or passive movements.
KEYWORDS:
Cuneus; PPPD; Precentral gyrus; Precuneus; Resting state functional magnetic resonance imaging
17.
Otol Neurotol. 2019 Aug;40(7):e747-e752. doi: 10.1097/MAO.0000000000002325.
A Validated Questionnaire to Assess the Severity of Persistent Postural-Perceptual Dizziness (PPPD): The Niigata PPPD Questionnaire (NPQ).
Abstract
OBJECTIVE:
To establish a questionnaire to diagnose and assess the severity of persistent postural-perceptual dizziness (PPPD).
STUDY DESIGN:
Retrospective chart review.
SETTING:
Tertiary referral center.
PATIENTS:
Fifty PPPD patients and 50 consecutive control patients with other vestibular disorders.
INTERVENTIONS:
Patients answered questions on three exacerbating factors of PPPD (upright posture/walking, movement, and visual stimulation), and each factor was evaluated using four questions scoring the severity from 0 (none) to 6 (unbearable). Somatic and psychological distress was evaluated by the Visual Analog Scale (VAS) and the Hospital Anxiety and Depression Scale (HADS), respectively.
MAIN OUTCOME MEASURES:
The questionnaire's reliability was tested by Cronbach's alpha, and it was validated by examining the differences in the questionnaire's scores between PPPD patients and controls. The area under the curve (AUC) of the receiver operating characteristic curve for each factor was calculated.
RESULTS:
Cronbach's alpha coefficient was >0.8 for all factors, except the movement factor. There were no significant differences in the VAS and HADS scores between the two groups. However, the combined and individual questionnaire scores for each factor were higher in PPPD patients than in controls, indicating the questionnaire's high validity. The AUC was widest for the visual stimulation factor (0.830), and a score of 9 (full score 24) had the best sensitivity (82%) and specificity (74%) for discriminating PPPD patients from controls.
CONCLUSIONS:
We developed a questionnaire that exhibited high reliability and validity in evaluating PPPD severity. The visual stimulation factor may be the most characteristic among the three exacerbating factors.
- PMID:
- 31219964
- PMCID:
- PMC6641087
- DOI:
- 10.1097/MAO.0000000000002325
18.
Tidsskr Nor Laegeforen. 2019 May 27;139(9). doi: 10.4045/tidsskr.18.0962. Print 2019 May 28.
Persistent postural-perceptual dizziness
[Article in English, Norwegian]
Abstract
Persistent symptoms of dizziness may be due to inappropriate compensatory strategies following an episode of acute dizziness. Common symptoms are dizziness in an upright position that is aggravated by visual stimuli and passive movement. In the World Health Organization’s new disease classification, ICD-11, the condition has been named persistent postural-perceptual dizziness. It is important to recognise this condition in order to avoid unnecessary investigation and to initiate the correct treatment.
19.
Ann Otol Rhinol Laryngol. 2019 Sep;128(9):869-878. doi: 10.1177/0003489419845014. Epub 2019 Apr 25.
The Interrelations Between Different Causes of Dizziness: A Conceptual Framework for Understanding Vestibular Disorders.
Abstract
BACKGROUND:
According to population-based studies that estimate disease prevalence, the majority of patients evaluated at dizziness clinics receive a single vestibular diagnosis. However, accumulating literature supports the notion that different vestibular disorders are interrelated and often underdiagnosed.
OBJECTIVE:
Given the complexity and richness of these interrelations, we propose that a more inclusive conceptual framework to vestibular diagnostics that explicitly acknowledges this web of association will better inform vestibular differential diagnosis.
METHODS:
A narrative review was performed using PubMed database. Articles were included if they defined a cohort of patients, who were given specific vestibular diagnosis. The interrelations among vestibular disorders were analyzed and placed within a conceptual framework.
RESULTS:
The frequency of patients currently receiving multiple vestibular diagnoses in dizziness clinic is approximately 3.7% (1263/33 968 patients). The most common vestibular diagnoses encountered in the dizziness clinic include benign paroxysmal positional vertigo (BPPV), vestibular migraine, vestibular neuritis, and Ménière's disease.
CONCLUSIONS:
A review of the literature demonstrates an intricate web of interconnections among different vestibular disorders such as BPPV, vestibular migraine, Ménière's disease, vestibular neuritis, bilateral vestibulopathy, superior canal dehiscence syndrome, persistent postural perceptual dizziness, anxiety, head trauma, and aging, among others.
KEYWORDS:
Ménière’s disease; anxiety; benign paroxysmal positional vertigo; miscellaneous; otolaryngology; otology; superior canal dehiscence; vestibular disorders; vestibular migraine
20.
Adv Otorhinolaryngol. 2019;82:170-179. doi: 10.1159/000490286. Epub 2019 Jan 15.
Psychiatric Considerations in the Management of Dizzy Patients.
Abstract
Research over the last 4 decades has revealed a great deal of information about psychiatric and functional causes, consequences, and comorbidity of vestibular syndromes. Primary care clinicians, neurologists, and otologists who are willing to set aside the 20th century notion of "psychogenic dizziness" and incorporate 21st century concepts about 5 behavioral entities into their practices will be rewarded for their efforts with a marked improvement in diagnostic acumen and therapeutic effectiveness. Panic attacks may cause or contribute to acute or episodic vestibular symptoms. Generalized anxiety and depression do the same for chronic vestibular symptoms. Fear of falling causes considerable functional impairment, particularly in the elderly. Persistent postural-perceptual dizziness, a newly defined functional vestibular disorder that was 145 years in the making, is the most common cause of chronic dizziness in neurotologic practice. These 5 disorders are the primary diagnoses in 8-10% of patients who consult neurologists or otologists for vestibular symptoms and may be present in up to 50% of patients with structural vestibular disorders. They affect the clinical course of other illnesses and outcomes of medical and surgical interventions. Fortunately, when recognized properly, they are among the most treatment responsive of all conditions that cause vestibular symptoms.
© 2019 S. Karger AG, Basel.
21.
BMJ Open. 2019 Apr 1;9(4):e024326. doi: 10.1136/bmjopen-2018-024326.
Working-age adults' perspectives on living with persistent postural-perceptual dizziness: a qualitative exploratory study.
Abstract
OBJECTIVES:
To (a) explore the experiences of persistent postural-perceptual dizziness (PPPD), formerly chronic subjective dizziness on the personal, work and social lives of working-age adults; (b) enhance current understandings of the condition and its impact on the lives of working-age adults and (c) highlight points for consideration and importance to clinical practice.
METHODS:
This qualitative exploratory study drew on interpretive descriptive methodology. Working-age adults (n=8) diagnosed with PPPD were recruited from a single New Zealand community-based specialist clinic. Data from interviews (n=8) and postinterview reflections (n=2) were analysed using thematic analysis.
RESULTS:
Three themes were constructed: (1) It sounds like I'm crazy-referring to the lack of medical, social and self-validation associated with PPPD; (2) I'm a shadow of my former self-representing the impact of the condition on sense of self and life trajectory and (3) How will I survive?- highlighting individual coping processes.
CONCLUSION:
This study contributed to the existing body of knowledge by highlighting the complexity and fluidity of experiencing PPPD. It also drew attention to the tension between the acute illness framework that forms the basis of many therapeutic interactions and the enduring psychosocial support needs of the person experiencing PPPD. The findings highlighted that contextual factors need to be taken into account and that a person-centred and biopsychosocial approach, rather than a condition-specific biomedical approach, is needed for care to be perceived as meaningful and satisfactory.
