Virtual Reality and Biofeedback for Adolescents With Chronic Dizziness

Persistent postural-perceptual dizziness (PPPD) is a chronic vestibular disorder characterized by dizziness, unsteadiness, or non-spinning vertigo exacerbated by position changes, active or passive motion, and complex or moving visual stimuli. PPPD was defined in 2017 as an addition to the International Classification of Vestibular Disorders and will be included in the next iteration of the International Classification of Diseases by the World Health Organization (ICD-11). It is a common diagnosis in patients presenting to tertiary centers for evaluation of vestibular symptoms. Although PPPD is most often described in the adult population, it is also common in children and adolescents with dizziness.

Vestibular migraine is the most common cause of episodic dizziness in children and adults. It can sometimes cause chronic, daily dizziness symptoms and can sometimes also trigger concurrent PPPD, which also causes chronic, daily dizziness.

The symptoms of chronic dizziness profoundly affect quality of life, often keeping children out of school. Moreover, most patients are symptomatic for many months or even years before receiving a diagnosis and initiating treatment. As PPPD is not likely to resolve spontaneously or without treatment, effective early treatment is crucial to alleviating symptom burden. Chronic vestibular migraine is typically treated primarily with medications, which can cause side effects and are sometimes inadequate to achieve complete symptom control.

PPPD is typically precipitated by an event that causes dizziness, vertigo, or unsteadiness, such as an acute or episodic peripheral vestibular disorder, concussion, psychological distress, or adverse medication effect. Though an utterly definitive model is still being established, it is widely accepted that PPPD may develop following these inciting events through the development and perpetuation of maladaptive compensatory strategies, such as overreliance on visual inputs to maintain equilibrium and balance, and heightened anxiety or body vigilance during self-motion or motion-rich environments. These responses to dizziness or unsteadiness are typically transient but become persistent and maladaptive in PPPD, leading to a "rewiring" of the brain that alters how cues related to balance and orientation are processed.

A multi-modal approach to chronic dizziness treatment is often taken to recalibrate maladaptive compensatory strategies and return the sensory system to normal function. One component of treatment includes cognitive behavioral therapy (CBT). The overall goals of CBT include reducing behaviors, thoughts, feelings, and symptoms that perpetuate chronic dizziness, particularly avoidance of environments that provoke dizziness, dependence on the visual system, and excessive monitoring of bodily sensations. Patients develop alternative strategies for responding to symptoms of dizziness or unsteadiness, such as relaxation or distraction techniques. With systematic desensitization exposure response prevention (SDERP) treatment, gradual exposure to provocative environments is essential, enabling patients to habituate to, rather than avoid, symptoms.