Persistent Postural-Perceptual Dizziness (PPPD)

PPPD Treatment and Vestibular Physiotherapy in Adelaide

Do you feel dizzy or unsteady most days, even though medical tests have not found a clear cause?

Do you feel worse when walking, standing, moving your head, looking at busy environments or shopping in a supermarket?

You may be experiencing Persistent Postural-Perceptual Dizziness (PPPD).

PPPD is a recognised vestibular disorder that causes persistent dizziness, unsteadiness and feelings of imbalance. It can be extremely frustrating and can have a significant impact on your work, exercise, social life and confidence.

At Advanced Neuro Rehab, our experienced Vestibular and Neurological Physiotherapists assess and treat people with PPPD using individualised vestibular rehabilitation, movement retraining and education to help you understand your symptoms and gradually return to the activities you enjoy.

What is PPPD?

Persistent Postural-Perceptual Dizziness (PPPD) is a condition involving ongoing dizziness, unsteadiness or a sensation of non-spinning vertigo.

Unlike traditional vertigo, PPPD does not necessarily feel like the room is spinning. Many people describe their symptoms as:

• Feeling dizzy or light-headed
• Feeling unsteady
• Rocking or swaying
• Feeling like you are on a boat
• Feeling disconnected from your surroundings
• Feeling as though the ground is moving
• Feeling like you are walking on a trampoline
• A floating or “off-balance” sensation
• Brain fog or difficulty concentrating
• Visual sensitivity
• Motion sensitivity

Symptoms are generally present on most days for at least three months and can fluctuate in severity.

What Makes PPPD Symptoms Worse?

One of the key features of PPPD is that symptoms are often triggered or increased by movement, being upright or visually busy environments.

You may notice your dizziness gets worse when:

• Standing or walking for long periods
• Moving your head
• Turning quickly
• Walking through a shopping centre or supermarket
• Looking at busy patterns or crowds
• Watching moving objects
• Using a computer or scrolling on your phone
• Driving or travelling in a car
• Walking on uneven surfaces
• Exercising
• Being in visually busy environments
• Looking up or down while walking

This can lead people to avoid activities because they are worried that movement will make their dizziness worse.

Over time, this can create a cycle where reduced activity and increased sensitivity make it harder to tolerate the movements and environments that trigger symptoms.

What Causes PPPD?

PPPD often develops following an event that initially affects the balance system.

Possible triggers include:

• BPPV
• Vestibular neuritis or neuronitis
• Ménière’s disease
• Vestibular migraine
• Concussion or mild traumatic brain injury
• Whiplash
• A period of significant dizziness or vertigo
• Panic attacks associated with dizziness
• Other medical or neurological conditions that affect balance

Sometimes PPPD develops after an obvious vestibular event, while in other cases there may not be a clear trigger.

PPPD can also occur alongside another vestibular condition, which can make symptoms more complex and sometimes more difficult to identify.

Why Does PPPD Happen?

Our balance depends on information coming from several systems, including:

• The inner ear
• Our eyes
• Sensation from our muscles and joints
• Our brain’s ability to process and combine this information

After a period of dizziness or imbalance, the brain can become more reliant on certain sources of information, particularly vision, to help maintain balance.

This can make visually busy environments, movement and changes in position feel overwhelming or uncomfortable.

The nervous system can also become more sensitive to movement and sensory information. This does not mean the symptoms are “all in your head” or that PPPD is simply anxiety.

PPPD is a real and recognised vestibular disorder.

However, stress, anxiety, poor sleep and fatigue can influence how strongly symptoms are experienced and can make it harder for the nervous system to adapt.

How is PPPD Diagnosed?

There is no single scan or blood test that confirms PPPD.

Diagnosis is based on your symptoms, their pattern over time and a thorough clinical assessment. Your physiotherapist may also consider other possible causes of dizziness and balance problems.

The Bárány Society diagnostic criteria describe PPPD as involving persistent dizziness, unsteadiness or non-spinning vertigo for three months or more, with symptoms typically made worse by upright posture, movement and visually complex environments.

Because dizziness can have many different causes, it is important to receive an appropriate assessment rather than assuming that all ongoing dizziness is PPPD.

How Can Vestibular Physiotherapy Help PPPD?

Vestibular rehabilitation is an important part of managing PPPD.

Treatment is not simply about avoiding the movements or environments that make you dizzy. Instead, we gradually and safely help your brain become more comfortable with movement and sensory information again.