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
KEYWORDS:
CSD; PPPD; chronic subjective dizziness; persistent postural-perceptual dizziness; qualitative
22.
J Otolaryngol Head Neck Surg. 2019 Mar 11;48(1):11. doi: 10.1186/s40463-019-0336-9.
A retrospective analysis of two tertiary care dizziness clinics: a multidisciplinary chronic dizziness clinic and an acute dizziness clinic.
Abstract
BACKGROUND:
Vertigo remains a diagnostic challenge for primary care, emergency, and specialist physicians. Multidisciplinary clinics are increasingly being employed to diagnose and manage patients with dizziness. We describe, for the first time in Canada, the clinical characteristics of patients presenting with chronic and acute dizziness to both a multidisciplinary chronic dizziness clinic (MDC) and a rapid access dizziness (RAD) clinic at The Ottawa Hospital (TOH).
METHODS:
We performed a retrospective review of all patients presenting to the MDC and RAD clinics at TOH from July 2015 to August 2017.
RESULTS:
Overall, 211 patients (median age: 61 years old) presented to the RAD clinic and 292 patients (median age: 55 years old) presented to the MDC. In the RAD clinic, 63% of patients had peripheral dizziness, of which 55% had BPPV, and only one patient had functional dizziness. Interestingly, only 25% of RAD diagnoses were concordant with emergency department diagnoses; moreover, only 33% of RAD patients had HiNTS completed, while 44% had CT scans, of which only one scan had an abnormal finding. Prior to assessment, all patients in the MDC had an unclear cause of dizziness. 28% of patients had vestibular dizziness and 21% had functional dizziness, of which 43% had persistent postural perceptual dizziness. Moreover, 12% of patients with functional dizziness also suffered from comorbid severe anxiety and depression.
CONCLUSIONS:
Dizziness is a heterogeneous disorder that necessitates multidisciplinary care, and clinics targeting both the acute and chronic setting can improve diagnostic accuracy, ensure appropriate diagnostic testing, and facilitate effective care plans for patients with dizziness.
KEYWORDS:
Acute dizziness; Chronic dizziness; Multidisciplinary; Retrospective; Vertigo
- PMID:
- 30857559
- PMCID:
- PMC6413454
- DOI:
- 10.1186/s40463-019-0336-9
- [Indexed for MEDLINE]
23.
J Vestib Res. 2018;28(5-6):369-378. doi: 10.3233/VES-190653.
Brain responses to virtual reality visual motion stimulation are affected by neurotic personality traits in patients with persistent postural-perceptual dizziness.
Abstract
OBJECTIVE:
Persistent postural perceptual dizziness (PPPD) is a common vestibular disorder of persistent dizziness and unsteadiness, exacerbated by upright posture, self-motion, and exposure to complex or moving visual stimuli. Previous functional magnetic resonance imaging (fMRI) studies found dysfunctional activity in the visual-vestibular cortices in patients with PPPD. Clinical studies showed that the anxiety-related personality traits of neuroticism and introversion may predispose individuals to PPPD. However, the effects of these traits on brain function in patients with PPPD versus healthy controls (HCs) have not been studied.
METHODS:
To investigate potential differential effects of neuroticism and introversion on functioning of their visuo-vestibular networks, 15 patients with PPPD and 15 HCs matched for demographics and motion sickness susceptibility underwent fMRI during virtual reality simulation of a rollercoaster ride in vertical and horizontal directions.
RESULTS:
Neuroticism positively correlated with activity in the inferior frontal gyrus (IFg), and enhanced connectivity between the IFg and occipital regions in patients with PPPD relative to HCs during vertical versus horizontal motion comparison.
CONCLUSIONS:
In patients with PPPD, neuroticism increased the activity and connectivity of neural networks that mediate attention to visual motion cues during vertical motion. This mechanism may mediate visual control of balance in neurotic patients with PPPD.
KEYWORDS:
Rollercoaster simulation; fMRI; persistent postural-perceptual dizziness; vestibular; visual motion stimulation
24.
Front Neurol. 2019 Feb 13;10:69. doi: 10.3389/fneur.2019.00069. eCollection 2019.
Influence of Visual and Vestibular Hypersensitivity on Derealization and Depersonalization in Chronic Dizziness.
Toupet M1,2,3, Van Nechel C3,4, Hautefort C3,5, Heuschen S2, Duquesne U3,4, Cassoulet A2, Bozorg Grayeli A1,6.
Abstract
Objective: The aim of this study was to investigate the relation between visual and vestibular hypersensitivity, and Depersonalization/Derealization symptoms in patients with chronic dizziness. Materials and Methods: 319 adult patients with chronic dizziness for more than 3 months (214 females and 105 males, mean age: 58 years, range: 13-90) were included in this prospective cross-sectional study. Patients underwent a complete audio-vestibular workup and 3 auto questionnaires: Hospital Anxiety and Depression (HAD), Depersonalization/Derealization Inventory (DDI), and an in-house questionnaire (Dizziness in Daily Activity, DDA) assessing 9 activities with a score ranging from 0 (no difficulty) to 10 (maximal discomfort) and 11 (avoidance) to detect patients with visual and vestibular hypersensitivity (VVH, a score > 41 corresponding to mean + 1 standard deviation). Results: DDI scores were higher in case of VVH (6.9 ± 6.79, n = 55 vs. 4.2 ± 4.81, n = 256 without VVH, p < 0.001, unpaired t-test), migraine (6.1 ± 6.40, n = 110 vs. 4.0 ± 4.42, n = 208no migraine, p < 0.001, unpaired t-test), and motion sickness (6.8 ± 5.93, n = 41 vs. 4.4 ± 5.11, n = 277 no motion sickness, p < 0.01, unpaired t-test). Women scored DDI higher than men (5.1 ± 5.42, n = 213 vs. 3.9 ± 4.91, n = 105, respectively, p < 0.05, unpaired t-test). DDI scores were also related to depression and anxiety. DDI score was also higher during spells than during the basal state. Conclusion: During chronic dizziness, Depersonalization/Derealization symptoms seem to be related to anxiety and depression. Moreover, they were prominent in women, in those with visual and vestibular hypersensitivity, migraine, and motion sickness.
KEYWORDS:
anxiety; chronic vertigo; depersonalization/derealization disorder; depression; migraine; motion sickness; optic flow vertigo; persistent postural-perceptual dizziness
25.
J Neurol. 2019 May;266(5):1236-1249. doi: 10.1007/s00415-019-09255-7. Epub 2019 Feb 26.
Postural control during galvanic vestibular stimulation in patients with persistent perceptual-postural dizziness.
