Association Between Catastrophizing and Dizziness-Related Disability Assessed With the Dizziness Catastrophizing Scale

Association of Benign Paroxysmal Positional Vertigo with Depression and Anxiety-A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the extent to which Benign Paroxysmal Positional Vertigo (BPPV) is associated with a higher prevalence of depression and anxiety in patients.

DATA SOURCES

Three databases including PubMed, Embase, and The Cochrane Library were searched by two independent authors from inception to June 12, 2022 for observational studies and randomized controlled trials investigating the association between BPPV and depression and anxiety. We included studies published as full-length articles in peer-reviewed journals with an adult population aged at least 18 years who have BPPV, detected through validated clinical methods like clinical diagnosis, interview and Dix-Hallpike test.

RESULTS

A total of 23 articles met the final inclusion criteria and 19 articles were included in the meta-analysis. BPPV was associated with a 3.19 increased risk of anxiety compared to controls, and 27% (17%-39%) of BPPV patients suffered from anxiety. Furthermore, the weighted average Beck's Anxiety Inventory score was 18.38 (12.57; 24.18), while the weighted average State-Trait Anxiety Index score was 43.08 (37.57; 48.60).

CONCLUSION

There appears to be some association between BPPV and anxiety, but further studies are required to confirm these associations. Laryngoscope, 134:526-534, 2024.

Does Catastrophizing Predict Response to Treatment in Patients With Vestibular Disorders? A Prospective Cohort Study

OBJECTIVE

Determine levels of catastrophizing in patients with vestibular disorders and prospectively evaluate their relationship with patient-reported outcome measures.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care neurotology vestibular disorders clinic.

PATIENTS

Adult patients with various vestibular disorders.

INTERVENTIONS

Patients were given the Dizziness Handicap Inventory (DHI) and the Dizziness Catastrophizing Scale (DCS) at a baseline visit and follow-up visit after treatment.

MAIN OUTCOME MEASURES

Correlation studies were used to determine the relationships between DHI and DCS. Multivariable linear regression was performed to determine the relationship between DCS and DHI change with treatment, accounting for demographic variables.

RESULTS

Forty-six subjects completed both the DHI and the DCS before and after treatment. Patients with higher baseline DCS scores had higher baseline DHI scores ( p < 0.001). There was a significant improvement in both DHI score ( p < 0.001) and DCS ( p < 0.001) at follow-up. Patients who had reduction in DCS scores during were more likely to show reduction in DHI scores ( p < 0.001). A subset of patients had a mindfulness-based stress reduction program included in their treatment. These patients had a greater reduction in both DCS and DHI scores at follow-up compared with those who received other treatments.

CONCLUSIONS

Catastrophizing is associated with higher pretreatment DHI scores and worse treatment outcomes. Addressing dizziness catastrophizing may help improve vestibular outcomes.

The Psychometric Properties of the 9-Item Vestibular Activities Avoidance Instrument

OBJECTIVE

The purpose of this study was to establish the psychometric properties of the 9-Item Vestibular Activities Avoidance Instrument (VAAI-9), a patient-reported outcome measure developed to identify fear avoidance beliefs in persons with vestibular disorders.

METHODS

This prospective cohort study included 100 participants 18 years and older seeking care at a balance disorders clinic for dizziness. Participants completed the VAAI-9, the Dizziness Handicap Inventory (DHI), and other patient-reported outcomes at the initial visit and the 3-month follow-up. To measure test-retest reliability, the VAAI-9 was completed again 5 days after the initial visit and was analyzed using a 2-way mixed ICC for absolute agreement. Internal consistency was determined using the Cronbach alpha. The Spearman correlation coefficient was used to assess convergent validity of the VAAI-9 with other outcomes. Receiver operating characteristic curves were used to identify baseline VAAI-9 cutoff scores for those who reported mild (DHI ≤ 30) or moderate or severe (DHI > 30) perceived disability at the 3-month follow-up.

