Persistent Postural Perceptual Dizziness and cervical spine instability

Ross Hauser, MD

If you have been diagnosed with Persistent Postural Perceptual Dizziness, it may have been explained to you by your doctors that this is a mystery ailment with an unknown cause. None the less you have episodes of dizziness, but the room does not spin. You have a problem where you feel like you are swaying like being on a boat, but to other people around you, you are not swaying at all. You may have had your doctor explain Persistent Postural Perceptual Dizziness as a possible diagnosis because you have a history of concussion or whiplash or previous or simultaneous diagnoses of Benign paroxysmal positional vertigo, vestibular neuritis (an inflammation of the vestibular nerve, a nerve in the ear that provides information to your brain to help keep you balanced,) Meniere’s disease, Dysautonomia (problems or disease of the autonomic nervous system) or Mal de debarquement syndrome which can cause that swaying feeling.

Even though you were told that you have Persistent Postural Perceptual Dizziness, and you may have some of the diagnoses and conditions mentioned above at the same time, you may still not have understood exactly what Persistent Postural Perceptual Dizziness (PPPD) is or what it describes and how it is different than these other problems you are facing. PPPD remains a mystery to you. In patients we see with a diagnosis of PPPD, some do not understand what this diagnosis is although they know they have it. These people and possibly yourself included, are not alone in having this problem not explained well.

I don’t understand my Persistent Postural Perceptual Dizziness diagnosis

In a January 2021 study in the Journal of Vestibular Research: Equilibrium & Orientation (1) other doctors expressed concern that patients may not understand what their diagnosis of Persistent Postural Perceptual Dizziness means and in fact may understand it to mean something completely different than what was explained to them. This is what the researchers of this paper noted:

Theme 1: Reassurance

Theme 2: Fear of diagnosis

Theme 3: Some patients had difficulty understanding terminology.

Theme 4: How do I make sense of this diagnosis?

Do you see yourself in any of the themes? A good guess is that for many of you reading this article you probably see all these themes in yourself. You may have been glad you had a diagnostic label but then you were concerned that this would be just another diagnostic label among many that you have been given, some of which you may not even understand. In some cases, some people think that even their doctors do not understand what Persistent postural-perceptual dizziness is.

Understanding the Persistent Postural Perceptual Dizziness diagnosis

Here is a research study (2) from a team of Brazilian specialists that tries to outline what Persistent Postural Perceptual Dizziness is. This paper was published in 2015 soon after the 2014 formalization of the term “Persistent Postural Perceptual Dizziness” as a diagnostic classification. Here is what these researchers shared with their fellow doctors.

“with no clinical explanation for its persistence”

“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 (the simplest explanation is your ability to perform more than one motor skill at a time, for instance, walking and talking at the same time), presents changes and most patients manifest significant anxiety.”

This same study however does list a series of symptoms and conditions associated with Persistent Postural Perceptual Dizziness. First, let’s look at the people who were in this study:

The most prevalent comorbidities (other conditions these people suffered from) were:

What are we seeing in this image? The ligaments of the upper cervical spine that hold the cervical vertebrae and the skull in their correct alignment to each other.

In this article, we will discuss neck problems in people who suffer from dizziness. These neck problems include the upper cervical spine and craniocervical instability. This instability comes from damaged and weak cervical spine ligaments. In this illustration, we see C0-C2 ligament attachments. This includes the alar ligament, Co-C1 capsular ligament, C1-C2 capsular ligament, accessory atlantoaxial ligament, and the transverse ligament.

One in five of these people had a neck problem. Understanding the Persistent Postural Perceptual Dizziness diagnosis in the patient with cervical spine instability.

As we see, Persistent Postural Perceptual Dizziness (PPPD) can be “triggered” by many things and has symptoms and conditions related to a disrupted diabetes metabolism. If you are reading this article we will be focusing on the problem that one in five people in the above study had, cervical syndrome. They had neck pain and they suffer from conditions and symptoms consistent with craniocervical instability, upper cervical spine instability, cervical spine instability, or problems related to neck pain.