Abstract
Over the past years galvanic vestibular stimulation (GVS) has been increasingly applied to stimulate the vestibular system in health and disease, but not in patients with persistent postural-perceptual dizziness (PPPD) yet. We functionally tested motion perception thresholds and postural responses to imperceptible noisy (nGVS) and perceptible bimastoidal GVS intensities in patients with PPPD with normal vestibulo-ocular reflexes. We hypothesized that GVS destabilizes PPPD patients under simple postural conditions stronger compared to healthy controls. They were compared to healthy subjects under several conditions each with the eyes open and closed: baseline with firm platform support, standing on foam and cognitive demand (count backward). Low and high GVS intensities (range 0.8-2.8 mA) were applied according to the individual thresholds and compared with no GVS. PPPD patients showed a reduced perception threshold to GVS compared to healthy control subjects. Median postural sway speed increased with stimulus intensity and on eye closure, but there was no group difference, irrespective of the experimental condition. Romberg's ratio was consistently lower during nGVS than in all other conditions. Group-related dissociable effects were found with the eyes closed in (i) the baseline condition in which high GVS elicited higher postural sway of PPPD patients and (ii) in the foam condition, with better postural stability of PPPD patients during perceptible GVS. Group and condition differences of postural control were neither related to anxiety nor depression scores. GVS may be helpful to identify thresholds of vestibular perception and to modulate vestibulo-spinal reflexes in PPPD, with dissociable effects with respect to perceptible and imperceptible stimuli. The sway increase in the baseline of PPPD may be related to an earlier transition from open- to closed-loop mode of postural control. In contrast, the smaller sway of PPPD in the foam condition under visual deprivation is in line with the known balance improvement under more demanding postural challenges in PPPD. It is associated with a prolonged transition from open- to closed-loop postural feedback control. It could also reflect a shift of intersensory weighting with a smaller dependence on proprioceptive feedback control in PPPD patients under complex tasks. In summary, GVS discloses differences between simple and complex balance tasks in PPPD.
KEYWORDS:
Galvanic vestibular stimulation; Persistent perceptual–postural dizziness; Postural control
26.
J Neural Transm (Vienna). 2019 May;126(5):697. doi: 10.1007/s00702-019-01977-2.
Correction to: Cerebral perfusion abnormalities in patients with persistent postural-perceptual dizziness (PPPD): a SPECT study.
Abstract
The authors inadvertently forgot to provide the following funding information in the original publication: This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Science and ICT (2018R1A6A3A11041118).
Erratum for
- Cerebral perfusion abnormalities in patients with persistent postural-perceptual dizziness (PPPD): a SPECT study. [J Neural Transm (Vienna). 2019]
27.
Ann Otol Rhinol Laryngol. 2019 Apr;128(4):323-329. doi: 10.1177/0003489418823017. Epub 2019 Jan 4.
Vestibular Rehabilitation Therapy Outcomes in Patients With Persistent Postural-Perceptual Dizziness.
Abstract
OBJECTIVES::
Persistent postural-perceptual dizziness (PPPD) represents an important category of vertigo. Medical treatment and psychotherapy provide convenient control of symptoms. However, these management strategies can have inconvenient side effects and short-term relief, respectively. Vestibular rehabilitation therapy (VRT) is a self-conducted habituation program that can be personalized to the subject's needs to give adequate symptom relief without side effects. The present study aims to test the effect of VRT on patients with PPPD.
METHODS::
Participants were diagnosed as having PPPD by the exclusion of organic vestibular lesions. The study involved 2 groups with PPPD: Group I, treated with the VRT, and Group II, treated with the VRT plus placebo. The Dizziness Handicap Inventory (DHI), a self-assessment scale, was used to evaluate the VRT outcomes.
RESULTS::
There was a significant decrease in functional, physical, and total scores on the DHI in both groups after VRT. Adding the placebo did not have supplementary outcomes. The patients who did not benefit from the VRT had a significantly longer duration of PPPD, more complex aggravating factors, more composite VRT exercises, and a higher DHI score than the patients who benefited from VRT.
CONCLUSIONS::
Customized VRT adequately reduced symptoms and improved quality of life in subjects with PPPD.
KEYWORDS:
Dizziness Handicap Inventory; habituation; persistent postural-perceptual dizziness; vertigo; vestibular rehabilitation therapy
28.
Curr Opin Neurol. 2019 Feb;32(1):137-144. doi: 10.1097/WCO.0000000000000632.
Vestibular rehabilitation: advances in peripheral and central vestibular disorders.
Abstract
PURPOSE OF REVIEW:
Rehabilitation for persons with vertigo and balance disorders is becoming commonplace and the literature is expanding rapidly. The present review highlights recent findings of both peripheral and central vestibular disorders and provides insight into evidence related to new rehabilitative interventions. Risk factors will be reviewed to create a better understanding of patient and clinical characteristics that may effect recovery among persons with vestibular disorders.
RECENT FINDINGS:
Clinical practice guidelines have recently been developed for peripheral vestibular hypofunction and updated for benign paroxysmal positional vertigo. Diagnoses such as persistent postural-perceptual dizziness (PPPD) and vestibular migraine are now defined, and there is growing literature supporting the effectiveness of vestibular rehabilitation as a treatment option. As technology advances, virtual reality and other technologies are being used more frequently to augment vestibular rehabilitation. Clinicians now have a better understanding of rehabilitation expectations and whom to refer based on evidence in order to improve functional outcomes for persons living with peripheral and central vestibular disorders.
SUMMARY:
An up-to-date understanding of the evidence related to vestibular rehabilitation can assist the practicing clinician in making better clinical decisions for their patient and hopefully result in optimal functional recovery.
29.
J Neural Transm (Vienna). 2019 Feb;126(2):123-129. doi: 10.1007/s00702-018-1948-3. Epub 2018 Oct 31.
Cerebral perfusion abnormalities in patients with persistent postural-perceptual dizziness (PPPD): a SPECT study.
Erratum in
- Correction to: Cerebral perfusion abnormalities in patients with persistent postural-perceptual dizziness (PPPD): a SPECT study. [J Neural Transm (Vienna). 2019]
Abstract
Persistent postural-perceptual dizziness (PPPD) is a recently defined syndrome with chronic dizziness interrupting daily life. Although the high levels of anxiety and functional changes in postural control strategy and multi-sensory information processing and integration may be underlying the pathophysiology, its neural mechanisms are poorly understood. The aim of this study was to examine the regional cerebral blood flow (rCBF) in patients with PPPD using single photon emission computed tomography (SPECT). A total of 25 patients with PPPD and 25 healthy controls participated in the study. All participants underwent brain SPECT and the patients completed the Dizziness Handicap Inventory. SPECT images were compared between the groups, and the correlation of rCBF and disease severity/duration was assessed in patients. Compared with controls, PPPD patients showed a significantly decreased rCBF in the insula and frontal lobe, mainly in the left posterior insula, bilateral superior frontal gyrus, right inferior frontal gyrus, right precentral gyrus, and left medial orbital gyrus. Additionally, PPPD patients showed a significant rCBF increase in the bilateral cerebellum compared with controls. The results of our study suggest that the altered rCBF in the insular, frontal, and cerebellar cortices might be reflecting the process of maladaptation and the compensatory responses for the changes in PPPD.
KEYWORDS:
Brain perfusion; Persistent postural-perceptual dizziness; Regional cerebral blood flow; Single photon emission computed tomography
30.
Curr Treat Options Neurol. 2018 Oct 13;20(12):50. doi: 10.1007/s11940-018-0535-0.
Treatment of Persistent Postural-Perceptual Dizziness (PPPD) and Related Disorders.
Abstract
PURPOSE OF REVIEW:
Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder of functional dizziness that in the International Classification of Diseases in its 11th revision (ICD-11) supersedes phobic postural vertigo and chronic subjective dizziness. Despite efforts to unify the diagnosis of functional (somatoform) dizziness, patients will present with a variety of triggers, perpetuating factors, and comorbidities, requiring individualized treatment. This article will review different treatment strategies for this common functional neurological disorder and provide practical recommendations for tailored therapy.
RECENT FINDINGS:
An emerging understanding of the underlying pathophysiology that considers vestibular, postural, cognitive, and emotional aspects can enable patients to profit from vestibular rehabilitation, as well as cognitive-behavioral therapy (CBT). Crucially, approaches from CBT should inform and augment physiotherapeutic techniques, and, on the other hand, vestibular exercises or relaxation techniques can be integrated into CBT programs. Antidepressant medication might further facilitate rehabilitation, though the mechanisms are yet to be elucidated, and the level of evidence is low. In PPPD and related disorders, vestibular rehabilitation combined with CBT, and possibly supported by medication, can help patients escape a cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in everyday life.