RESULTS

The mean age of the study cohort was 49 (SD = 16) years; 73 (73%) were women. Seventy-one participants completed the 5-day follow-up, and 68 completed the 3-month follow-up. The VAAI-9 demonstrated excellent internal consistency (α = 0.91) and test-retest reliability (ICC = 0.90). Baseline VAAI-9 scores had moderate to strong associations with other outcome measures at baseline and 3 months. A baseline VAAI-9 score of 26 or higher had a sensitivity of 80.6% and a specificity of 78.4% for identifying a DHI score of >30 at 3 months (area under the curve = 0.86).

CONCLUSIONS

The results provide evidence of excellent reliability and validity for the 9-item VAAI in persons with vestibular disorders. A baseline VAAI-9 score of ≥26 identified individuals at risk of persistent moderate to severe disability due to dizziness.

IMPACT

Initial levels of fear avoidance beliefs measured using the VAAI-9 provided important prognostic information about outcomes for persons with vestibular symptoms.

Development and validation of the dizziness fear-avoidance behaviours and beliefs inventory for patients with vestibular disorders

The purpose of this study is to present the development and analysis of the factorial structure and psychometric properties of a new self-administered questionnaire (Dizziness Fear-Avoidance Behaviours and Beliefs Inventory (D-FABBI)) designed to measure fear-avoidance behaviors and cognitions related to dizziness disability. A mixed-method design combining a qualitative study with an observational and cross-sectional study was employed to develop (content validity) and psychometrically validate (construct validity, reliability, and convergent/discriminant validity) a new instrument. A total of 198 patients with vestibular disorders (acute vestibular syndrome (AVS), 23.2%; chronic vestibular syndrome (CVS), 35.4%; and episodic vestibular syndrome (EVS) 41.4%) were recruited. Sociodemographic characteristics, the Dizziness Handicap Inventory (DHI) and the Hospital Anxiety and Depression Scale (HADS) and D-FABBI were evaluated. The final version of the D-FABBI consists of 17 items distributed across two subscales: activities of daily living fear-avoidance and movement fear-avoidance. The D-FABBI showed high internal consistency (Cronbach α = 0.932; 95% CI [0.91-0.94]) and so did the subscales (Cronbach α > 0.8). The exploratory structural equation model and confirmatory factor analysis provided better fit results, with a comparative fit index and root mean square error of approximation values of 0.907 to 0.081. No floor or ceiling effects were identified. There was a positive, significant, and moderate-strong magnitude correlation with the total DHI (r = 0.62) and low-moderate with respect to the HADS depression (r = 0.35) and HADS anxiety subscales (r = 0.26). The patients with CVS had a higher D-FABBI score than those with AVS or EVS. The D-FABBI appears to be a valid and reliable instrument for measuring the fear-avoidance behaviors and cognition related to dizziness disability of patients with vestibular disorders.

Musculoskeletal pain patterns and association between dizziness symptoms and pain in patients with long term dizziness - a cross-sectional study

BACKGROUND

The impact of long-term dizziness is considerable both on the personal level and in society and may lead to self-imposed restrictions in daily activities and social relations due to fear of triggering the symptoms. Musculoskeletal complaints seem to be common in persons with dizziness, but studies addressing these complaints as a widespread occurrence, are scarce. This study aimed to examine the occurrence of widespread pain in patients with long-term dizziness and investigate the associations between pain and dizziness symptoms. Further, to explore whether diagnostic belonging is related to the occurrence of pain.

METHODS

This cross-sectional study was conducted in an otorhinolaryngology clinic and included 150 patients with persistent dizziness. The patients were categorized into three groups: episodic vestibular syndromes, chronic vestibular syndromes, and non-vestibular group. The patients completed questionnaires on dizziness symptoms, catastrophic thinking, and musculoskeletal pain when entering the study. Descriptive statistics were used to describe the population, and associations between pain and dizziness were investigated by linear regression.