Problems related to neck pain may be an oversimplification and not truly reflective of the condition of the person who suffers from Persistent postural-perceptual dizziness. It is however a starting point for some people, a point of origin to help discover the causes and possible solutions to the challenges they face.

Concussion and whiplash

Some people who suffer from Persistent Postural Perceptual Dizziness have their origin of symptoms in a whiplash or concussion event. When they contact us they describe their challenges as one that they have been dealing with for years. They tell us their stories and these stories have a common thread through them of conditions and symptoms of cervical spine instability. Their stories go something like this:

Over the last few years, I have been treated for post-concussion syndrome and PPPD. I have been dealing mainly with problems of occipital headaches, digestive disorders, a sensation of pressure in my head, or intracranial pressure. I have learned to live with these conditions although I wish they would go away. I have symptoms every day. I have no real treatment plan other than the daily dealing of these symptoms. 

Post-Concussion Syndrome

In the people we see with similar medical histories, maybe like yourself, Persistent Postural Perceptual Dizziness is one of many conditions that they suffer from. In people with post-concussion syndrome, symptoms can be long-term, mysterious, unexplained and their post-concussion syndrome has now turned into a persistent post-concussion syndrome. Please see our article: When persistent post-concussion syndrome turns into a neurologic mystery. It describes patient’s medical journeys and the challenges they face and how restoring cervical spine stability may help them.

Upper cervical instability and vestibular disorders

We will often be contacted by people who have a primary diagnosis of vestibular disorders of which Persistent Postural Perceptual Dizziness is considered one. Under the umbrella term vestibular disorders, the person’s Persistent Postural Perceptual Dizziness will be explained as a problem of the inner ear. These problems can also be interpreted as problems of:

Focus on the inner ear

For more on the problems of the inner ear and balance please see my article: When cervical spine instability causes ear pain, ear fullness, sound sensitivity, and hearing problems.

Again, what these people have in common is an existing diagnosis that they have some type of cervical spine instability. Further, that their problem of Persistent Postural Perceptual Dizziness started shortly after vestibular migraine, acute vertigo, balance issues, dizziness, or vision motion disruption.

Treatment of Persistent postural-perceptual dizziness

This article focuses on the treatment of cervical spine instability as a means to restore normal blood flow in and out of the brain and to alleviate problems of pinched cranial nerves. This will be explained below. Typically the treatment of cervical spine instability is not thought of as the forefront of treatment for PPPD. As mentioned in the research above a neck problem was identified in one of five patients. This indicates that treatment of cervical spine instability would not be effective for many people with PPPD. But the treatment of cervical spine instability could be effective for many others.

Treatments that may have been suggested to you but may not have helped

That you are reading this article is an indication that you are looking for other treatments for your problems of dizziness. Your doctors may have recommended to you various therapies. An underlying theme in treating Persistent Postural Perceptual Dizziness is that many treatments and remedies may be needed.

A focus on vestibular rehabilitation exercises, the neck, and shoulders

Vestibular rehabilitation exercises are a broad description trying to address the many problems of dizziness. For the people for whom it worked, some report the long process of retraining their brains to accept the “right” messages from the legs, eyes, and ears as to where this person was in relation to the ground where they stood. Some people found that if they do a lot of walking, this retrains the brain to understand and accept the right “balancing” messages. Still for others, exercising the neck and shoulder areas may offer some benefit as it may reduce spasms and tightness and possibly reduce compression on nerves, or as we will see veins and arteries.

Vestibular rehabilitation exercises are part of the treatment program for many forms of dizziness, as stated above. A December 2020 study in the journal Brain Behavior (3) suggests that “Therapeutic principles comprise cognitive-behavioral therapy, vestibular rehabilitation exercises, and serotonergic medication (serotonin reuptake inhibitors (SSRIs) antidepressant.) Follow-up observations after multimodal interdisciplinary therapy reveal an improvement in symptoms in most patients with chronic dizziness.”