KEYWORDS:
Chronic subjective dizziness; Cognitive-behavioral therapy; Functional neurological disorder; Persistent postural-perceptual dizziness; Phobic postural vertigo; Vestibular rehabilitation
31.
Otol Neurotol. 2018 Dec;39(10):1291-1303. doi: 10.1097/MAO.0000000000002010.
Persistent Postural-Perceptual Dizziness-A Systematic Review of the Literature for the Balance Specialist.
Abstract
OBJECTIVE:
To present a systematic review of the current data on persistent postural-perceptual dizziness (PPPD), a useful and relatively new diagnosis for a disorder that has previously been known by many different names. In addition, to discuss diagnostic criteria and management strategies for this condition with the otologist in mind.
DATA SOURCES:
CINAHL, Embase, PubMed, Medline, PsycINFO, PubMed, Google Scholar.
REVIEW METHOD:
The phrase "persistent postural-perceptual dizziness" and its acronym "PPPD" were used.
RESULTS:
From 318 articles, 15 were selected for full analysis with respect to PPPD. Most were case-control studies, with one consensus paper from the Bárány Society available. Overall, the pathophysiology of PPPD remains relatively poorly understood, but is likely to be a maladaptive state to a variety of insults, including vestibular dysfunction and not a structural or psychiatric one. Cognitive behavioral therapy, vestibular rehabilitation, selective serotonin uptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) all seem to have a role in its management.
CONCLUSIONS:
PPPD is useful as a diagnosis for those treating dizziness as it helps to define a conglomeration of symptoms that can seem otherwise vague and allows for more structured management plans in those suffering from it.
32.
Ideggyogy Sz. 2018 Jul 30;71(7-08):221-235. doi: 10.18071/isz.71.0221.
[Paradigm shift in management of patients with vertigo and imbalance].
[Article in Hungarian; Abstract available in Hungarian from the publisher]
Abstract
Dizziness is one of the most common causes of medical visits. Management of the dizzy patient may be challenging both for the general practitioner, in emergency departments, and special clinics, as behind a seemingly homogeneous clinical presentation several very different etiologies may occur. Research of the last two century enriched our knowledge about physiology and pathophysiology of the vestibular system. Much knowledge is now available about the labyrinth being able to sense head motions and gravity, processing of afferent vestibular stimuli, reflectory oculomotor and postural control, or recovery of the vestibular system. Based on scientific results new beside tests have been introduced including provocation maneuvers for detecting ectopic otoliths in different semicircular canals, head impulse test to examine function of the vestibulo-ocular reflex, and the HINTS+ battery for differentiation of peripheral or central origin of an acute vestibular syndrome. Technical innovations like videooculography and vestibular evoked myogenic potentials enable us to selectively and side-specifically examine the function of all six semicircular canals and two otolith organs. Pathomechanism of disorders with vertigo and dizziness became more clear resulting in the development or amendment of diagnostic criteria of several vestibular disorders including vestibular migraine, Menière's disease, benign paroxysmal positional vertigo, persistent postural-perceptual dizziness, bilateral vestibulopathy. Broader knowledge about the pathomechanism promoted the development of new therapeutic methods like different repositioning maneuvers in benign paroxysmal positional vertigo, pharmaceutical therapies, vestibular rehabilitation, and psychotherapy. We aimed to summarize the novelties in the field of oto-neurology.
KEYWORDS:
benign paroxysmal positional vertigo; head impulse test; stroke; vertigo; vestibulare migraine
33.
Front Neurol. 2018 May 7;9:261. doi: 10.3389/fneur.2018.00261. eCollection 2018.
Comprehensive Clinical Profile of Mal De Debarquement Syndrome.
Abstract
BACKGROUND:
There has been increasing awareness that post-motion triggered rocking self-vertigo can last for months or years, a disorder known as Mal de Debarquement Syndrome (MdDS). A similar feeling of oscillating self-motion can occur without a motion trigger in some individuals, leading to controversy about whether motion triggered (MT) and non-motion triggered (non-MT) symptoms ultimately represent the same disorder. Recognizing the similarities and differences between MT and non-MT MdDS can prevent unnecessary diagnostic testing and lead to earlier and more effective treatments.
METHODS:
Standardized questionnaire assessment and follow-up interviews of individuals with persistent MT or non-MT MdDS (>1 month) examined at a University Dizziness Clinic.
FINDINGS:
Questionnaires were available on 80 individuals with persistent MT MdDS and 42 with non-MT MdDS. Sex distribution (81% female) and age of onset (mean 43.4 ± 12.2 years MT; 42.1 ± 15.2 years non-MT) were comparable between MT and non-MT MdDS (p > 0.05). Mean duration of illness was significantly longer in the non-MT group (82.8 ± 64.2 months) than the MT group (35.4 ± 46.4 months) (p < 0.001). There was no correlation between trigger type and age of onset or duration of illness for MT MdDS. Improvement with re-exposure to motion (driving) was typical for both (MT = 89%, non-MT = 64%), but non-MT individuals more frequently had symptoms exacerbated with motion (MT = 0%; non-MT = 10%). Peri-menstrual and menstrual worsening of symptoms was typical in both MT and non-MT MdDS (each 71%). Both MT and non-MT MdDS exhibited a higher population baseline prevalence of migraine (23% and 38%, respectively). Benzodiazepines and SSRI/SNRIs were helpful in both subtypes of MdDS (>50% individuals with a positive response). Physical therapy was modestly helpful in the MT (56%) subtype but not in non-MT (15%). Vestibular therapy made as many individuals worse as better in MT and none improved in the non-MT group.
CONCLUSION:
General demographic characteristics and exacerbating factors are similar in MT and non-MT MdDS, but there are differences in the duration of illness, effect of motion on symptoms, and response to therapy. Recognizing clinical features of MdDS subtypes may allow for better tailoring of therapy and potentially serve as classification criteria for new clinical designations.
KEYWORDS:
Mal de Debarquement Syndrome; clinical spectrum; persistent postural perceptual dizziness; rocking vertigo; therapeutics
34.
Brain Imaging Behav. 2019 Jun;13(3):798-809. doi: 10.1007/s11682-018-9900-6.
Reduced cortical folding in multi-modal vestibular regions in persistent postural perceptual dizziness.
Nigro S1, Indovina I2,3, Riccelli R2,3, Chiarella G4, Petrolo C4, Lacquaniti F2,3,5, Staab JP6, Passamonti L7,8.
Abstract
Persistent postural perceptual dizziness (PPPD) is a common functional vestibular disorder that is triggered and sustained by a complex interaction between physiological and psychological factors affecting spatial orientation and postural control. Past functional neuroimaging research and one recent structural (i.e., voxel-based morphometry-VBM) study have identified alterations in vestibular, visuo-spatial, and limbic brain regions in patients with PPPD and anxiety-prone normal individuals. However, no-one thus far has employed surface based morphometry (SBM) to explore whether cortical morphology in patients with PPPD differs from that of healthy people. We calculated SBM measures from structural MR images in 15 patients with PPPD and compared them to those from 15 healthy controls matched for demographics, personality traits known to confer risk for PPPD as well as anxiety and depressive symptoms that are commonly comorbid with PPPD. We tested for associations between SBM measures and dizziness severity in patients with PPPD. Relative to controls, PPPD patients showed significantly decreased local gyrification index (LGI) in multi-modal vestibular regions bilaterally, specifically the posterior insular cortices, supra-marginal gyri, and posterior superior temporal gyri (p < 0.001). Within the PPPD group, dizziness severity positively correlated with LGI in visual areas and negatively with LGI in the right superior parietal cortex. These findings demonstrate abnormal cortical folding in vestibular cortices and correlations between dizziness severity and cortical folding in visual and somatosensory spatial association areas in PPPD patients, which provides new insights into the pathophysiological mechanisms underlying this disorder.