RESULTS

Pain was reported by 94.5% of the patients. A significantly higher prevalence of pain was reported in all the ten pain sites examined compared to the general population. Number of pain sites and pain intensity were associated with the dizziness severity. Number of pain sites was also associated with dizziness-related handicap, but not with catastrophic thinking. There was no association between pain intensity and dizziness-related handicap or catastrophic thinking. Pain was equally distributed in the diagnostic groups.

CONCLUSION

Patients with long-term dizziness have a considerably higher prevalence of pain and number of pain sites than the general population. Pain co-exists with dizziness and is associated with dizziness severity. These findings may indicate that pain should be systematically assessed and treated in patients with persisting dizziness.

Cross-cultural adaptation and validation of the Norwegian Dizziness Catastrophizing Scale in persons with dizziness

BACKGROUND AND PURPOSE

Dizziness Catastrophizing Scale (DCS) is a questionnaire covering catastrophizing thoughts related to dizziness. The aims of this study were to cross-culturally adapt the DCS into Norwegian (DCS-N) and to examine the internal consistency, content and construct validity, and test-retest reliability of the instrument.

METHOD

Patients (18-67 years) with long-term dizziness were recruited from an ear, nose, and throat (ENT) clinic in Western Norway. Validity of the DCS-N was assessed by evaluating data quality (missing, floor and ceiling effects), content validity (relevance, comprehensiveness, and comprehensibility), structural validity (principal component analysis), internal consistency (Cronbach's alpha), and construct validity (predefined hypotheses). Test-retest reliability was examined by intraclass correlation coefficient (ICC1.1 ), standard error of measurement (SEM), smallest detectable change (SDC), and limits of agreement.

RESULTS

In total, 97 women and 53 men, mean age (SD) 46.5 (12.7) with dizziness were included (in the study). A subgroup of 44 patients participated in test-retest assessment. Overall, the DCS-N was easy to comprehend. The principal component analysis supported a one-factor solution and internal consistency was satisfactory (α 0.93). Construct validity was acceptable; all the predefined hypotheses were confirmed. Test-retest reliability demonstrated ICC1.1 of 0.90 and a SEM of 4.9. SDC was estimated to be ±13.6.

DISCUSSION

The DCS-N demonstrated acceptable measurement properties for assessing catastrophizing thoughts in patients with long-term dizziness. Further studies should examine the responsiveness of the DCS-N and a factor analysis should be undertaken in a larger population.

Dizziness, psychological disorders and cognitive decline

INTRODUCTION

Dizziness is a common disorder, particularly among the elderly population. Aim of this paper was to revise the current concepts surrounding the relationship between dizziness, psychological disorders and cognitive decline.

EVIDENCE ACQUISITION

This is a PRISMA-compliant systematic review, including observational studies in people with dizziness. Database inception, Medline/Cochrane/Embase/Web of Science/Scopus/NHS evidence were searched until October 30, 2019.

EVIDENCE SYNTHESIS

Overall 22 studies, and 65,730 participants were included. Eleven studies were cross-sectional, 7 cross-sectional controlled, 2 prospective case-control, 1 retrospective case series, and 1 cohort study. The persistence of vestibular impairment (for 6 months or more) was correlated to the presence of psychological disorders affecting patient's Quality of Life and causing social anxiety, particularly in some conditions such as Ménière's disease. Interestingly, vestibular loss has been also correlated to cognitive impairment, with certain vestibular dysfunctions reported to be more prevalent in cognitive impaired individuals.

CONCLUSIONS

The current literature suggests that there is an association between vestibular function, psychological disorders and cognitive functions. The findings from this review could be useful in informing on the need for a multidimensional diagnostic and rehabilitative programs for patients with dizziness. More studies could explore the role of counseling or behavioral therapy with an aim to reduce the perceived dizziness-related disability.