A 2018 study in the journal Practical Neurology (4) suggested that “Once recognized, PPPD can be managed with effective communication and tailored treatment strategies, including specialized physical therapy (vestibular rehabilitation), serotonergic (antidepressants) medications and cognitive-behavioral therapy.”

The neck, the vagus nerve, and Persistent Postural Perceptual Dizziness

Our treatments as mentioned, focus on cervical spine instability. We believe our treatments can help many people not only with PPPD but with the symptoms and conditions that accompany PPPD, symptoms, and conditions we see in cervical spine instability patients.

An August 2020 study in the Reviews in the Neurosciences (5) made these suggestions as to the treatment of PPPD. There is a lot being said in this short paragraph. I will expand and explain the concepts. Here is what the researchers noted:

Let’s stop here for some explanation and visual aid to understanding.

What are we seeing in this image? Arterial and venous obstruction of fluid into and out of the brain

I like to explain to patients this vital component of their brain health, the ability to flush out waste fluids from the brain and replace these fluids with fresh fluid, as the analogy of a Brain Toilet Obstruction. The feedback from our patients made it clear this analogy seemed to resonate with them as the best way to understand the fluid in and fluid out of “brain-draining.”

In the above study that we are exploring, a concern of “a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region.”

In this split image, the image to the left shows a stable neck with a normal cervical spine curvature. Everything is in the cervical spine in is its proper place. Cerebrospinal fluid drains and refills within the brain.

In the image to the right, we see cervical spine instability. The displacement of the C1 is exerting pressure on the arteries and veins leading into and out of the brain. The Cerebrospinal fluid is now backing up into the brain. In this situation, frontal lobe damage can occur.

The brain needs to drain out or flush out toxins and refill itself with fresh fluids. In the image to the right, it is pointed out that obstruction of the veins and arteries will cause a “clogged toilet.” What happens when the toilet clogs?

This may explain: “a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region.”

What are we seeing in this next image?

A cause of the problems of intracranial pressure and impeded blood flow into the brain may be found in the relationship of the internal carotid artery to the upper cervical vertebrae. The internal carotid artery sits just in front of the transverse process of the atlas (C1) and the axis (C2) The blood flow of the internal carotid artery to the upper cervical vertebrae can be constricted or blocked by atlantoaxial (upper) cervical instability.

Relationship of the internal carotid artery to the upper cervical vertebrae. The internal cartoid artery sits just in front of the transverse process of the atlas (C1) and the axis (C2). Even its blood flow can be constricted or blocked by atlanto-axial (upper) cervical instability.

Vagus nerve problems or problems of vagal tone

Returning to the study published in the Reviews in the Neurosciences, the researchers concluded: “Selective serotonin uptake inhibitors and serotonin-norepinephrine reuptake inhibitors are the mainstay drugs for the management of PPPD patients. However, a significant proportion of PPPD patients do not show improvement in response to standard drug therapy. The employment of alternative and complementary treatment strategies, including vestibular rehabilitation therapy (neck and shoulder therapy), cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients.

What are we seeing in this image?

If you look at the illustration below you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves. The one on the left side of your body and the one on the right side of your body.

If you look at the illustration above you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves. The one on the left side of your body and the one on the right side of your body.

The Vagus Nerve, Persistent Postural Perceptual Dizziness, and the other conditions you may suffer from.

When we started our work in patients with the mystery ailments, conditions, and symptoms of cervical spine instability, we started focusing on the dysfunction of the Vagus Nerve as a primary factor and explanation to these problems. Medical research had long made a connection between “vagal tone” or vagus nerve function and neurologic and vascular type disorders.

Let’s look at an October 2018 study in the Journal of Neurology. (6) The title of this research is “Non-invasive vagus nerve stimulation significantly improves the quality of life in patients with persistent postural-perceptual dizziness.” It comes from the Department of Neurology, University Hospital, Ludwig Maximilian University of Munich.

“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 significant comorbidity with anxiety disorders and depression. Further, these patients show an activation of the autonomic nervous system resulting in symptoms such as nausea, an increase in heart rate, and sweating.