KEYWORDS:
Local gyrification index; Occipital cortex; Persistent postural perceptual dizziness; Superior parietal cortex; Surface based morphometry; Vestibular cortex
- PMID:
- 29860587
- PMCID:
- PMC6538588
- DOI:
- 10.1007/s11682-018-9900-6
- [Indexed for MEDLINE]
35.
J Neurol. 2018 Oct;265(Suppl 1):63-69. doi: 10.1007/s00415-018-8894-8. Epub 2018 May 21.
Non-invasive vagus nerve stimulation significantly improves quality of life in patients with persistent postural-perceptual dizziness.
Abstract
Persistent postural-perceptual dizziness (PPPD) is one of the most common causes of chronic vestibular disorders, with a substantial portion of the affected patients showing no significant improvement to standard therapies (i.e., pharmacotherapy, behavioral psychotherapy). Patients with PPPD have been shown to have a significant comorbidity with anxiety disorders and depression. Further, these patients show an activation of the autonomic nervous system resulting in symptoms such as nausea, increase of heart rate, and sweating. Based on the comorbidities and the activation of the autonomic nervous system, we addressed the question whether non-invasive vagus nerve stimulation (nVNS) might be a treatment option for these patients. In this prospective study we, therefore, applied nVNS to patients with treatment-refractory (to the standard therapy) PPPD. The stimulation protocol was similar to previous studies in patients with cluster headache and consisted of stimulations during exacerbations or acute attacks of vertigo, but also with regular stimulations in the morning and evening as prophylactic treatment. Results showed that non-invasive vagus nerve stimulation significantly improved quality of life, as measured by the EQ-5D-3L (p = 0.04), and depression, as measured by the HADS-D (p = 0.002), in the nVNS group, but not in the age- and sex-matched group with standard of care (SOC) treatment. Moreover, in the pooled analysis (additional 4 weeks of stimulation also in the SOC-group), less severe vertigo attacks/exacerbations (p = 0.04), a decrease in total postural sway path as measured by posturography (p = 0.02), as well as tendentious less anxiety (p = 0.08), occurred after stimulation. These data imply that short term nVNS is a safe and promising treatment option in patients with otherwise refractory PPPD.
KEYWORDS:
Non-invasive vagus nerve stimulation (nVNS); Parasympathetic nervous system (PSNS); Persistent postural-perceptual dizziness (PPPD); Quality of life (QOL); Sympathetic nervous system (SNS); Total postural sway
36.
Zhonghua Yi Xue Za Zhi. 2018 Apr 24;98(16):1227-1230. doi: 10.3760/cma.j.issn.0376-2491.2018.16.008.
[Etiological analysis on patients with vertigo or dizziness].
[Article in Chinese; Abstract available in Chinese from the publisher]
Abstract
Objective: To explore the spectrum of causes for patients with vertigo or dizziness in the Department of Neurology, and provide a reference for diagnosis and treatment of patients with vertigo or dizziness. Methods: Clinical data of patients in the Department of Neurology, Baotou Central Hospital between January 2016 and September 2017 was retrospectively analyzed. The target group under study was diagnosed based on the uniform diagnostic criteria. Results: A total of 9 200 patients with a chief complaint of vertigo or dizziness were included. The ratio of male to female was 1∶1.8, with an age range of 19 to 85 years. The different etiology was as follows: benign paroxysmal positional vertigo (BPPV) (3 148 cases, 34.22%), persistent postural-perceptual dizziness (PPPD) (2 006 cases, 21.80%), vertigo caused by cerebrovascular diseases (1 463 cases, 15.90%), vestibular neuritis (741 cases, 8.05%), vestibular migraine (536 cases, 5.83%), vestibular paroxysmia (336 cases, 3.65%), Ménière disease (187 cases, 2.03%), drug-induced vertigo (96 cases, 1.04%), neurological degenerative diseases (74 cases, 0.80%), sudden sensorineural hearing loss (51 cases, 0.55%), multiple sclerosis and neuromyelitis optica (21 cases, 0.23%), other reasons (22 cases, 0.24%), unknown reasons (519 cases, 5.64%). Conclusions: Dizziness is resulted from various causes, and BPPV is the most common reason. Vertigo caused by cerebrovascular diseases appears to gradually increase along with age. PPPD is very common in clinical practice, so clinicians needs to be highly aware of BPPV and PPPD. Although those dizziness diseases have a low incidence, they should not be ignored. There are still certain proportion of vertigo patients whose diagnosis are undetermined.
KEYWORDS:
Dizziness; Epidemiology; Vertigo; Vestibular diseases
37.
Biomed Res Int. 2018 Mar 7;2018:8518631. doi: 10.1155/2018/8518631. eCollection 2018.
Cognitive Behavior Therapy as Augmentation for Sertraline in Treating Patients with Persistent Postural-Perceptual Dizziness.
Abstract
BACKGROUND:
Persistent postural-perceptual dizziness (PPPD) is a common vestibular disorder. This study was conducted to assess whether the addition of cognitive behavior therapy (CBT) could significantly improve the efficacy and acceptability of sertraline in treating PPPD.
METHODS:
PPPD patients were recruited and randomly assigned to control and experiment groups. Patients in both groups received sertraline 50-200 mg/day, and only patients in the experiment group received CBT (twice a week, one hour per time). The treatment was continued for eight weeks. At baseline, week 2, week 4, and week 8, the 25-item Dizziness Handicap Inventory (DHI), Hamilton Anxiety Rating Scale (HARS), and Hamilton Depression Rating Scale (HDRS) were used to assess the self-perceived handicapping effects caused by PPPD, anxiety, and depressive symptoms, respectively. The dose of sertraline used and the adverse events in both groups were recorded and analyzed.
RESULTS:
In total, 91 PPPD patients were randomly assigned to the control group (n = 45) and experiment group (n = 46). After eight weeks of treatment, the average DHI scores, HDRS scores, and HARS scores were significantly decreased in both groups. But compared to the control group, the experiment group had significantly lower average DHI score, HDRS score, and HARS score at weeks 4 and 8. Moreover, the dose of sertraline used in the experiment group was significantly lower than that in the control group, and adverse events occurred more frequently in the control group than in the experiment group (48.9% versus 26.1%, p = 0.025).
CONCLUSION:
These results demonstrated that the addition of CBT could significantly improve the efficacy and acceptability of sertraline in treating PPPD and reduce the dose of sertraline used.
38.
Hum Brain Mapp. 2018 Aug;39(8):3340-3353. doi: 10.1002/hbm.24080. Epub 2018 Apr 15.
Altered brain function in persistent postural perceptual dizziness: A study on resting state functional connectivity.
