Persistent Postural-Perceptual Dizziness-A Systematic Review of the Literature for the Balance Specialist

Biobehavioral approach to distinguishing panic symptoms from medical illness

Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.

Short-Term Benefits from Manual Therapy as an Adjunct Treatment for Persistent Postural-Perceptual Dizziness Symptoms: A Preliminary Prospective Case Series

Persistent dizziness and balance deficits are common, often with unknown etiology. Persistent Postural-Perceptual Dizziness (3PD) is a relatively new diagnosis with symptoms that may include dizziness, unsteadiness, or non-vertiginous dizziness and be persistent the majority of time over a minimum of 90 days. The purpose of this case series was to investigate short-term outcomes of reducing dizziness symptoms using a manual therapy intervention focused on restoring mobility in the fascia using a pragmatically applied biomechanical approach, the Fascial Manipulation® method (FM®), in patients with 3PD. The preliminary prospective case series consisted of twelve (n = 12) patients with persistent complaints of dizziness who received systematic application of manual therapy to improve fascial mobility after previously receiving vestibular rehabilitation. The manual therapy consisted of strategic assessment and palpation based on the model proposed in the FM® Stecco Method. This model utilizes tangential oscillations directed toward the deep fascia at strategic points. Six males (n = 6) and females (n = 6) were included with a mean age of 68.3 ± 19.3 years. The average number of interventions was 4.5 ± 0.5. Nonparametric paired sample t-tests were performed. Significant improvements were observed toward the resolution of symptoms and improved outcomes. The metrics included the Dizziness Handicap Inventory and static and dynamic balance measures. The Dizziness Handicap Inventory scores decreased (i.e., improved) by 43.6 points (z = -3.1 and p = 0.002). The timed up and go scores decreased (i.e., improved) by 3.2 s (z = -2.8 and p = 0.005). The tandem left increased (i.e., improved) by 8.7 s (z = 2.8 and p = 0.005) and the tandem right increased (i.e., improved) by 7.5 s (z = 2.8 and p = 0.005). Four to five manual therapy treatment sessions appear to be effective for short-term improvements in dizziness complaints and balance in those with 3PD. These results should be interpreted with caution as future research using rigorous methods and a control group must be conducted.

Clinical characteristics of persistent postural-perceptual dizziness and its visual subtype in Korean patients: A multicenter cross-sectional study

OBJECTIVES

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder for which the Bárány Society has established diagnostic criteria. This nationwide multicenter study aims to investigate the clinical features of individuals with definite PPPD and clinical variant PPPD who do not fully meet the diagnostic criteria, with a particular focus on visual exaggeration.

METHODS

Between September 2020 and September 2021, a total of 76 individuals with definite PPPD and 109 individuals with clinical variant PPPD who did not meet all three exacerbating factors outlined in Criterion B were recruited from 18 medical centers in South Korea. The study gathered information on demographic factors, clinical manifestations, balance scales, and personality assessments.

RESULTS

Comparative analysis between groups with definite PPPD and clinical variant with visual exacerbation revealed no significant differences in sociodemographic characteristics, clinical course, dizziness impact, and specific precipitants. Only disease duration was significantly longer in definite PPPD compared with variant with visual exacerbation. However, the variant without visual exacerbation displayed significantly reduced rates of panic disorder, diminished space-motion discomfort, lesser impact of dizziness, and decreased prevalence of depression when compared with the definitive PPPD.

CONCLUSION

This is the first comprehensive nationwide study examining clinical features of both definite PPPD patients and its clinical variants, considering visual exacerbating factors. Differences in dizziness and personality traits emerged between definite PPPD and its potential variant without visual issues. Our results highlight the possibility of a distinct clinical variant of PPPD influenced by visual dependency.