Based on the comorbidities and the activation of the autonomic nervous system, we addressed the question of whether non-invasive vagus nerve stimulation might be a treatment option for these patients.”

And this of course is one of the explanations we have been exploring as well. If you focused on the vagus nerve, can you successfully treat PPPD, nausea, an increase of heart rate, sweating, anxiety, depression, and other problems? What the researchers of this study suggested was:

In patients who had vagus nerve stimulation, who had previously not responded to the standard therapies of  PPPD, showed that non-invasive vagus nerve stimulation significantly improved quality of life and depression, further the researchers reported less severe vertigo attacks/exacerbations, a decrease in total postural sway path as well as tendentious less anxiety occurred after stimulation. These data imply that short-term vagal nerve stimulation is a safe and promising treatment option in patients with otherwise refractory or non-responsive PPPD.

Vagus nerve stimulators at our center

In some cases, our patients are recommended to use a vagus nerve stimulator. This is not a primary treatment.

Vagus Nerve Stimulator

Vagus nerve stimulators are known to:

Persistent Postural Perceptual Dizziness and vestibular rehabilitation therapy

In the above research much is discussed surrounding the idea of vestibular rehabilitation therapy. In other studies, a discussion of the effectiveness of the Cawthorne-Cooksey Exercise program for vestibular rehabilitation is discussed. In your medical journey, a physical therapist may have mentioned the Cawthorne-Cooksey exercises of described exercises similar to those in this program.

The goal of the Cawthorne-Cooksey Exercise program is to:

For some people, this type of therapy can be very effective. Certainly, someone with suspected cervical spine instability as the cause of their balance and dizziness problems could benefit. But what if these exercises are limited in their capacity to help but do not help at all? Should someone give up on the principles of strengthening the cervical spine? Or correcting posture or cervical spinal curvature?

The connection between cervical neck instability and neurologic and vascular type disorders

When we started our regenerative medicine practice back in 1993, one of the phenomena we studied in neck pain patients was, why did they have dizziness? Why did they have a lost sense of balance? Swaying? Visual hallucinations and strange sound sensations in their ears? Why did they have brain fog if they had no history of concussion? So for us, treating neck pain problems in patients with these other conditions and relating these conditions to their neck pain was not a new idea. But at the time, back in 1993, it was certainly something debated. Even today it is debated.

Is an answer to Persistent Postural Perceptual Dizziness to be found in damaged and weak cervical spine ligaments?

Above, I cited research that said 1 in 5 people in one particular study with Persistent postural-perceptual dizziness suffered from cervical dysfunction or neck problems. But where did neck problems of degenerative disc disease, cervical stenosis, herniated or compressed cranial nerves, jugular veins, and carotid arteries come from?

What are we seeing in this image?

A patient with severe cervical spine instability. Instability here is shown as a neck whose bones are out of place and a lost natural curve. In the image, this person’s C1 (atlas) and C2 (axis) have floated some two inched to the front of the neck and from their normal optimal alignment. How did the C1 and C2 float away like this? Cervical spine ligaments hold the vertebrae in place and help maintain the neck’s normal curvature. When the neck ligaments are weak, damaged, or torn they can not hold the vertebrae where they are supposed to be, the vertebrae then float out of place. What happens when the vertebrae become hypermobile and float away? The nerves, veins, and arteries that are connected to these vertebrae themselves suffer from significant stretching and compression. This includes the spinal cord, the vagus nerve, and the superior cervical sympathetic ganglion. Among the many things the superior cervical sympathetic ganglion and its nerve branches are responsible for is brain drainage, lymphatics, and blood supply.

The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free, and non-damaging. When the ligaments are suffering from degenerative wear and tear or excessive looseness or laxity that prevents the ligaments from holding the vertebrae together, the ligaments lose their ability to control the proper motion of your head. The head begins to move in a destructive, degenerative manner on top of your neck.

