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Demystifying Dizziness- Persistent Postural Perceptual Dizziness

Persistent postural perceptual dizziness…wow, try saying that 10-times fast! It will get your head spinning and your tongue tied, which, unfortunately, is not all that uncommon of a sensation for someone experiencing this disorder. Persistent postural perceptual dizziness, or PPPD/3PD for ease, is a condition that has been described for decades, but has only recently been defined as its own neurological disorder.

PPPD is often described as a feeling of non-spinning dizziness, unsteadiness, or light headedness lasting days to months and is often worse in upright postures, such as standing or sitting. Have you ever experienced the drunken sailor feeling? Now imagine feeling that ALL THE TIME. As its name suggests, this is a persistent feeling of imbalance that can begin to affect all aspects of someone’s daily life and ability to function. So what causes this?

PPPD Explained

Our posture is one of those unique systems in our body that we can control both consciously and sub-consciously. For example, you have probably been told at one point in your life to sit or stand up straight. Upon hearing this command, you are able to make the appropriate adjustments to your posture. However, as soon as you get distracted by doing something else, your body doesn’t immediately collapse to the ground because you are no longer thinking about your posture. In other words, your brain starts running a lot of sub-conscious background systems to help keep you upright and able to move without having to use conscious thought.

These background systems include coordinating and integrating information coming from different sensory systems- primarily your vestibular system (inner ears), your visual system (eyes), and your somatosensory system (body). These three sensory systems work together to form your balance system. When information coming from one of these systems does not match the information from the other two systems it creates a sensory mismatch in the brain. This in turn can trigger an adaptive response, which may elicit feelings of unsteadiness or imbalance.

For example, when you walk across on ice your brain senses this as a threat. It will reflexively mute the information coming from your vestibular system and increase its reliance on visual and body sensory information to help you better navigate your path. You will likely feel your body tense and stiffen and will probably be watching the ground or your feet as you move across the ice. Once you are off the ice, the threat is removed, and you begin to relax.

For someone with PPPD, their brain gets stuck running this threat response. The normal filters that the brain would typically use to damped sensations of movement fail and the person becomes hyper-consciously aware of their posture, body movements, and visual stimuli around them at all times. This in-turn triggers the feeling of constantly being in motion, off balance, and unsteady. The longer that this sensation lasts the more anxious a person may become, which amplifies the sensation of being dizzy and turns this into a vicious cycle.

What triggers PPPD?

PPPD can affect anyone at any given time; however, it is more commonly diagnosed in females ages 30-50. This breakdown in the brain’s ability to filter and modulate sensory information regarding our body’s movement and position in space typically occurs following an initial event that triggers an episode of dizziness or vertigo. This triggering event may include:

What are the common symptoms of PPPD?

It can be quite challenging to try to describe the sensation of what you may be feeling if you have PPPD. Often there is a non-specific feeling of being in motion or unsteadiness (though not a spinning sensation), even if you are not moving. This is typically made worse with upright postures, active and passive movement, and environments that have a lot of visual stimulation, such as grocery stores, patterned carpets, or scrolling on the computer. Because your brain thinks you are in motion and in danger of falling, you will likely tend to stiffen up, resulting in increased neck, shoulder, and jaw tension, slowed walking speeds with shorter steps, fear and anxiety of falling, and mental and physical fatigue.

Unfortunately, in order to be diagnosed with PPPD, these symptoms need to present for a minimum of three months. Over this time, the intensity of the dizziness may wax and wane throughout the day, but never fully go away for an extended period of time (ie, days).

What can you do about it?

The biggest challenge when it comes to treating PPPD is recognizing it and understanding why the brain has become hyper-sensitive to your posture and movement. Typically, this involves a team approach to address all aspects of the condition and optimize recovery. This may include:

  • Physiotherapy/vestibular therapy to help desensitize the brain to movement and re-coordinate sensory information coming from the eyes, ears, and body

  • A trial of medication managed by your family doctor or an EENT to help with side effects of the condition, such as anxiety and depression

  • Cognitive behavioural therapy performed by a psychologist to help manage the anxiety and avoidance tactics that typically develop the longer someone is experiencing PPPD

  • Treatments to address the initial triggering event such as chiropractic and massage therapy to help manage the muscle tension and abnormal movement patterns that can develop, and quantitative brain mapping and neurofeedback treatment to evaluate the neurophysiological imbalances

While there is still much to learn about this disorder and its general length of recovery, it is possible to regain function and return to your daily activities. Finding a team of knowledgeable practitioners to work with is the first critical step to optimizing your recovery and will help you to build confidence and take back control of your health.

Demystifying Dizziness – Persistent Postural Perceptual Dizziness


Popkirov S, et al. Pract Neurol 2018;18:5–13. doi:10.1136/practneurol-2017-001809


Dr. Speranza is an upper cervical Chiropractor in Calgary, Alberta, Canada. She follows the protocols of the National Upper Cervical Chiropractic Association (NUCCA) to help people experiencing problems with postural related dizziness regain balance, return to doing the activities that they love, and ultimately take back control of their health.

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