Abstract
This study used resting state functional magnetic resonance imaging (rsfMRI) to investigate whole brain networks in patients with persistent postural perceptual dizziness (PPPD). We compared rsfMRI data from 38 patients with PPPD and 38 healthy controls using whole brain and region of interest analyses. We examined correlations among connectivity and clinical variables and tested the ability of a machine learning algorithm to classify subjects using rsfMRI results. Patients with PPPD showed: (a) increased connectivity of subcallosal cortex with left superior lateral occipital cortex and left middle frontal gyrus, (b) decreased connectivity of left hippocampus with bilateral central opercular cortices, left posterior opercular cortex, right insular cortex and cerebellum, and (c) decreased connectivity between right nucleus accumbens and anterior left temporal fusiform cortex. After controlling for anxiety and depression as covariates, patients with PPPD still showed decreased connectivity between left hippocampus and right inferior frontal gyrus, bilateral temporal lobes, bilateral insular cortices, bilateral central opercular cortex, left parietal opercular cortex, bilateral occipital lobes and cerebellum (bilateral lobules VI and V, and left I-IV). Dizziness handicap, anxiety, and depression correlated with connectivity in clinically meaningful brain regions. The machine learning algorithm correctly classified patients and controls with a sensitivity of 78.4%, specificity of 76.9%, and area under the curve = 0.88 using 11 connectivity parameters. Patients with PPPD showed reduced connectivity among the areas involved in multisensory vestibular processing and spatial cognition, but increased connectivity in networks linking visual and emotional processing. Connectivity patterns may become an imaging biomarker of PPPD.
© 2018 Wiley Periodicals, Inc.
KEYWORDS:
functional connectivity; persistent postural perceptual dizziness; resting state functional imaging; support vector machine; vertigo
39.
Pract Neurol. 2018 Feb;18(1):3-4. doi: 10.1136/practneurol-2017-001817. Epub 2018 Jan 4.
Persistent postural-perceptual dizziness: a useful new syndrome.
KEYWORDS:
PPPD; chronic dizziness; functional neurological disorder; vertigo; vestibular therapy
- PMID:
- 29305493
- PMCID:
- PMC5800327
- DOI:
- 10.1136/practneurol-2017-001817
- [Indexed for MEDLINE]
40.
Swiss Med Wkly. 2017 Dec 27;147:w14566. doi: 10.4414/smw.2017.14566. eCollection 2017.
Treatment of dizziness: an interdisciplinary update.
Spiegel R1, Rust H2, Baumann T3, Friedrich H4, Sutter R5, Göldlin M6, Rosin C7, Müri R6, Mantokoudis G4, Bingisser R7, Strupp M8, Kalla R6.
Abstract
This review provides an update on interdisciplinary treatment for dizziness. Dizziness can have various causes and the treatment offered should depend on the cause. After reading this article, the clinician will have an overview of current treatment recommendations. Recommendations are made for the most prevalent causes of dizziness including acute and chronic vestibular syndromes, vestibular neuritis, benign paroxysmal positional vertigo, endolymphatic hydrops and Menière’s disease, vestibular paroxysmia and vestibular migraine, cardiac causes, transient ischaemic attacks and strokes, episodic ataxia type 2, persistent postural-perceptual dizziness, bilateral vestibulopathy, degenerative, autoimmune and neoplastic diseases, upbeat- and downbeat nystagmus. Recommendations include clinical approaches (repositioning manoeuvres), medication (adding, removing or changing current medication depending on aetiology), vestibular physiotherapy, ergotherapy and rehabilitation, treatment of chest pain or stroke units and surgical interventions. If symptoms are acute and severe, medication with antivertigo agents is recommended as a first step, for a maximum period of 3 days. Following initial symptom control, treatment is tailored depending on aetiology. To assist the clinician in obtaining a useful overview, the level of evidence and number needed to treat are reported whenever possible based on study characteristics. In addition, warnings about possible arrhythmias due to medication are issued, and precautions to enable these to be avoided are discussed.
41.
Pract Neurol. 2018 Feb;18(1):5-13. doi: 10.1136/practneurol-2017-001809. Epub 2017 Dec 5.
Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness.
Abstract
Persistent postural-perceptual dizziness (PPPD) is a newly defined diagnostic syndrome that unifies key features of chronic subjective dizziness, phobic postural vertigo and related disorders. It describes a common chronic dysfunction of the vestibular system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness. The disorder constitutes a long-term maladaptation to a neuro-otological, medical or psychological event that triggered vestibular symptoms, and is usefully considered within the spectrum of other functional neurological disorders. While diagnostic tests and conventional imaging usually remain negative, patients with PPPD present in a characteristic way that maps on to positive diagnostic criteria. Patients often develop secondary functional gait disorder, anxiety, avoidance behaviour and severe disability. Once recognised, PPPD can be managed with effective communication and tailored treatment strategies, including specialised physical therapy (vestibular rehabilitation), serotonergic medications and cognitive-behavioural therapy.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
KEYWORDS:
chronic subjective dizziness; functional dizziness; persistent postural-perceptual dizziness; phobic postural vertigo; visual vertigo
42.
J Psychosom Res. 2017 Dec;103:95-101. doi: 10.1016/j.jpsychores.2017.10.007. Epub 2017 Oct 16.
Cerebral gray matter changes in persistent postural perceptual dizziness.
Wurthmann S1, Naegel S2, Schulte Steinberg B3, Theysohn N4, Diener HC5, Kleinschnitz C6, Obermann M7, Holle D8.
Abstract
BACKGROUND:
Persistent postural perceptual dizziness (PPPD) is the most common vestibular syndrome in middle-aged patients. Multisensory maladjustment involving alterations of sensory response pattern including vestibular, visual and motion stimuli is thought to be a key pathophysiological correlate of this disorder.
OBJECTIVE:
We aimed to identify regional gray matter changes in PPPD patients that might be involved in the underlying pathophysiology of this disorder.
METHODS:
42 PPPD patients and healthy age and gender matched controls were investigated using magnetic resonance imaging-based voxel-based morphometry. All patients fulfilled the current diagnostic criteria for PPPD, established by the Bárány-Society based on previous criteria for chronic subjective dizziness and phobic postural vertigo.
RESULTS:
PPPD patients showed gray matter volume decrease in the temporal cortex, cingulate cortex, precentral gyrus, hippocampus, dorsolateral prefrontal cortex, caudate nucleus and the cerebellum. A negative correlation of disease duration and gray matter volume was observed in the visual cortex, supplementary motor area and somatosensory processing structures.
CONCLUSIONS:
In patients with PPPD areas involved in multisensory vestibular processing show gray matter volume decrease. These brain regions resemble those previously described for other vestibular disorders. Longer duration of disease leads to a more pronounced gray matter alteration, which might represent maladaptive mechanisms within the course of disease.
Copyright © 2017 Elsevier Inc. All rights reserved.
KEYWORDS:
Chronic subjective dizziness; Functional vestibular disorder; Persistent postural perceptual dizziness; Phobic postural vertigo; Voxel-based morphometry
43.
Front Neurol. 2017 Oct 17;8:529. doi: 10.3389/fneur.2017.00529. eCollection 2017.
Altered Insular and Occipital Responses to Simulated Vertical Self-Motion in Patients with Persistent Postural-Perceptual Dizziness.
Riccelli R1,2, Passamonti L3,4, Toschi N5,6, Nigro S4, Chiarella G7, Petrolo C7, Lacquaniti F1,2, Staab JP8,9, Indovina I1,2.
Abstract
BACKGROUND:
Persistent postural-perceptual dizziness (PPPD) is a common functional vestibular disorder characterized by persistent symptoms of non-vertiginous dizziness and unsteadiness that are exacerbated by upright posture, self-motion, and exposure to complex or moving visual stimuli. Recent physiologic and neuroimaging data suggest that greater reliance on visual cues for postural control (as opposed to vestibular cues-a phenomenon termed visual dependence) and dysfunction in central visuo-vestibular networks may be important pathophysiologic mechanisms underlying PPPD. Dysfunctions are thought to involve insular regions that encode recognition of the visual effects of motion in the gravitational field.