Functional Dizziness as a Spatial Cognitive Dysfunction

(1) Background: Persistent postural-perceptual dizziness (PPPD) is a common chronic dizziness disorder with an unclear pathophysiology. It is hypothesized that PPPD may involve disrupted spatial cognition processes as a core feature. (2) Methods: A cohort of 19 PPPD patients underwent psycho-cognitive testing, including assessments for anxiety, depression, memory, attention, planning, and executive functions, with an emphasis on spatial navigation via a virtual Morris water maze. These patients were compared with 12 healthy controls and 20 individuals with other vestibular disorders but without PPPD. Vestibular function was evaluated using video head impulse testing and vestibular evoked myogenic potentials, while brain magnetic resonance imaging was used to exclude confounding pathology. (3) Results: PPPD patients demonstrated unique impairments in allocentric spatial navigation (as evidenced by the virtual Morris water maze) and in other high-demand visuospatial cognitive tasks that involve executive functions and planning, such as the Towers of London and Trail Making B tests. A factor analysis highlighted spatial navigation and advanced visuospatial functions as being central to PPPD, with a strong correlation to symptom severity. (4) Conclusions: PPPD may broadly impair higher cognitive functions, especially in spatial cognition. We discuss a disruption in the creation of enriched cognitive spatial maps as a possible pathophysiology for PPPD.

Similarities between explaining dizziness and explaining pain? Exploring common patient experiences, theoretical models, treatment approaches and potential therapeutic narratives for persistent dizziness or pain

Pain and dizziness are common experiences throughout the lifespan. However, nearly a quarter of those with acute pain or dizziness experience persistence, which is associated with disability, social isolation, psychological distress, decreased independence, and poorer quality of life. Thus, persistent pain or dizziness impacts peoples' lives in similarly negative ways. Conceptual models of pain and dizziness also have many similarities. Many of these models are more expansive than explaining mere symptoms; rather they describe pain or dizziness as holistic experiences that are influenced by biopsychosocial and contextual factors. These experiences also appear to be associated with multi-modal bodily responses related to evaluation of safety, threat detection and anticipation, as influenced by expectations, and predictions anticipation, not simply a reflection of tissue injury or pathology. Conceptual models also characterize the body as adaptable and therefore capable of recovery. These concepts may provide useful therapeutic narratives to facilitate understanding, dethreaten the experience, and provide hope for patients. In addition, therapeutic alliance, promoting an active movement-based approach, building self-efficacy, and condition-specific approaches can help optimize outcomes. In conclusion, there are significant overlaps in the patient experience, theoretical models and potential therapeutic narratives that guide care for people suffering with persistent pain or dizziness.

The Effects of Vibro-Tactile Biofeedback Balance Training on Balance Control and Dizziness in Patients with Persistent Postural-Perceptual Dizziness (PPPD)

BACKGROUND

Patients with persistent postural-perceptual dizziness (PPPD) frequently report having problems with balance control. Artificial systems providing vibro-tactile feedback (VTfb) of trunk sway to the patient could aid recalibration of "falsely" programmed natural sensory signal gains underlying unstable balance control and dizziness. Thus, the question we examine, retrospectively, is whether such artificial systems improve balance control in PPPD patients and simultaneously reduce the effects of dizziness on their living circumstances. Therefore, we assessed in PPPD patients the effects of VTfb of trunk sway on balance control during stance and gait tests, and on their perceived dizziness.

METHODS

Balance control was assessed in 23 PPPD patients (11 of primary PPPD origin) using peak-to-peak amplitudes of trunk sway measured in the pitch and roll planes with a gyroscope system (SwayStar™) during 14 stance and gait tests. The tests included standing eyes closed on foam, walking tandem steps, and walking over low barriers. The measures of trunk sway were combined into a Balance Control Index (BCI) and used to determine whether the patient had a quantified balance deficit (QBD) or dizziness only (DO). The Dizziness Handicap Inventory (DHI) was used to assess perceived dizziness. The subjects first underwent a standard balance assessment from which the VTfb thresholds in eight directions, separated by 45 deg, were calculated for each assessment test based on the 90% range of the trunk sway angles in the pitch and roll directions for the test. A headband-mounted VTfb system, connected to the SwayStar™, was active in one of the eight directions when the threshold for that direction was exceeded. The subjects trained for 11 of the 14 balance tests with VTfb twice per week for 30 min over a total of 2 consecutive weeks. The BCI and DHI were reassessed each week and the thresholds were reset after the first week of training.