Oral Health-Related Quality of Life among Chinese Chronic Orofacial Pain Patients with Psychological Health Problems: A Moderated Mediation Model

Psychological therapies are important for comprehensive chronic orofacial pain (COFP) treatment. This study is to validate the effects of psychological factors on oral health-related quality of life (OHRQoL) among COFP patients in China. Pain catastrophizing, which is a subjective cognitive emotion used to manage the psychological aspects of pain among COFP patients, was examined in relation to COFP severity and OHRQoL. All 479 participants were recruited in Changsha, Hunan Province, China. Cronbach's alpha coefficients (0.868-0.960), composite reliability scores (0.924-0.969), and average variance extracted from each construct (0.555-0.753) all indicated a good model fit. Pearson's correlation analysis showed that age and education status have a positive correlation with COFP severity, pain catastrophizing, and anxiety. COFP severity was related to anxiety, depression, and COFP-OHRQoL. Pain catastrophizing was related to employment status. Anxiety and depression symptoms indirectly mediated the correlation between COFP severity and COFP-OHRQoL. As a second-stage moderator, pain catastrophizing moderated the mediating effects of anxiety symptoms and depression symptoms. Our findings suggest that anxiety, depression, and pain catastrophizing should be evaluated jointly to improve COFP-OHRQoL among COFP patients. This evidence will help therapists to comprehensively treat patients for the best treatment effect.

Effectiveness of vestibular rehabilitation therapy in patients with idiopathic Cerebellar Ataxia with Bilateral Vestibulopathy (iCABV)

OBJECTIVE

To evaluate the benefit of vestibular rehabilitation therapy (VRT) in the management of patients with idiopathic cerebellar ataxia with bilateral vestibulopathy (iCABV).

BACKGROUND

iCABV is a hindbrain degenerative disorder with impairment of both central and peripheral vestibular pathways. There is combined failure of four compensatory eye movement systems including the vestibulo-ocular reflex (VOR), optokinetic reflex, smooth pursuit and the visually enhanced vestibulo-ocular reflex (VVOR). Phenotypic presentation includes postural and gait instability, oscillopsia and dizziness with active head movement. The benefit of VRT in iCABV patients has not been established.

METHODS

A retrospective review was performed on a cohort of twelve patients diagnosed with iCABV in a multidisciplinary neuro-otology clinic. All participated in VRT and completed their suggested course of VRT. The following clinical measures were assessed before starting and after finishing VRT: 1) Dizziness Handicap Inventory (DHI), 2) Activities-Specific Balance Confidence (ABC) Scale, 3) Catastrophization scale, 4) Positive Affective Negative Affective Score (PANAS), 5) Dynamic Gait Index (DGI) and 6) Modified Clinical Test of Sensory Interaction in Balance (mCTSIB). The number of falls historically was recorded in addition to gait speed (ft./sec).

RESULTS

Following VRT, patients were found to have improved balance on mCTSIB (condition 4 : 7 vs 18 seconds, P = 0.04) and a better postural stability with a reduced number of falls (p = 0.01). No statistically significant improvement was seen in the DHI, ABC, Catastrophization scale, DGI, PANAS and gait speed (p > 0.05).

CONCLUSIONS

iCABV patients who underwent VRT were found to have a better postural stability and reduced risk of falls. VRT was not found to significantly improve patients' overall subjective perception of their symptoms or their psychological status.

