Web-based vestibular rehabilitation in persistent postural-perceptual dizziness

Persistent postural-perceptual dizziness: A functional neuro-otologic disorder

Persistent postural-perceptual dizziness (PPPD) is a functional neuro-otologic disorder that is the most frequent cause of chronic vestibular syndrome. The core vestibular symptoms include dizziness, unsteadiness, and non-spinning vertigo, which are exacerbated by an upright posture or walking, active or passive motion, and exposure to moving or complex visual stimuli. PPPD is mostly precipitated by acute or episodic vestibular diseases; however, its symptoms cannot be accounted for by its precipitants. PPPD is not a diagnosis of exclusion, but may coexist with other structural diseases. Thus, when diagnosing PPPD, the patient's symptoms must be explained by PPPD alone or by PPPD in combination with a structural illness. PPPD is most frequently observed at approximately 50 years of age, with a female predominance. Conventional vestibular tests do not reveal any specific signs of PPPD. However, the head roll-tilt subjective visual vertical test and gaze stability test after exposure to moving visual stimuli may detect the characteristic features of PPPD, that is, somatosensory- and visually-dependent spatial orientation, respectively. Therefore, these tests could be used as diagnostic tools for PPPD. Regarding the pathophysiology of PPPD, neuroimaging studies suggest shifts in interactions among visuo-vestibular, sensorimotor, and emotional networks, where visual inputs dominate over vestibular inputs. Postural control also shifts, leading to the stiffening of the lower body. To treat PPPD, selective serotonin reuptake inhibitors/serotonin noradrenaline reuptake inhibitors, vestibular rehabilitation, and cognitive behavioral therapy are used alone or in combination.

Effectiveness of Telerehabilitation in Dizziness: A Systematic Review with Meta-Analysis

Dizziness can be a debilitating condition with various causes, with at least one episode reported in 17% to 30% of the international adult population. Given the effectiveness of rehabilitation in treating dizziness and the recent advancements in telerehabilitation, this systematic review aims to investigate the effectiveness of telerehabilitation in the treatment of this disorder. The search, conducted across Medline, Cochrane Central Register of Controlled Trials, and PEDro databases, included randomized controlled trials assessing the efficacy of telerehabilitation interventions, delivered synchronously, asynchronously, or via tele-support/monitoring. Primary outcomes focused on dizziness frequency/severity and disability, with secondary outcomes assessing anxiety and depression measures. Seven articles met the eligibility criteria, whereas five articles contributed to the meta-analysis. Significant findings were observed regarding the frequency and severity of dizziness (mean difference of 3.01, p < 0.001), disability (mean difference of -4.25, p < 0.001), and anxiety (standardized mean difference of -0.16, p = 0.02), favoring telerehabilitation. Telerehabilitation shows promise as a treatment for dizziness, aligning with the positive outcomes seen in traditional rehabilitation studies. However, the effectiveness of different telerehabilitation approaches requires further investigation, given the moderate methodological quality and the varied nature of existing methods and programs.

Validity and reliability of the Niigata PPPD Questionnaire in a Western population

PURPOSE

To analyze the psychometric properties of the Niigata Questionnaire (NPQ) for use in a European population with persistent postural-perceptual dizziness (PPPD).

METHODS

Observational study included 140 patients with different vestibular conditions. Construct validity, internal consistency and concurrent validity were analyzed. Intra-class correlation coefficient (ICC), standard error of measurement (SEM) and minimal detectable change (MDC) were calculated. Receiver operating characteristic (ROC) curve was used to test diagnostic values.

RESULTS

Of the 140 patients, 47 had a diagnosis of PPPD. Factorial analysis showed a single-factor structure and concurrent validity analysis showed strong correlations with other instruments. Cronbach alpha coefficients of 0.938 for the total score, 0.869 for the standing and gait subscale, 0.803 for the subscale of movements and 0.852 for the visual stimulation subscale were obtained. The reproducibility was substantial except for the standing subscale, which could be considered moderate. For the standing, movement and visual stimulation subscales and for the total score, the SEM was 3.27, 2.41, 2.50 and 6.63, respectively, and the MDC was 6.40, 4.72, 4.91 and 12.99, respectively. The NPQ total score showed an area under the curve (AUC) of 0.661, a sensitivity of 72.34 and a specificity of 55.91 for discriminating between PPPD and other vestibular disorders.

