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Systematic review
Predictors of persistent postural-perceptual dizziness (PPPD) and similar forms of chronic dizziness precipitated by peripheral vestibular disorders: a systematic review
  1. Aaron Trinidade1,2,
  2. Verónica Cabreira3,4,
  3. Joel A Goebel5,
  4. Jeffrey P Staab6,
  5. Diego Kaski7,
  6. Jon Stone4
  1. 1 Department of Otolaryngology, Southend University Hospital, Southend-on-Sea, UK
  2. 2 Faculty of Medicine, Anglia Ruskin University Medical School, Chelmsford, UK
  3. 3 Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
  4. 4 Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
  5. 5 Department of Neuro-otology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
  6. 6 Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
  7. 7 Department of Neuro-otology, University College London, London, UK
  1. Correspondence to Aaron Trinidade, Southend University Hospital NHS Foundation Trust, Southend-on-Sea, SS0 0RY, UK; aaron.trinidade{at}


Background The literature on predictors of persistent postural-perceptual dizziness (PPPD) following peripheral vestibular insults has not been systematically reviewed.

Methods We systematically reviewed studies on predictors of PPPD and its four predecessors (phobic postural vertigo, space-motion discomfort, chronic subjective dizziness and visual vertigo). Investigations focused on new onset chronic dizziness following peripheral vestibular insults, with a minimum follow-up of 3 months. Precipitating events, promoting factors, initial symptoms, physical and psychological comorbidities and results of vestibular testing and neuroimaging were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results We identified 13 studies examining predictors of PPPD or PPPD-like chronic dizziness. Anxiety following vestibular injury, dependent personality traits, autonomic arousal and increased body vigilance following precipitating events and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness. Disease-related abnormalities of the otolithic organs and semi-circular canals and age-related brain changes seem to be important only in a minority of patients. Data on pre-existing anxiety were mixed.

Conclusions After acute vestibular events, psychological and behavioural responses and brain maladaptation are the most likely predictors of PPPD, rather than the severity of changes on vestibular testing. Age-related brain changes appear to have a smaller role and require further study. Premorbid psychiatric comorbidities, other than dependent personality traits, are not relevant for the development of PPPD.

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  • Twitter @aarontrinidade, @veronicabreira, @jonstoneneuro

  • Contributors AT and VC performed the literature review. AT was responsible for the manuscript with VC and JS primarily editing. DK, JAG and JPS provided senior guidance and secondary editing. AT is the guarantor and accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding JPS was supported by grant W81XWH-18-1-0760 from the US Army Medical Research and Materiel Command via the Congressionally Directed Medical Research Program. VC receives funding from the EU H2020 Marie Skłodowska-Curie Innovative Training Network, grant agreement 956673.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.