Post-traumatic peripheral vestibular disorders (excluding positional vertigo) in workers following head injury

Benign paroxysmal positional vertigo has typically been reported to be the most common cause of post-traumatic dizziness. There is however paucity in the literature about other peripheral vestibular disorders post-head injury. This article provides an overview of other causes of non-positional dizziness post-head trauma from our large institutional experience. The UHN WSIB Neurotology database (n = 4291) between 1998 and 2018 was retrospectively studied for those head-injured workers presenting with non-positional peripheral vestibular disorders. All subjects had a detailed neurotological history and examination and vestibular testing including video nystagmography, video head impulse testing (or a magnetic scleral search coil study), vestibular-evoked myogenic potentials, and audiometry. Imaging studies included routine brain and high-resolution temporal bone CT scans and/or brain MRI. Based on a database of 4291 head-injured workers with dizziness, 244 were diagnosed with non-positional peripheral vertigo. Recurrent vestibulopathy (RV) was the most common cause of non-positional post-traumatic vertigo. The incidence of Meniere's disease in the post-traumatic setting did not appear greater than found in the general population. The clinical spectrum pertaining to recurrent vestibulopathy, Meniere's disease, delayed endolymphatic hydrops, drop attacks, superior semicircular canal dehiscence syndrome, and uncompensated peripheral vestibular loss are discussed.

Receiving Long-Term Disability or Pursuing a Legal Claim May Prevent Recovery From Chronic Dizziness

OBJECTIVES/HYPOTHESIS

Chronic dizziness (CD) and imbalance have multiple etiologies. CD is strongly linked with psychiatric and psychological comorbidities, thus an interdisciplinary approach, including psychopharmacological interventions, is recommended. Despite the use of this comprehensive treatment approach, the recovery of individuals with CD that pursue long-term disability (LTD) insurance or legal claims (LC) appears hampered. As such, we aimed to compare symptom recovery from CD in an interdisciplinary setting between patients receiving LTD/LC versus those who were not, and to explore the factors that may contribute to changes in symptom severity.

STUDY DESIGN

Retrospective cohort study.

METHODS

Dizziness-related diagnoses were extracted from the charts of 195 adults in an outpatient interdisciplinary neurotology clinic in Toronto, Canada. Patients with baseline Dizziness Handicap Inventory (DHI) and Dizziness Catastrophizing Scale (DCS) assessments between August 2012 and July 2018 and a mean follow-up visit within approximately 10 months were included. The study participants were categorized as "LTD/LC+" (n = 92) or "LTD/LC-" (n = 103), referring to either receiving or pursuing LTD/LC or not, respectively.

RESULTS

There were differences in the mean percentage changes in DHI (t[187] = 3.02, P = .003) and DCS (t[179] = 2.63, P = .009) scores between LTD/LC+ and LTD/LC- patients. LTD/LC+ patients showed 8.0% and 7.6% mean increases in DHI and DCS scores, respectively, whereas LTD/LC- patients showed 21.5% and 25.9% reductions in DHI and DCS scores, respectively, controlling for age, sex, and baseline illness severity.

CONCLUSIONS

Patients receiving or pursuing LTD insurance or a legal claim did not improve from CD and dizziness catastrophizing compared to those who were not. Future studies are required to test these findings prospectively and to determine the factors that may contribute to symptom recovery, including the anxiety-aggravating effects of the LTD/LC process and the deleterious consequences of developing a sick-role while afflicted with a chronic illness.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Fear Avoidance Beliefs Are Associated With Perceived Disability in Persons With Vestibular Disorders

OBJECTIVE

The purpose of this study was to determine the association between fear-avoidance beliefs and disability in 3 months in people with vestibular disorders while accounting for demographic and clinical characteristics.

METHODS

This prospective cohort study included people aged 18 to 100 years who reported dizziness. Participants were recruited from a balance disorders clinic and outpatient physical therapy clinics. All participants completed the Vestibular Activities Avoidance Instrument (VAAI) and the Hospital Anxiety and Depression Scale at baseline and the Vestibular Activities and Participation measure (VAP), dizziness Visual Analogue Scale (VAS), and 12-item Short Form Health Questionnaire at baseline and 3-month follow-up. A modified version of the VAAI included 9 items abstracted from the 81-item VAAI. The relationships between 9-item VAAI scores and follow-up measures of disability were assessed using Spearman correlation coefficients. Linear regression models were analyzed to determine the effect of fear-avoidance beliefs on follow-up VAP score while accounting for baseline outcome measures.