CONCLUSIONS

The NPQ is feasible for use in a Western population and presents a uni-factorial structure, high internal consistency and strong correlation with other instruments. The reliability can be considered substantial. The NPQ has low accuracy in discriminating between subjects with or without PPPD.

Online vestibular rehabilitation for chronic vestibular syndrome: 36-month follow-up of a randomised controlled trial in general practice

BACKGROUND

Vestibular rehabilitation (VR) is the preferred treatment for chronic vestibular symptoms such as dizziness and vertigo. An internet-based programme was developed to increase uptake of VR. The authors have previously reported that internet-based VR resulted in a clinically relevant decrease of vestibular symptoms for up to 6 months, compared with usual care.

AIM

To evaluate long-term outcomes of internet-based VR in patients with chronic vestibular syndrome.

DESIGN AND SETTING

A randomised controlled trial was conducted in Dutch general practice involving 322 participants aged ≥50 years with chronic vestibular syndrome. Participants were randomised to stand-alone VR, blended VR (with physiotherapy support), and usual care. Usual care participants were allowed to cross over to stand-alone VR 6 months after randomisation.

METHOD

Participants were approached 36 months after randomisation. The primary outcome was the presence of vestibular symptoms as measured by the vertigo symptom scale-short form (VSS-SF). Secondary outcomes were dizziness-related impairment, anxiety, depressive symptoms, and healthcare utilisation.

RESULTS

At 36-month follow-up, 65% of participants filled in the VSS-SF. In the usual care group, 38% of participants had crossed over to VR at 6 months. There were no significant differences in vestibular symptoms between VR groups and usual care (mean difference = -0.8 points, 95% confidence interval [CI] = -2.8 to 1.2, for stand-alone VR; -0.3, 95% CI = -2.2 to 1.7, for blended VR). In VR groups, clinically relevant improvement compared with baseline was maintained over time.

CONCLUSION

Internet-based VR provides a maintained improvement of vestibular symptoms for up to 36 months in patients with chronic vestibular syndrome.

The effect of self-management vestibular rehabilitation on persistent postural-perceptual dizziness

Objective

To investigate the effects of self-management vestibular rehabilitation (VR) on the subjective symptoms of dizziness and postural stability in persistent postural-perceptual dizziness (PPPD).

Study design

Retrospective case review.

Methods

The medical records of 30 patients newly diagnosed with PPPD based on the Bárány Society's diagnostic criteria were reviewed. Nineteen patients (4 males and 15 females; age range 27-84 years, mean age ± standard deviation 57.4 ± 14.2 years) who was newly instructed to self-management VR were included and instructed to perform self-management VR for 2 months.

Results

One patient did not visit the outpatient clinic again, and in the remaining 18 patients, 4 (22%) discontinued VR at their own discretion. In the 12 patients who completed 2 months of VR (67%), there was a significant improvement in Niigata PPPD Questionnaire (NPQ) and Dizziness Handicap Inventory (DHI) scores after VR compared to those before VR (p < .05). However, the mean velocity of center of pressure (COP) movement (velocity) and the envelopment area traced by COP movement (area), as well as the Romberg ratio and foam ratio of velocity and area, did not differ significantly after VR when compared to those before VR (p > .05).

Conclusions

For PPPD, self-management VR improved subjective symptoms of dizziness, but not stability of standing posture. It is necessary to improve patients' adherence to the treatment.

Level of evidence

4.

[Research progress on the questionnaire related to persistent postural-perceptual dizziness]

Persistent postural-perceptual dizziness（PPPD） is the most common chronic vestibular disease, the clinical manifestation is dizziness, unstable and non-rotational dizziness for three months or more. And the symptom is exacerbated by upright posture, active or passive movement, and complex visual stimuli. In addition, PPPD is a functional disease, so routine vestibular function tests and imaging tests are often negative. According to the diagnostic criteria established by the Barany Association, the diagnosis of PPPD often relies on history. This article provides a review of PPPD-related questionnaires.