RESULTS

On average, the patients showed an improved balance control in the BCI values after 2 weeks of VTfb training (24% p = 0.0001). The improvement was greater for the QBD patients than for the DO patients (26 vs. 21%), and greater for the gait tests than the stance tests. After 2 weeks, the mean BCI values of the DO patients, but not the QBD patients, were significantly less (p = 0.0008) than the upper 95% limit of normal age-matched reference values. A subjective benefit in balance control was spontaneously reported by 11 patients. Lower (36%), but less significant DHI values were also achieved after VTfb training (p = 0.006). The DHI changes were identical for the QBD and DO patients and approximately equal to the minimum clinical important difference.

CONCLUSIONS

These initial results show, as far as we are aware for the first time, that providing VTfb of trunk sway to PPPD subjects yields a significant improvement in balance control, but a far less significant change in DHI-assessed dizziness. The intervention benefitted the gait trials more than the stance trials and benefited the QBD group of PPPD patients more than the DO group. This study increases our understanding of the pathophysiologic processes underlying PPPD and provides a basis for future interventions.

Using interpretative phenomenological analysis to probe the lived experiences of persistent postural-perceptual dizziness (PPPD)

BACKGROUND

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic neuro-vestibular condition characterised by subjective dizziness, non-spinning vertigo, and postural imbalance. Symptoms are typically induced by situations of visuo-vestibular conflict and intense visual-motion.

OBJECTIVE

Little research has focused on the lived experiences of people with PPPD. Therefore, our objective was to present an in-depth exploration of patient experiences and sense-making, and the effect of PPPD on psycho-social functioning.

METHODS

We conducted semi-structured interviews with 6 people with PPPD, who were recruited from an Audiovestibular department in Wales. We present a case-by-case Interpretive Phenomenological Analysis (IPA) for each participant and present common themes.

RESULTS

Our analysis revealed a range of superordinate and subordinate themes, individualised to each participant, but broadly described under the following headings: dismissal and non-belief, identity loss, dissociative experiences, poor psychological well-being and processes of sense-making.

CONCLUSION

The qualitative experiences documented in this study will help clinicians and researchers to better understand the lived experiences of PPPD, how PPPD patients make sense of their symptoms, and the psycho-social impacts of the condition.

Pharmacological Properties of Jaeumgeonbi-Tang on Redox System and Stress-Related Hormones in Chronic Subjective Dizziness: A Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Trial

Jaeumgeonbi-Tang (JGT), a traditional herbal medicine, has been used to treat dizziness and vertigo in Korea and China for hundreds of years. The purpose of this study was to evaluate the pharmacological properties of JGT in chronic subjective dizziness (CSD) patients. A randomized, double-blind, parallel-group and placebo-controlled trial was performed with a total of 50 CSD patients. The patients were randomly assigned to one of two groups: JGT or placebo (n = 25 for each). All participants received the treatment (placebo or JGT, 24 g/day) for 4 weeks. We analyzed the serum levels of oxidative stressors, antioxidants, and stress hormones. Serum levels of lipid peroxidation, but not nitric oxide, were significantly decreased in the JGT group. JGT not only prevented the decline of serum total glutathione contents and total antioxidant capacity, but it also increased superoxide dismutase and catalase activities. Serum levels of stress hormones including cortisol, adrenaline, and serotonin were notably normalized by JGT treatment, but noradrenaline levels were not affected. Regarding the safety and tolerability of JGT, we found no allergic, adverse, or side effects in any of the participants. JGT showed beneficial effects on CSD patients by improving redox status and balancing psycho-emotional stress hormones.

