Multimodal treatment of persistent postural-perceptual dizziness

Abstract

Background: Persistent postural-perceptual dizziness (PPPD) is a chronic disorder with fluctuating symptoms of dizziness, unsteadiness, or vertigo for at least three months. Its pathophysiological mechanisms give theoretical support for the use of multimodal treatment. However, there are different therapeutic programs and principles available, and their clinical effectiveness remains elusive.

Methods: A database of patients who participated in a day care multimodal treatment program was analyzed regarding the therapeutic effects on PPPD. Vertigo Severity Scale (VSS) and Hospital Anxiety and Depression Scale (HADS) were assessed before and 6 months after therapy.

Results: Of a total of 657 patients treated with a tertiary care multimodal treatment program, 46.4% met the criteria for PPPD. PPPD patients were younger than patients with somatic diagnoses and complained more distress due to dizziness. 63.6% completed the follow-up questionnaire. All patients showed significant changes in VSS and HADS anxiety, but the PPPD patients generally showed a tendency to improve more than the patients with somatic diagnoses. The change in the autonomic-anxiety subscore of VSS only reached statistical significance when comparing PPPD with somatic diagnoses (p = .002).

Conclusions: Therapeutic principles comprise cognitive-behavioral therapy, vestibular rehabilitation exercises, and serotonergic medication. However, large-scale, randomized, controlled trials are still missing. Follow-up observations after multimodal interdisciplinary therapy reveal an improvement in symptoms in most patients with chronic dizziness. The study was not designed to detect diagnosis-specific effects, but patients with PPPD and patients with other vestibular disorders benefit from multimodal therapies.

Keywords: cognitive-behavioral therapy; functional dizziness; multimodal treatment; persistent postural-perceptual dizziness; vestibular rehabilitation.

Figure 1

Clinical characteristics of the patients. (a) Age and gender. (b) Clinical diagnoses of the patients with somatic diagnoses. (c) Triggering and coexisting illnesses in PPPD patients. BPPV, benign paroxysmal positional vertigo; BV, bilateral vestibulopathy; CV, central vertigo; MD, Meniere's disease; MultD, multisensory deficit; sync, syncope; VitB12, vitamin B12 deficiency; VM, vestibular migraine; VN, vestibular neuritis; VP, vestibular paroxysmia; VS, vestibular schwannoma

Figure 2

Change in scores before and 6 months after therapy week. (a) VSS. (b) HADS, (c) visual analog scale of intensity of dizziness and distress due to dizziness. The change is shown as 95% confidence interval and mean of differences. Note that these differences are calculated from pretreatment scores minus post‐treatment scores. A clinical improvement is represented by a positive value of the difference