Non-pharmacological interventions for persistent postural-perceptual dizziness (PPPD)

BACKGROUND

Persistent postural-perceptual dizziness (PPPD) is a chronic balance disorder, which is characterised by subjective unsteadiness or dizziness that is worse on standing and with visual stimulation. The condition was only recently defined and therefore the prevalence is currently unknown. However, it is likely to include a considerable number of people with chronic balance problems. The symptoms can be debilitating and have a profound impact on quality of life. At present, little is known about the optimal way to treat this condition. A variety of medications may be used, as well as other treatments, such as vestibular rehabilitation.  OBJECTIVES: To assess the benefits and harms of non-pharmacological interventions for persistent postural-perceptual dizziness (PPPD).  SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 21 November 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with PPPD, which compared any non-pharmacological intervention with either placebo or no treatment. We excluded studies that did not use the Bárány Society criteria to diagnose PPPD, and studies that followed up participants for less than three months.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vestibular symptoms (assessed as a dichotomous outcome - improved or not improved), 2) change in vestibular symptoms (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) generic health-related quality of life and 6) other adverse effects. We considered outcomes reported at three time points: 3 to < 6 months, 6 to ≤ 12 months and > 12 months. We planned to use GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: Few randomised controlled trials have been conducted to assess the efficacy of different treatments for PPPD compared to no treatment (or placebo). Of the few studies we identified, only one followed up participants for at least three months, therefore most were not eligible for inclusion in this review.  We identified one study from South Korea that compared the use of transcranial direct current stimulation to a sham procedure in 24 people with PPPD. This is a technique that involves electrical stimulation of the brain with a weak current, through electrodes that are placed onto the scalp. This study provided some information on the occurrence of adverse effects, and also on disease-specific quality of life at three months of follow-up. The other outcomes of interest in this review were not assessed. As this is a single, small study we cannot draw any meaningful conclusions from the numeric results.  AUTHORS' CONCLUSIONS: Further work is necessary to determine whether any non-pharmacological interventions may be effective for the treatment of PPPD and to assess whether they are associated with any potential harms. As this is a chronic disease, future trials should follow up participants for a sufficient period of time to assess whether there is a persisting impact on the severity of the disease, rather than only observing short-term effects.

How do patients with chronic dizziness experience a web-based home rehabilitation programme for customised vestibular therapy ('WeBaVeR')? A qualitative study

BACKGROUND

Vestibular rehabilitation therapy (VRT) is the first choice approach for chronic dizziness. However, current home treatment programmes often lack attention to the individual needs of the patient and the integration of visual desensitisation therapy. We therefore developed a customised web-based VRT programme containing visual desensitisation exercises.

OBJECTIVE

To assess the user experience (usability, satisfaction, acceptability, and quality) of patients with chronic dizziness with the customised WEb-BAsed VEstibular Rehabilitation, further called 'WeBaVeR'.

METHODS

Patients with chronic dizziness, attending the Department of Otorhinolaryngology of the Antwerp University Hospital (period September 2021 to May 2022), received a customised programme, i.e. exercises supported by our web application and booklet. The programme lasted 6 weeks, with weekly supervision by phone. Patients' user experience was examined with the System Usability Scale (SUS), Client Satisfaction Questionnaire (CSQ), Service User Technology Acceptability Questionnaire (SUTAQ), and the User version of the Mobile Application Rating Scale (uMARS).

RESULTS

Twelve patients with chronic dizziness (mean age: 45.33 ± 13.26 years) participated. The overall rated level of perceived usability (mean SUS score: 78.75 ± 8.95 points), satisfaction (mean CSQ score: 33.08 ± 3.37 points), acceptability (mean SUTAQ score: 105.67 ± 13.40 points) and quality (mean uMARS score: 94.58 ± 10.69 points) was good. The main remarks concerned the user interface and the interactive capabilities of the web application, and that WeBaVeR does not increase health awareness, or accessibility to health care providers.

CONCLUSION

Patients with chronic dizziness consider WeBaVeR as useful, acceptable, satisfactory and of good quality. To facilitate implementation in practice, further optimisation of WeBaVeR based on the feedback received, is useful.

Home-based Vestibular Rehabilitation: A Feasible and Effective Therapy for Persistent Postural Perceptual Dizziness (A Pilot Study)

INTRODUCTION

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder where there is persistent dizziness or unsteadiness occurring on most days for more than 3 months duration. Treatment recommendations for PPPD include vestibular rehabilitation therapy (VRT) with or without medications and/or cognitive behavioral therapy.

OBJECTIVES

This paper is a pilot study designed to compare the effects of Bal Ex as a home-based VRT on the quality of life (EQ-5D), dizziness handicap (DHI) and mental health (DASS-21) against hospital-based VRT.