Potential risk factors of persistent postural-perceptual dizziness: a pilot study

BACKGROUND

Persistent postural-perceptual dizziness (PPPD) unifies the main characteristics of chronic subjective dizziness, visual vertigo and related diseases, which is a common chronic disease in neurology. At present, the pathology of PPPD is not fully understood.

OBJECTIVE

In this single-center retrospective case series review, we aim to investigate the potential risk factors of PPPD.

METHODS

Eighty inpatients diagnosed with PPPD were recruited with 81 apparently healthy controls. Patient-specific clinico-radiological data were collected from both groups. Conditions of hypertension, diabetes, smoking, and drinking were derived from medical history. Blood test results were recorded including total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fibrinogen, vitamin B12, folic acid, total cholesterol, triglyceride, and folate level. The subjects were examined by carotid artery CTA and cranial MRI, and the imaging findings of carotid atherosclerosis (CAS), white matter hyperintensities (WMHs) and lacunar infarction (LI) were recorded. Binary logistic regression analysis was used to investigate the difference between the case and control groups. Significance was defined as p value less than 0.05.

RESULTS

The prevalence rate of hypertension in the case group was significantly higher than that in the control group, and the detection rates of CAS, WMHs, and LI in the case group were significantly higher than those in the control group (p < 0.05 for all).

CONCLUSION

Hypertension, CAS, WMHs, and LI are associated with PPPD, which may be potential risk factors for its development.

Spectral Composition of Body Sway in Persistent Postural-Perceptual Dizziness

OBJECTIVE

Previous studies in phobic postural vertigo patients showed characteristic frequency changes in body sway fluctuations, raising the question whether similar spectral changes can be also observed in the recently defined syndrome of persistent postural-perceptual dizziness (PPPD).

STUDY DESIGN

Cross-sectional prospective study.

SETTING

Tertiary referral center.

SUBJECTS

Sixty-one PPPD patients and 41 healthy controls.

INTERVENTIONS

Static balance was assessed while standing on firm surface with eyes open or closed (conditions 1 and 2) and while standing on foam with eyes open or closed (conditions 3 and 4). Postural sway was analyzed by means of time (sway area and standard deviation) and frequency domain metrics. The latter was based on comparisons of the percentage of energy in each of three frequency bands: low (0-0.5 Hz), middle (0.05-2 Hz), and high frequency (2-20 Hz).

MAIN OUTCOME MEASURE

Stabilometric time and frequency domain parameters.

RESULTS

Time domain metrics deteriorated significantly from conditions 1 through condition 4 in patients and controls. Spectral changes, however, were more abundant in PPPD subjects than in controls. Patients showed increased low frequency, but decreased high frequency spectral power in condition 3 as compared to condition 2. Dizziness Handicap Inventory score was positively correlated with middle frequency and negatively correlated with low frequency fluctuations.

CONCLUSIONS

We conclude that PPPD patients exhibit a time domain sway pattern in different conditions which is grossly similar to that of controls. However, sensory feedback conditions with equal sway area show unique differences in their spectral content in PPPD patients. Moreover, perceived severity of dizziness is associated with greater body oscillations in the middle frequency band.

Vertigo: Streamlining the Evaluation through Symptom Localization

Vertigo is defined as the illusion of internal or external motion. The evaluation of a patient with vertigo in the primary care setting should not necessarily focus on providing a specific diagnosis. Rather, the physician should aim to localize the lesion. This practice streamlines the workup of patients. This article provides detailed information regarding appropriate organ system-based clinical history and the clinical workup of vertigo. Additional signs and symptoms that can facilitate appropriate referral and treatment are highlighted. Although disorder-specific treatments exist the mainstay of therapy for vertigo-induced pathology is physical therapy.