Your rehabilitation program may include:

• Vestibular rehabilitation exercises
• Gaze stability exercises
• Balance retraining
• Habituation exercises
• Gradual exposure to movement
• Visual motion exercises
• Walking with head movements
• Dual-task exercises
• Functional movement retraining
• Progressive exposure to busy environments
• Cardiovascular exercise
• Education about dizziness and the balance system
• Individualised home exercises

The exercises are carefully selected and progressed according to your symptoms, goals and tolerance.

Vestibular rehabilitation aims to help your nervous system adapt to movement and reduce the sensitivity that contributes to ongoing dizziness and imbalance.

Why Do I Feel Worse in Supermarkets?

A supermarket is a common example of an environment that can trigger PPPD symptoms.

Bright lights, shelves full of products, moving people, patterned floors and constantly changing visual information can provide a large amount of sensory information for your brain to process.

This can result in increased dizziness, nausea, unsteadiness or a feeling of being overwhelmed.

Rather than avoiding supermarkets completely, your physiotherapist can gradually expose you to these environments as part of your rehabilitation program.

This approach can help your brain become more comfortable processing visual movement and complex environments again.

What Can I Do to Manage PPPD?

Understanding your symptoms is an important part of recovery.

Depending on your individual presentation, your physiotherapist may help you:

• Gradually increase your activity levels
• Return to exercise
• Reduce avoidance of movement
• Build confidence with walking
• Improve balance
• Manage visual sensitivity
• Gradually return to busy environments
• Develop strategies for managing symptom flare-ups
• Establish an appropriate home exercise program

Recovery is usually gradual rather than immediate. It is important to find the right level of challenge — enough to encourage adaptation without repeatedly overwhelming your symptoms.

Vestibular rehabilitation exercises should be individually prescribed following an appropriate assessment rather than simply following generic online dizziness exercises.

A Multidisciplinary Approach to PPPD

PPPD can be complex and sometimes requires support from several healthcare professionals.

Depending on your presentation, we may work alongside your:

• GP
• Neurologist
• ENT specialist
• Audiologist
• Psychologist
• Other medical or allied health professionals

Medication may be considered by your treating doctor in some cases, while psychological strategies such as cognitive behavioural therapy may also form part of a broader treatment plan for some people.

At Advanced Neuro Rehab, we focus on the physical and vestibular rehabilitation component and communicate with your healthcare team when appropriate.

Why Choose Advanced Neuro Rehab for PPPD?

At Advanced Neuro Rehab, we are experienced in dizziness, balance and vestibular rehabilitation.

Our Neurological and Vestibular Physiotherapists have extensive experience assessing people with persistent dizziness, visual motion sensitivity, vestibular migraine, concussion and other vestibular conditions that can overlap with PPPD.

We take the time to understand your individual symptoms and, importantly, what your dizziness is stopping you from doing.

Our goal is not simply to reduce your dizziness — it is to help you get back to living your life with confidence.

Frequently Asked Questions

What does PPPD feel like?

PPPD can feel different for everyone. Common descriptions include feeling dizzy, light-headed, unsteady, like you are rocking or swaying, walking on a boat or trampoline, or feeling overwhelmed in visually busy environments.

Is PPPD the same as vertigo?

Not usually. PPPD typically causes persistent dizziness, unsteadiness or non-spinning sensations rather than the intense spinning sensation commonly associated with conditions such as BPPV. However, PPPD can occur alongside other vestibular conditions.

Can vestibular physiotherapy help PPPD?

Yes. Vestibular rehabilitation is an important treatment option for PPPD and aims to gradually improve tolerance to movement, visual stimuli and balance challenges.

Why do I feel dizzy in supermarkets?

Supermarkets contain lots of moving and visually complex information. If your balance system has become sensitive to visual movement, these environments can increase dizziness and unsteadiness.

Can PPPD go away?

Many people experience significant improvement with appropriate treatment. Recovery can take time, particularly when symptoms have been present for a long period. A tailored rehabilitation program can help you gradually return to activities and environments that have become difficult.

Can PPPD happen after concussion?

Yes. Concussion or mild traumatic brain injury can be a trigger for PPPD. Persistent dizziness after concussion can also have several possible causes, so a thorough vestibular assessment is important.

Can PPPD cause brain fog?

Some people with PPPD report difficulty concentrating, fatigue or a feeling of “brain fog”, particularly when their dizziness is worse.

Is PPPD caused by anxiety?

No. PPPD is a recognised vestibular disorder and is not simply a psychological condition. However, anxiety and stress can interact with the balance system and may influence symptom severity and recovery.

What should I do if I have had dizziness for months?

Persistent dizziness should be assessed rather than simply ignored or avoided. A Vestibular Physiotherapist can assess your symptoms, consider possible causes and determine whether vestibular rehabilitation may be appropriate for you.