DESIGN

This was an assessor-blinded, randomized controlled pilot study where PPPD patients were randomly selected to undergo Bal Ex, the home-based VRT (intervention group) or hospital-based (control group) VRT. The participants were reviewed at 4 weeks and 12 weeks after the start of therapy to assess the primary endpoints using the subjective improvement in symptoms as reported by patients, changes in DHI scores, DASS-21 scores and EQ5D VAS scores.

RESULTS

Thirty PPPD patients successfully completed the study with 15 in each study group. Within 4 weeks, there were significant improvements in the total DHI scores as well as anxiety levels. By the end of 12 weeks, there were significant improvements in the DHI, DASS-21 and EQ5D. The degree of improvement between Bal Ex and the control was comparable.

CONCLUSION

VRT is an effective modality in significantly improving quality of life, dizziness handicap, depression, and anxiety levels within 3 months in PPPD. Preliminary results show Bal Ex is as effective as hospital-based VRT and should be considered as a treatment option for PPPD.

Perception, knowledge, and attitude of medical doctors in Saudi Arabia about the role of physiotherapists in vestibular rehabilitation: a cross-sectional survey

Objectives

There is compelling scientific evidence about the role of physiotherapists in vestibular rehabilitation. However, patients with vestibular-associated dizziness and balance disturbances are seldom referred to physiotherapists in Saudi Arabia. Therefore, this study aims to achieve insight into perceptions, knowledge, attitudes, and referral practices among Saudi Arabian medical doctors relating to the role of physiotherapists in vestibular rehabilitation.

Methods

A sample of 381 medical doctors practicing in Saudi Arabia participated in this nationwide cross-sectional study. The sample was obtained from 226 hospitals across 13 provinces of Saudi Arabia by stratified sampling method. The 23-item questionnaire developed by a team of experts was emailed to medical doctors practicing in various hospitals across Saudi Arabia.

Results

Out of 1,231 medical doctors invited, 381 medical doctors responded, giving a response rate of 30.9%. One hundred ninety-three (50.6%) medical doctors reported managing patients with vestibular rehabilitation. The most preferred specialist for managing patients with vestibular disorders was an Ear Nose Throat (ENT) specialist (n = 173, 89.6%). Related Sample Cochran's Q test showed statistically significant difference between preferred specialist for managing patients with vestibular disorders (ENT specialists, physiotherapists, nurses, occupational therapists and audiologists) (χ2(4) = 482.476, p = 0.001). Out of 193 medical doctors, 153 (79.2%) reported no role of the physiotherapist in vestibular rehabilitation. One hundred forty-five (75.1%) of medical doctors reported that they were not aware of the role of physiotherapists in vestibular rehabilitation. Only 27 (15.5%) medical doctors reported referring patients with vestibular disorders to physiotherapists.

Conclusion

The study reports that physiotherapy services are underutilized in vestibular rehabilitation due to limited referral from Saudi Arabian medical doctors. Therefore, there is a need to increase the awareness among Saudi Arabian doctors about the physiotherapist's role in vestibular rehabilitation.

Web-based vestibular rehabilitation in persistent postural-perceptual dizziness

OBJECTIVES

The aims of the study were to investigate the feasibility and preliminary outcome of a Norwegian web-based self-help application for vestibular rehabilitation (VR) among patients with high symptom burden of chronic dizziness fulfilling the criteria for persistent postural-perceptual dizziness (PPPD).

MATERIALS AND METHODS

The web application consists of six weekly online sessions, with written information and video presentations. It is self-instructive and freely available on NHI.no (https://nhi.no/for-helsepersonell/vestibular-rehabilitering/). Ten consecutive patients referred to a neurologic outpatient clinic for chronic dizziness were included. They signed informed consent forms and were examined at inclusion and after three months. State of health and symptom burden were recorded using Vertigo symptom score (VSS), Niigata symptom score (NPQ), Patient Health Questionnaire (PHQ-9) and health-related quality of life score (EQ5D-5L). Experiences with the program were measured using a semi-structured interview at the end of the study.

RESULTS

Nine out of ten patients completed the program. The findings suggest that the web application was easy to use, instructive and educatable. Challenges were the load of exercises, motivation to continue training during relapses and performing the body rolling on the floor. Participants had high symptom burden (VSS mean 32.9) and long duration of symptoms in years (mean 11.5). The participants improved on average 6.9 points on the VSS score.

CONCLUSIONS

This web application for chronic dizziness appears to be feasible and may reduce symptoms in patients who have struggled with serious and long-lasting dizziness.