The hunt for muscle pain, muscle spasms, and weakened neck muscles as the cause of Persistent Postural Perceptual Dizziness

Above we discussed the success some therapists had with Persistent Postural Perceptual Dizziness patients in helping their symptoms by getting the shoulder and neck muscles to relax.

Regenerative Medicine Injections | Caring Cervical Realignment Therapy

Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can then restrict blood flow to the brain, pinch on nerves (a pinched nerve causing vertigo), and cause other symptoms associated with joint instability, including cervical instability.

Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments

Above we spoke about the vertebrae not being in the right place and this is caused by cervical spine ligament laxity or damage. The muscles of the neck may then spasm and thicken as a result of the muscle trying to do a job it was really not intended to do. Hold the cervical vertebrae in place. We also spoke about people who suffer dizziness when they move their heads a certain way.

Look at these images below. When the patient looks down, there is a 6 mm (about 2/10ths of an inch) space between the C1-C2. There is room for some vessels and nerves to get through. When the same patient looks up, 0 mm or NO SPACE. Everything in between gets pinched.

The space between C1 and C2 varies with head movement.

In this section, we are going to talk about the realistic non-surgical options for the treatment of cervical spine instability and compressed cervical arteries and their related symptoms.

Treating cervical ligaments – published research from Caring Medical

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders including problems created by neck instability. Above, we discussed our 2014 research headed by Danielle R. Steilen-Matias, PA-C, (7) we also noted that when the cervical ligaments are injured, they become stretched out and loose. This allows for excessive abnormal movement of the cervical vertebrae.

Treating and stabilizing the cervical ligaments can alleviate the problems of cervical vertigo by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause.

Actual Prolotherapy treatment

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Caring Cervical Realignment Therapy (CCRT)

As we discussed in reviewing the research above, our goal is to provide long-term solutions to the problems and symptoms of chronic neck pain and instability such as headaches, dizziness, vertigo, lightheadedness, imbalance, and a host of other symptoms attributed to neck injuries.

Caring Cervical Realignment Therapy combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connects vertebrae, and re-establish normal biomechanics and encourage the restoration of lordosis. This is our treatment method of moving towards putting a patient’s cervical spine back into place.

Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

Treatments for cervical spine realignment – restoring the curve without surgery

When we start looking at the most recent research papers surrounding treatments for cervical spine realignment, we often find ourselves reading a lot of new research on cervical spine surgery procedures. Non-surgical treatments for cervical spine realignment are, for the most part, fewer and far between. There is a rush in medicine to surgically correct cervical spine abnormalities including the loss of the natural cervical spine curve. In our office, we rush more to non-surgical applications to help the patient with cervical spine instability and abnormal curvature of the spine. But what if you were told surgery should be strongly considered?

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding Persistent Postural Perceptual Dizziness. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Herdman D, Evetovits A, Donkin Everton H, Murdin L. Is ‘persistent postural perceptual dizziness’a helpful diagnostic label? A qualitative exploratory study. Journal of Vestibular Research. 2020 Dec 2(Preprint):1-1. [Google Scholar]
2 Bittar RS, von Söhsten Lins EM. Clinical characteristics of patients with persistent postural-perceptual dizziness. Brazilian journal of otorhinolaryngology. 2015 May 1;81(3):276-82. [Google Scholar]
3 Axer H, Finn S, Wassermann A, Guntinas‐Lichius O, Klingner CM, Witte OW. Multimodal treatment of persistent postural–perceptual dizziness. Brain and Behavior. 2020 Dec;10(12):e01864. [Google Scholar]
4 Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Practical neurology. 2018 Feb 1;18(1):5-13. [Google Scholar]
5 Sun L, Xiang K. A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management. Reviews in the Neurosciences. 2020 Aug 27;31(6):675-80. [Google Scholar]
6 Eren OE, Filippopulos F, Sönmez K, Möhwald K, Straube A, Schöberl F. Non-invasive vagus nerve stimulation significantly improves quality of life in patients with persistent postural-perceptual dizziness. Journal of neurology. 2018 Oct;265(1):63-9. [Google Scholar]
7 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]

 

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