METHODS:
We tested for altered activity in vestibular and visual cortices during self-motion simulation obtained via a visual virtual-reality rollercoaster stimulation using functional magnetic resonance imaging in 15 patients with PPPD and 15 healthy controls (HCs). We compared between groups differences in brain responses to simulated displacements in vertical vs horizontal directions and correlated the difference in directional responses with dizziness handicap in patients with PPPD.
RESULTS:
HCs showed increased activity in the anterior bank of the central insular sulcus during vertical relative to horizontal motion, which was not seen in patients with PPPD. However, for the same comparison, dizziness handicap correlated positively with activity in the visual cortex (V1, V2, and V3) in patients with PPPD.
CONCLUSION:
We provide novel insight into the pathophysiologic mechanisms underlying PPPD, including functional alterations in brain processes that affect balance control and reweighting of space-motion inputs to favor visual cues. For patients with PPPD, difficulties using visual data to discern the effects of gravity on self-motion may adversely affect balance control, particularly for individuals who simultaneously rely too heavily on visual stimuli. In addition, increased activity in the visual cortex, which correlated with severity of dizziness handicap, may be a neural correlate of visual dependence.
KEYWORDS:
chronic subjective dizziness; functional magnetic resonance imaging; insula; persistent postural-perceptual dizziness; rollercoaster simulation; vestibular system
44.
J Vestib Res. 2017;27(4):191-208. doi: 10.3233/VES-170622.
Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society.
Abstract
This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.
KEYWORDS:
Bárány Society; Chronic subjective dizziness; classification; phobic postural vertigo; space motion discomfort; visual vertigo
45.
Zh Nevrol Psikhiatr Im S S Korsakova. 2017;117(4):28-33. doi: 10.17116/jnevro20171174128-33.
[Persistent postural-perceptual dizziness].
[Article in Russian; Abstract available in Russian from the publisher]
Abstract
AIM:
To study persistent postural perceptual dizziness (PPPD) in outpatients with benign paroxysmal positional vertigo (BPPV) and patients with presbiataxia (PAt).
MATERIAL AND METHODS:
Eighty-four patients with PPPD, including 14 with Meniere's disease (MD), 19 with BPPV, 17 with a history of ischemic stroke (IS) in the vertebrobasilar system and 34 with Pat, were examined. For the diagnosis of anxiety, the original 15-point questionnaire with the Likert Scale structure was used. Patients received anvifen (aminophenylbutyric acid hydrochloride) in dose of 250 mg 3 times a day for 6 weeks. Results and сonclusion. The most common trigger of PPPD was sleep deprivation. The highest level of anxiety was identified in the PAt group (19,5±2,89). There was a good effect of the drug: it reduced anxiety in all patients studied. The quality of sleep was improved as well. The authors recommend anvifen as the drug of choice in patients with PPPD during vestibular rehabilitation and cognitive-behavioral therapy.
KEYWORDS:
aminophenylbutyric acid hydrochloride; anvifen; anxiety; dizziness; persistent postural perceptual dizziness
46.
Curr Opin Neurol. 2017 Feb;30(1):107-113. doi: 10.1097/WCO.0000000000000417.
Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness.
Abstract
PURPOSE OF REVIEW:
Functional dizziness is the new term for somatoform or psychogenic dizziness. The aim of this study is to review arguments for the new nomenclature, clinical features, possible pathomechanisms, and comorbidities of functional dizziness.
RECENT FINDINGS:
The prevalence of functional dizziness as a primary cause of vestibular symptoms amounts to 10% in neuro-otology centers. Rates of psychiatric comorbidity in patients with structural vestibular syndromes are much higher with nearly 50% and with highest rates in patients with vestibular migraine, vestibular paroxysmia, and Ménière's disease. Pathophysiologic processes seem to include precipitating events that trigger anxiety-related changes in postural strategies with an increased attention to head and body motion and a cocontraction of leg muscles. Personality traits with high levels of neuroticism and low levels of extraversion appear as risk factors for anxiety and depressive disorders and increased morbidity in functional disorders.
SUMMARY:
Correct and early diagnosis of functional dizziness, as primary cause or secondary disorder after a structural vestibular syndrome, is very important to prevent further chronification and enable adequate treatment. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically.
47.
Handb Clin Neurol. 2016;139:447-468. doi: 10.1016/B978-0-12-801772-2.00037-0.
Functional (psychogenic) dizziness.
Abstract
Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.
© 2016 Elsevier B.V. All rights reserved.
KEYWORDS:
balance; chronic subjective dizziness; dizziness; eye movements; gait; persistent postural-perceptual dizziness; phobic postural vertigo; psychogenic; stance; vertigo; vestibular system
48.
Int J Audiol. 2017 Jan;56(1):33-37. Epub 2016 Aug 17.
Analysis of the characteristics of persistent postural-perceptual dizziness: A clinical-based study in China.
Abstract
OBJECTIVE:
Persistent postural-perceptual dizziness (PPPD) is a common cause of chronic dizziness, but only a few studies have reported its clinical characteristics, and no related research has been performed in China. Therefore, the purpose of this study was to analyze the characteristics of PPPD for the first time in China.
DESIGN:
Data was collected from all patients during standard clinical practice, and further to evaluate the characteristics of PPPD comparing with the control group.
STUDY SAMPLE:
A total of 43 patients diagnosed with PPPD were selected as the study group for analysis.
RESULTS:
Women were significantly more represented in the study group than men, and in the majority of cases the age of onset was in middle-age, and sleep quality was clearly decreased compared with controls, with more statistically significantly higher levels of anxiety. Personality analysis identified that neuroticism was significantly higher than in controls.
CONCLUSIONS:
In this sample we showed that PPPD was more represented in female patients, the age of onset was 40-60 years old, the majority of patients had sleep disorders, anxiety was the main mood disorder to be identified, and personality analysis found that neurotic personality may be the risk factor for developing PPPD. Further large scale studies are suggested in China.
KEYWORDS:
Clinical characteristics; persistent postural-perceptual dizziness; personality traits
49.
Handb Clin Neurol. 2016;137:341-51. doi: 10.1016/B978-0-444-63437-5.00024-8.
Functional and psychiatric vestibular disorders.
Staab JP1.
Abstract
Behavioral factors have long been recognized as affecting spatial orientation and balance function. Neuroanatomic and neurophysiologic studies conducted worldwide over the last 30 years have substantially advanced our knowledge about the inherently strong connectivity among threat/anxiety, vestibular, visual, and somatosensory systems in the brain. Clinical investigations have shed greater light on the nature of functional and psychiatric disorders that manifest or magnify vestibular morbidity. Concepts of these syndromes have changed over 150 years. Even their nomenclature has had different meanings in different eras. This chapter will review functional and psychiatric vestibular disorders. Terminology will follow the International Classification of Diseases, 11th edition, beta draft and the International Classification of Vestibular Disorders. Anxiety plays a central role in behavioral vestibular morbidity. Anxiety, traumatic stress, obsessive, and depressive disorders may be primary causes of episodic and chronic vestibular symptoms or secondary complications of other vestibular disorders. These psychiatric illnesses affect 30-50% of patients who consult neurologists or otologists for vestibular symptoms. Coexisting psychiatric disorders adversely affect treatment for patients with structural vestibular diseases, especially when unrecognized. Persistent postural-perceptual dizziness is the leading cause of long-term vestibular disability. Fortunately, pharmacologic, psychotherapeutic, and rehabilitative treatments of these illnesses have improved in recent years.