RESULTS

All participants (n = 404) completed the baseline assessment (mean age = 54 years), and 286 (71%) completed the 3-month assessment. The mean 9-item VAAI score was 25 (SD = 14) at baseline and was significantly associated with VAP (ρ = 0.54), 12-item Short Form Health Questionnaire component scores (ρ = -0.53; -0.44), and dizziness VAS at follow-up (ρ = 0.37). Approximately 38% of the variation in VAP score at follow-up was predicted by age, number of medications, 9-item VAAI score, dizziness VAS, and Hospital Anxiety and Depression Scale-depression score when considered together (R2 = 0.38).

CONCLUSION

Fear-avoidance beliefs are associated with measures of disability at 3 months and are predictive of activity limitations and participation restrictions at 3 months when controlling for age, medications, baseline dizziness, and depression symptom severity in people with vestibular disorders.

IMPACT

Measurement of fear-avoidance beliefs may provide important prognostic information, suggesting that an assessment of fear-avoidance beliefs could be used by clinicians to identify individuals at greater risk of disability after a vestibular disorder.

LAY SUMMARY

Fear-avoidance beliefs in people who have vestibular disorders are associated with disability at 3 months and predict limitations in daily activities at 3 months.

Episodic versus Chronic Dizziness: An Analysis of Predictive Factors

OBJECTIVES

To elucidate differences in demographic and clinical characteristics between patients with episodic and chronic dizziness.

METHODS

A cross-sectional, observational study of 217 adults referred for dizziness at 1 tertiary center was undertaken. Subjects were split into a chronic dizziness group (>15 dizzy days per month) and an episodic dizziness group (<15 dizzy days per month).

RESULTS

217 adults (average age, 53.7 years; 56.7% female) participated. One-third (n = 74) met criteria for chronic dizziness. Dizziness handicap inventory (DHI) scores were significantly higher in those with chronic dizziness compared to those with episodic dizziness (53.9 vs 40.7; P < .001). Comorbid depression and anxiety were more prevalent in those with chronic dizziness (44.6% and 47.3% vs 37.8% and 35.7%, respectively; P > .05). Abnormal vestibular testing and abnormal imaging studies did not differ significantly between the 2 groups. Ménière's disease and BPPV were significantly more common among those with episodic dizziness, while the prevalence of vestibular migraine did not differ according to chronicity of symptoms. A multivariate regression that included age, sex, DHI, history of anxiety and/or depression, associated symptoms, and dizziness triggers was able to account for 15% of the variance in the chronicity of dizziness (pseudo-R² = 0.15; P < .001).

CONCLUSIONS

Those who suffer from chronic dizziness have significantly higher DHI and high comorbid rates of depression and anxiety than those with episodic dizziness. Our findings show that factors other than diagnosis alone are important in the chronification of dizziness, an observation that could help improve on multimodal treatment options for this group of patients.

Exploratory Factor Analysis of the Vestibular Activities Avoidance Instrument

Importance

Fear avoidance is a behavioral response to dizziness that can lead to chronic symptoms and maladaptation of the vestibular system, but there is no valid and reliable clinical measure of fear avoidance for persons with dizziness. Although the Vestibular Activities Avoidance Instrument (VAAI) was developed to identify fear avoidance beliefs in persons with dizziness, it was considered too long for clinical use.

Objective

To continue development of the VAAI for clinical use by reducing its length and by assessing the internal consistency and construct validity through associations with measures of disability, quality of life, and psychological well-being.

Design, Setting, and Participants

This prospective cohort study conducted from February 2018 to December 2019 at a tertiary care balance disorders clinic and in outpatient physical therapy clinics in the United States included 404 adults with dizziness.

