By Millie Brecheisen, physiotherapist in Basel. Updated: 1 October 2026.
‘I feel as though I’m floating all day, especially in shops. Yet my tests are normal.’ This description can suggest PPPD. The symptoms are real. Diagnosis depends on a specific clinical pattern, and understanding the possible mechanisms helps to choose a coherent approach to treatment.
PPPD is more than ‘just stress’
PPPD stands for persistent postural perceptual dizziness. It is a chronic functional vestibular disorder. People often describe floating, rocking as if on a boat, unsteadiness or dizziness without spinning on most days for at least three months. Symptoms typically increase when standing, moving or entering visually complex environments. Recent models focus on a lasting change in how the brain weighs vision, vestibular signals, body position and predictions about movement, rather than a single structural lesion [1].
PPPD can develop after vestibular neuritis, BPPV, vestibular migraine, a concussion or a period of marked instability. The original trigger may have resolved while the system remains overly alert to movement. This helps explain why an MRI or vestibular tests can be normal without the symptoms being imaginary.
What patients notice in daily life
PPPD does not always make the room spin. People may say ‘I’m floating’, ‘the floor moves’, ‘I feel less steady in a shop’, ‘I have to concentrate to walk’ or ‘screens wear me out’. Supermarkets, stations, crowds, escalators, driving and scrolling on a phone are common triggers.
Vestibular migraine can coexist with PPPD. The two diagnoses sometimes overlap, but they are not the same. Vestibular migraine is more episodic, whereas PPPD produces ongoing discomfort that fluctuates throughout the day [1].
How to assess it properly
The diagnosis is clinical and based on positive diagnostic criteria. Assessment looks for the PPPD pattern and any coexisting problem that could change treatment. Vestibular physiotherapy may assess balance, walking with head movements, gaze stability, visual tolerance, neck mobility and the response to exercise. Medical assessment remains important when the diagnosis is not established or the symptoms are unusual.
Two opposite mistakes should be avoided: attributing every symptom to the inner ear, or concluding that everything is psychological because structural tests are reassuring.
Which treatments may help?
Treatment often combines several approaches. Vestibular rehabilitation uses gradual exposure to movements and situations that are actually difficult, without aiming to provoke the strongest possible symptoms. It may include balance, head movements, walking, visual tasks and a return to everyday activities. Recent reviews suggest a possible benefit from vestibular physiotherapy, although treatment protocols remain varied [2, 3].
Depending on the presentation, cognitive behavioural therapy, migraine management or medication may be discussed with the doctor. The aim is not to persuade someone to ignore their symptoms. It is to gradually rebuild a more reliable perception of movement and participation in daily life.
The strength of the evidence needs to be explained. A 2023 Cochrane review found no eligible randomised placebo controlled trials of SSRIs or SNRIs for PPPD. This does not demonstrate that they are ineffective, but it highlights uncertainty. Prescribing and monitoring these medicines are medical responsibilities [4].
When to seek urgent assessment
Weakness on one side, sudden speech difficulty, new double vision, a sudden inability to walk, an unusually severe headache or acute vertigo with neurological signs require urgent medical assessment. PPPD is chronic and should not be used to explain a new acute presentation.
Clinical points that help make sense of the assessment
Keep these criteria in mind: symptoms on most days for at least three months, aggravated by being upright, active or passive movement and complex visual environments. Look for a triggering event, then check that another diagnosis does not better explain the whole pattern. In the clinic, the Dizziness Handicap Inventory (DHI), balance, walking, visual tolerance and avoidance behaviour can guide follow up.
How to build a progression that fits daily life
One example, adjusted to the assessment, is to begin with a short outing in a quiet environment before introducing a busier place. The aim is to increase participation without making every attempt exhausting.
- Choose a specific activity to regain: walking outside, a short shopping trip or using a screen.
- Record what triggers symptoms and how long it takes to recover.
- Change one difficulty at a time, then check whether this helps in real life.
A bad day does not necessarily mean treatment has failed. If progress remains stuck, review the dose and coexisting problems instead of automatically increasing the exercises.
A physiotherapy assessment in Basel
In Basel, assessment can help plan a return to walking, shops, transport or work. Rehabilitation for PPPD is coordinated with the doctor and, when needed, psychological care. Bring reports from previous tests and examples of the situations that most limit your daily life.
Frequently asked questions
Can PPPD improve or resolve?
Substantial improvement is possible, but the pace varies. A gradual, coherent approach is generally more useful than permanently avoiding movement.
Why do supermarkets make symptoms worse?
Busy and moving visual scenes place high demands on sensory integration. Visual dependence may be increased in PPPD.
Is physiotherapy always enough?
No. Some people need vestibular rehabilitation combined with migraine treatment, a psychological approach or medical follow up.
Related articles
- Dizziness and vestibular rehabilitation in Basel
- Vestibular migraine: dizziness with or without a headache
- Dizziness in supermarkets and on screens: understanding VID
- VID treatment: rehabilitating dizziness triggered by visual motion
Scientific references
[1] Staab JP. Persistent Postural-Perceptual Dizziness: Review and Update on Key Mechanisms of the Most Common Functional Neuro-otologic Disorder. Neurol Clin. 2023. Read the reference on PubMed.
[2] Suica Z et al. Comparative effectiveness of non-pharmacological treatments in patients with persistent postural-perceptual dizziness: a systematic review and effect sizes analyses. Frontiers in Neurology, 2024. Read the reference on PubMed.
[3] Effect of vestibular rehabilitation therapy in patients with persistent postural perceptual dizziness: systematic review and meta-analysis. 2025. Read the reference on PubMed.
[4] Webster KE et al. Pharmacological interventions for persistent postural-perceptual dizziness (PPPD). Cochrane Database of Systematic Reviews, 2023. Read the reference on PubMed.
This information explains possible mechanisms and rehabilitation options. Diagnosis and treatment depend on an individual assessment.
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