© 2016 Elsevier B.V. All rights reserved.
KEYWORDS:
anxiety disorders; cognitive therapy; depression; persistent postural-perceptual dizziness; selective serotonin reuptake inhibitor; vestibular habituation
50.
J Vestib Res. 2016 Jul 2;26(3):319-26. doi: 10.3233/VES-160583.
Posturographic profile of patients with persistent postural-perceptual dizziness on the sensory organization test.
Abstract
BACKGROUND/OBJECTIVE:
Persistent postural-perceptual dizziness (PPPD) was defined by expert consensus for the forthcoming International Classification of Diseases, 11th edition. Its diagnostic criteria were derived from phobic postural vertigo and chronic subjective dizziness. Two key symptoms are postural unsteadiness and visually induced dizziness. We observed that patients with PPPD tended to perform poorly on multiple conditions of the EquiTest® Sensory Organization Test (SOT) and sought to investigate this phenomenon systematically.
METHODS:
We examined cross-sectional, pair-wise group differences in mean scores from SOT conditions 1-6 and composite scores among 20 patients with PPPD, 15 patients recovered from acute vestibular syndromes, and 15 normal individuals (all female, 43 ± 9 years old). We also compared proportions of patients in each group with abnormal sensory analyses, and poor performance across multiple conditions.
RESULTS:
Patients with PPPD had significantly lower mean scores than normal individuals on conditions 2-6 and the composite, and lower than recovered patients on conditions 2-3. Recovered patients had significantly lower mean scores than normal individuals on conditions 4-6 and the composite. Patients with PPPD had the greatest likelihood of abnormal sensory analyses.
CONCLUSIONS:
Patients with PPPD had difficulties with postural control across multiple sensory challenges, consistent with postulated neurophysiologic mechanisms of this condition.
KEYWORDS:
Posturography; Sensory Organization Test; anxiety; persistent postural-perceptual dizziness; vestibular function tests
51.
PLoS One. 2015 Nov 16;10(11):e0142468. doi: 10.1371/journal.pone.0142468. eCollection 2015.
Persistent Postural-Perceptual Dizziness: A Matter of Higher, Central Dysfunction?
Holle D1, Schulte-Steinberg B1, Wurthmann S1, Naegel S1, Ayzenberg I2, Diener HC1, Katsarava Z3, Obermann M1.
Abstract
OBJECTIVE:
Persistent postural-perceptual dizziness (PPPD) is the most common vestibular disorder in the age group between 30 and 50 years. It is considered to be based on a multisensory maladjustment involving alterations of sensory response pattern including vestibular, visual and motion stimuli. Previous data supported a link between vestibular and pain mechanism. The aim of the study was to investigate whether other sensory inputs such as pain stimuli might be altered in terms of a more widespread central perception dysfunction in this disorder.
METHODS:
Nociceptive blink reflex was measured in 27 patients with PPPD and compared with 27 healthy, age and gender matched controls. The habituation of the R2 component of the blink reflex was evaluated as the percentage area-under-the curve (AUC) decrease in ten consecutive blocks of five averaged rectified responses. Additionally, clinical characteristics were evaluated.
RESULTS:
In patients with PPPD a lack of habituation was observed compared to healthy controls. Relative AUC decreased between the first and the tenth block by 19.48% in PPPD patients and by 31.63% (p = 0.035) in healthy controls. There was no correlation between clinical data (course of disease, comorbid depression, medication, trigger factors) or electrophysiological data (perception threshold, pain threshold, stimulus intensity) and habituation pattern. No trigeminal sensitization in terms of facilitation of absolute values could be detected.
CONCLUSION:
Our study results supports the hypothesis of the multisensory dimension of impaired sensory processing in patients with PPPD extends beyond vestibular/visual motion stimuli and reflexive postural/oculomotor control mechanisms to other sensory inputs such as pain perception in terms of a more generalized disturbed habituation pattern.
- PMID:
- 26569392
- PMCID:
- PMC4646356
- DOI:
- 10.1371/journal.pone.0142468
- [Indexed for MEDLINE]
52.
J Vestib Res. 2015;25(2):97-103; quiz 103-4. doi: 10.3233/VES-150551.
Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: A pilot study.
Abstract
BACKGROUND:
Persistent postural-perceptual dizziness (PPPD) (formerly chronic subjective dizziness) may be treated using the habituation form of vestibular and balance rehabilitation therapy (VBRT), but therapeutic outcomes have not been formally investigated.
OBJECTIVE:
This pilot study gathered the first data on the efficacy of VBRT for individuals with well-characterized PPPD alone or PPPD plus neurotologic comorbidities (vestibular migraine or compensated vestibular deficits).
METHODS:
Twenty-six participants were surveyed by telephone an average of 27.5 months after receiving education about PPPD and instructions for home-based VBRT programs. Participants were queried about exercise compliance, perceived benefits of therapy, degree of visual or motion sensitivity remaining, disability level, and other interventions.
RESULTS:
Twenty-two of 26 participants found physical therapy consultation helpful. Fourteen found VBRT exercises beneficial, including 8 of 12 who had PPPD alone and 6 of 14 who had PPPD with co-morbidities. Of the 14 participants who found VBRT helpful, 7 obtained relief of sensitivity to head/body motion, 5 relief of sensitivity to visual stimuli, and 4 complete remission. Comparable numbers for the 12 participants who found VBRT not helpful were 1 (head/body motion), 3 (visual stimuli), and 0 (remission).
CONCLUSIONS:
This pilot study offers the first data supporting the habituation form of VBRT for treatment of PPPD.
KEYWORDS:
Persistent postural-perceptual dizziness; chronic subjective dizziness; habituation; vestibular rehabilitation
53.
Braz J Otorhinolaryngol. 2015 May-Jun;81(3):276-82. doi: 10.1016/j.bjorl.2014.08.012. Epub 2014 Sep 6.
Clinical characteristics of patients with persistent postural-perceptual dizziness.
Abstract
INTRODUCTION:
Persistent postural-perceptual dizziness is the dizziness that lasts for over three months with no clinical explanation for its persistence. The patient's motor response pattern presents changes and most patients manifest significant anxiety.
OBJECTIVE:
To evaluate the clinical characteristics of patients with persistent postural and perceptual dizziness.
METHODS:
statistical analysis of clinical aspects of patients with persistent postural-perceptual dizziness.
RESULTS:
81 patients, average age: 50.06±12.16 years; female/male ratio: 5.7/1; main reasons for dizziness: visual stimuli (74%), body movements (52%), and sleep deprivation (38%). The most prevalent comorbidities were hypercholesterolemia (31%), migraine headaches (26%), carbohydrate metabolism disorders (22%) and cervical syndrome (21%). DHI, State-Trait Anxiety Inventory - Trait, Beck Depression Inventory, and Hospital Anxiety and Depression Scale questionnaires were statistically different (p<0.05) when compared to controls. 68% demonstrated clinical improvement after treatment with serotonin reuptake inhibitors.
CONCLUSION:
Persistent postural-perceptual dizziness affects more women than men, with a high associated prevalence of metabolic disorders and migraine. Questionnaires help to identify the predisposition to persistent postural-perceptual dizziness. The prognosis is good with adequate treatment.
Copyright © 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.
KEYWORDS:
Ansiedade; Anxiety; Comorbidade; Comorbidity; Depression; Depressão; Dizziness; Tontura
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