Main Outcomes and Measures

Participants completed the 81-item VAAI, the Vestibular Activities and Participation (VAP) measure, the 12-Item Short Form Health Survey (SF-12), and the Hospital Anxiety and Depression Scale (HADS) at baseline. Exploratory factor analysis of the VAAI was conducted to reduce the number of items. Internal consistency of the reduced VAAI was determined by calculating the Cronbach α. Convergent validity was assessed by examining the associations between the reduced VAAI and the VAP, the SF-12, and the HADS using Spearman correlation coefficients.

Results

Data from 404 adults (mean [SD] age, 54.0 [17.0] years; 64.6% women) were included in the analyses. The exploratory factor analysis indicated that 2 factors explained the underlying constructs of the 81-Item VAAI. The first factor was retained and measured the construct of fear avoidance. The VAAI was reduced to 9 items (VAAI-9). The VAAI-9 showed excellent internal consistency (Cronbach α = 0.92) and was positively associated with the VAP (ρ = 0.81) and the HADS anxiety (ρ = 0.47) and depression (ρ = 0.64) subscales, and negatively associated with physical (ρ = -0.76) and mental (ρ = -0.47) health-related quality of life.

Conclusions and Relevance

These findings indicate that the VAAI-9 is a short, internally consistent, valid measure of fear avoidance and is associated with quality of life, activity limitations and participation restrictions, and psychological well-being. The next steps in the development of the VAAI-9 will include validation in an external sample, assessment of test-retest validity, and prospective investigations of its association with future disability.

Vestibular rehabilitation in Europe: a survey of clinical and research practice

Vestibular rehabilitation (VR) is practiced across Europe but little in this area has been quantified. The aim of this study was to investigate current VR assessment, treatment, education, and research practices. This was an online, cross-sectional survey with 39 VR specific questions and four sections: demographics, current practice, education, and research. The survey was disseminated through the Dizzynet network to individual therapists through country-specific VR special interest groups. Results were analysed descriptively. A thematic approach was taken to analyse open questions. A total of 471 individuals (median age 41, range 23 - 68 years, 73.4% women), predominately physiotherapists (89.4%) from 20 European countries responded to the survey. They had worked for a median of 4 years (range < 1 - 35) in VR. The majority (58.7%) worked in hospital in-patient or out-patient settings and 21.4% in dedicated VR services. Most respondents specialized in neurology, care of the elderly (geriatrics), or otorhinolaryngology. VR was reported as hard/very hard to access by 48%, with the main barriers to access identified as lack of knowledge of health care professionals (particularly family physicians), lack of trained therapists, and lack of local services. Most respondents reported to know and treat benign paroxysmal positional vertigo (BPPV 87.5%), unilateral vestibular hypofunction (75.6%), and cervicogenic dizziness (63%). The use of vestibular assessment equipment varied widely. Over 70% used high-density foam and objective gait speed testing. Over 50% used dynamic visual acuity equipment. Infrared systems, Frenzel lenses, and dynamic posturography were not commonly employed (< 20%). The most frequently used physical outcome measures were the Clinical Test of the Sensory Interaction of Balance, Functional Gait Assessment/Dynamic Gait Index, and Romberg/Tandem Romberg. The Dizziness Handicap Inventory, Visual Analogue Scale, Falls Efficacy Scale, and the Vertigo Symptom Scale were the most commonly used patient reported outcome measures. Adaptation, balance, and habituation exercises were most frequently used (> 80%), with virtual reality used by 15.6%. Over 70% reported knowledge/use of Semont, Epley and Barbeque-Roll manoeuvres for the treatment of BPPV. Most education regarding VR was obtained at post-registration level (89.5%) with only 19% reporting pre-registration education. There was strong (78%) agreement that therapists should have professionally accredited postgraduate certification in VR, with blended learning the most popular mode. Three major research questions were identified for priority: management of specific conditions, effectiveness of VR, and mechanisms/factors influencing vestibular compensation and VR. In summary, the survey quantified current clinical practice in VR across Europe. Knowledge and treatment of common vestibular diseases was high, but use of published subjective and objective outcome measures as well as vestibular assessment varied widely. The results stress the need of improving both training of therapists and standards of care. A European approach, taking advantage of best practices in some countries, seems a reasonable approach.