Persistent Postural-Perceptual Dizziness in Children and Adolescents

OBJECTIVE

Persistent postural-perceptual dizziness (PPPD) is a recently defined diagnostic syndrome characterized by chronic symptoms of dizziness, unsteadiness, and/or non-spinning vertigo. Although PPPD has been studied in adults, reports in the pediatric population are few. The goal of this study was to describe the presentation and treatment of PPPD in a group of pediatric patients.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

≤21 years old, who met Bárány Society consensus criteria for a diagnosis of PPPD and were followed for ≥6 months or until symptom resolution.

MAIN OUTCOME MEASURESS

Patient demographics, comorbidities, symptom chronicity, and response to treatment(s).

RESULTS

Of the 53 patients identified, 44 (83.0%) were women. Mean age at the time of initial evaluation was 14.6 years old. Common diagnoses in addition to PPPD included benign paroxysmal positional vertigo (64.2%), vestibular migraine (56.6%), and anxiety (28.3%). A high proportion of patients (43.4%) reported initially missing school or work due to their symptoms. Eighteen patients (34.0%) reported symptom resolution ranging from 2 to 48 months after diagnosis (median 9 mo). Of these patients, 15 of 18 attended physical therapy (PT), 11 of 18 attended cognitive behavioral therapy (CBT) and/or biofeedback therapy, and 10 of 18 took selective serotonin reuptake inhibitor (SSRI) medications, and 7 of 18 (40%) did a combination of all three therapies.

CONCLUSION

PPPD can impact patients at a young age, and prolonged symptoms present a significant burden to children and adolescents, many of whom are unable to attend school. Treatments such as PT, CBT, and SSRI medication may be effective.

Vestibular Physical Therapy and Fall Risk Assessment

Vestibular physical therapy (VPT) is a specialized form of evidence-based therapy designed to alleviate primary (vertigo, dizziness, imbalance, gait instability, falls) and secondary (deconditioning, cervical muscle tension, anxiety, poor quality of life, fear of falling/fear avoidance behavior) symptoms related to vestibular disorders. This article provides an overview of VPT, highlighting various exercise modalities used to treat a variety of vestibular disorders. Patient safety and fall prevention are paramount; therefore, fall risk assessment and treatment are also addressed.

Assessment of Potential Risk Factors for the Development of Persistent Postural-Perceptual Dizziness: A Case-Control Pilot Study

Objectives: (1) To assess whether neuroticism, state anxiety, and body vigilance are higher in patients with persistent postural-perceptual dizziness (PPPD) compared to a recovered vestibular patient group and a non-dizzy patient group; (2) To gather pilot data on illness perceptions of patients with PPPD. Materials and Methods: 15 cases with PPPD and two control groups: (1) recovered vestibular patients (n = 12) and (2) non-dizzy patients (no previous vestibular insult, n = 12). Main outcome measures: Scores from the Big Five Inventory (BFI) of personality traits, Generalized Anxiety Disorder - 7 (GAD-7) scale, Body Vigilance Scale (BVS), Dizziness Handicap Inventory (DHI), modified Vertigo Symptom Scale (VSS) and Brief Illness Perception Questionnaire (BIPQ). Results: Compared to non-dizzy patients, PPPD cases had higher neuroticism (p = 0.02), higher introversion (p = 0.008), lower conscientiousness (p = 0.03) and higher anxiety (p = 0.02). There were no differences between PPPD cases and recovered vestibular patients in BFI and GAD-7. PPPD cases had higher body vigilance to dizziness than both control groups and their illness perceptions indicated higher levels of threat than recovered vestibular patients. Conclusion: PPPD patients showed statistically significant differences to non-dizzy patients, but not recovered vestibular controls in areas such as neuroticism and anxiety. Body vigilance was increased in PPPD patients when compared with both recovered vestibular and non-dizzy patient groups. PPPD patients also exhibited elements of negative illness perception suggesting that this may be the key element driving the development of PPPD. Large scale studies focusing on this area in the early stages following vestibular insult are needed.