The Role of Prediagnosis Audiovestibular Dysfunction Versus Distress, Illness-Related Cognitions, and Behaviors in Predicted Ongoing Dizziness Handicap

OBJECTIVE

People with chronic vestibular diseases experience variable degrees of self-perceived disability. However, longitudinal data examining the predictive validity of relevant clinical variables alongside psychological variables are limited. The present study examined whether these factors predict self-reported dizziness handicap 3 months after assessment and diagnosis.

METHODS

Patients were recruited from a waiting list of a tertiary neuro-otology clinic and completed standardized mood, cognitive, behavioral, and dizziness handicap questionnaires before and 3 months after their initial consultation and diagnosis. All patients were clinically assessed and underwent comprehensive audiovestibular investigations.

RESULTS

Seventy-three percent of participants responded at follow-up (n = 135, 73% female, mean [standard deviation] age = 54.23 [17.53] years), of whom 88% were diagnosed with a neurotological condition. There were significant improvements in handicap, depression, and anxiety at 3 months. Thirty (22%) of 135 showed clinically meaningful improvement in handicap. The percentage of case-level depression and anxiety remained the same. Negative illness perceptions and symptom responses reduced, although participants still tended to view their condition negatively. Vestibular tests and type of diagnosis were not associated with self-reported handicap. Most baseline psychological variables significantly correlated with handicap at 3 months. When adjusting for baseline handicap and demographics, the baseline psychological variables only explained a significant ~3% of the variance in dizziness handicap at follow-up, with baseline handicap explaining most of the variance. All-or-nothing behavior was the most significant predictor.

CONCLUSIONS

Tertiary patients with vertigo and dizziness report negative illness perceptions and cognitive and behavioral responses to symptoms that are associated with self-reported handicap over time. Future studies are needed to investigate whether targeting these factors alongside traditional treatment approaches improves handicap in patients with chronic dizziness.

Vestibular deficits and psychological factors correlating to dizziness handicap and symptom severity

OBJECTIVE

To determine the relative contribution of demographic variables, objective testing and psychological factors in explaining the variance in dizziness severity and handicap.

METHODS

One-hundred and eighty-five consecutive patients on the waiting list to attend a diagnostic appointment in a tertiary neuro-otology clinic with a primary complaint of vertigo or dizziness completed a cross-sectional survey. Primary outcomes were the Dizziness Handicap Inventory and the vertigo subscale of the Vertigo Symptom Scale-Short Form. Psychological questionnaires assessed anxiety and depressive symptoms, illness perceptions, cognitive and behavioural responses to symptoms, beliefs about emotions and psychological vulnerability. Patients also underwent standardised audio-vestibular investigations and tests to reach a diagnosis at appointment.

RESULTS

Objective disease characteristics were not associated with handicap and only the presence of vestibular dysfunction on one test (caloric) was associated with symptom severity. Almost all the psychological factors were correlated with dizziness outcomes. The total hierarchical regression model explained 63% of the variance in dizziness handicap, and 53% was explained by the psychological variables. The regression model for symptom severity explained 36% of the variance, and 30% was explained by the psychological factors. In adjusted models, factors associated with dizziness handicap included age, female gender, distress, symptom focusing, embarrassment, avoidance, and beliefs about negative consequences. Fear avoidance was the only independent correlate in the fully adjusted model of symptom severity.

CONCLUSION

Self-reported dizziness severity and handicap are not correlated with clinical tests of vestibular deficits but are associated with psychological factors including anxiety, depression, illness perceptions, cognitive and behavioural responses.