The Clinical Key Features of Persistent Postural Perceptual Dizziness in the General Medicine Outpatient Setting: A Case Series Study of 33 Patients

Objective This case series aimed to investigate the clinical and pathological characteristics of persistent postural perceptual dizziness (PPPD). Methods We retrospectively examined the medical records of patients with chronic dizziness in our department, and tracked the percentage of PPPD, the age and sex, disorder duration, exacerbating factors for dizziness, and duration of momentary worsening dizziness. We also examined the duration of momentary worsening dizziness in cases of depression, anxiety disorder, and somatic symptom disorder. Results Among 229 patients with chronic dizziness, 14.4% (33/229) met the diagnostic criteria for PPPD. PPPD was the second most common disorder of patients with chronic dizziness after depression. The median age of patients with PPPD was 75 (75.8% female) and the median duration of the disorder was 60 months (range: 3-360 months). The exacerbating factors were motion without regard to direction or position (90.9%), upright posture (66.7%), and exposure to moving visual stimuli or complex visual patterns (30.3%). While the duration of momentary worsening dizziness was less than 10 minutes in 93.9% of patients with PPPD, the duration in patients with depression, anxiety disorder, and somatic symptom disorder were 3.6 % (2/55), 16.1% (5/31), and 0% (0/11), respectively. When the duration was less than 10 minutes, the odds ratios of PPPD for depression and anxiety disorder were 46.5 (95% CI: 6.1-362.0) and 40.3 (95% CI: 7.4-219.3), respectively. Conclusion Short episodes of momentary worsening dizziness constitute a distinctive feature of PPPD that may be useful for differentiating PPPD from other types of psychogenic dizziness.

A review on the alterations in the brain of persistent postural-perceptual dizziness patients and non-pharmacological interventions for its management

Persistent postural perceptual dizziness (PPPD) is a relatively newer term, and this term is included in the International Classification of Diseases in its 11th revision. The typical features of PPPD include the presence of persistent dizziness, non-spinning vertigo, and unsteadiness, and these symptoms are exacerbated during upright posture, movement, or visual stimuli. Moreover, the structural changes have also been identified in the brains of PPPD patients, particularly in visual, vestibular, and limbic areas. These include a decrease in the volume and gyration of gray matter, a decrease in the blood flow to the cortex region, and alterations in the structural and functional connectivity, particularly in the visual-vestibular networks. Moreover, the impairment in sensory processing is restricted not only to the vestibular and visual regions; instead, there is a generalized impairment in the sensory processing, and thus, there is a multisensory dimension of sensory impairment. 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, cognitive behavioral therapy, and non-invasive vagal nerve stimulation, is effective in the management of PPPD patients. The present review discusses the alterations in the brains of PPPD patients along with the possible non-pharmacological treatment options in these types of patients.

Spatial Navigation Is Distinctively Impaired in Persistent Postural Perceptual Dizziness

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.

Persistent postural-perceptual dizziness: current approaches to diagnosis and treatment

The cause of persistent postural-perceptual dizziness (PPPD) is considered to be chronic dysfunction of the regulatory system for maintaining equilibrium in general and that of the vestibular system in particular, which causes a persistent sensation of dizziness and/or unsteadiness. The pathogenetic mechanisms of PPPD are associated with impaired adaptation to an acute vertigo or unsteadiness episode due to various causes (vestibular, lipothymic, or emotional). Patients severely experience PPPD, which often leads to avoidant behavior and even disability. The timely diagnosis of this disorder and the use of right treatment, including vestibular rehabilitation, antidepressants, and cognitive behavioral therapy, are of great importance. Currently developed new treatments for PPPD are highly therapeutically effective. Among the medicines, Ginkgo biloba extract has been shown to be effective in improving vestibular compensation.