1
|
Wolf J, Limburg K, Sattel H, Lahmann C. Perceived illness consequences predict the long-term course of handicap in patients with vertigo and dizziness beyond vestibular abnormality. J Psychosom Res 2023; 172:111401. [PMID: 37315402 DOI: 10.1016/j.jpsychores.2023.111401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Vertigo and dizziness (VD) affect one third of the population during their lifetime. VD patients are oftentimes severely handicapped. One current study showed that illness perceptions, emotional as well as behavioral responses to illness were associated with VD-related handicap at 3-months follow-up. However, no study has yet investigated this association for a period longer than six months. This study aimed to investigate long-term associations of cognitive, emotional, and behavioral factors with VD-related handicap. METHODS In a naturalistic longitudinal study design, n = 161 patients with VD were examined at baseline, at 6-months follow-up, and at 12-months follow-up. Participants underwent neurological and psychiatric examinations as well as comprehensive psychological assessments using self-report questionnaires. RESULTS During the study period VD-related handicap decreased significantly (Cohen's d = .35, p < .001). Cognitive, emotional, and behavioral factors remained without significant change during the study period. Vestibular testing as well as the type of diagnosis were not associated with changes in VD-related handicap. Changes in perceived illness consequences (ß = .265, p < .001), depression (ß = .257, p < .001), and anxiety (ß = .206, p = .008) significantly predicted the course of VD-related handicap over 12 months, while the presence vs. absence of vestibular abnormality did not. CONCLUSION Our results extend findings that cognitive and emotional factors including perceived illness consequences, depression, and anxiety are associated with the long-term course of VD-related handicap and may provide therapeutic targets to improve long-term outcomes in patients with VD.
Collapse
Affiliation(s)
- Johannes Wolf
- Department of Psychiatry and Psychotherapy, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany.
| | - Karina Limburg
- Department of Conservative Orthopedics, Manual Medicine, and Pain Medicine, SANA Hospital, Munich, Germany
| | - Heribert Sattel
- Department of Psychosomatic Medicine and Psychotherapy, Hospital Rechts der Isar, Technical University Munich, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Freiburg, Albert-Ludwigs-University Freiburg, Germany
| |
Collapse
|
2
|
Kristiansen L, Magnussen LH, Wilhelmsen KT, Maeland S, Nordahl SHG, Hovland A, Clendaniel R, Boyle E, Juul-Kristensen B. Self-Reported Measures Have a Stronger Association With Dizziness-Related Handicap Compared With Physical Tests in Persons With Persistent Dizziness. Front Neurol 2022; 13:850986. [PMID: 35911903 PMCID: PMC9334819 DOI: 10.3389/fneur.2022.850986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAssociations between dizziness-related handicap and a variety of self-reported measures have been reported. However, research regarding associations between dizziness-related handicap and aspects of functioning that includes both physical tests and self-reported measures is scarce.ObjectiveThe purpose of the study was to describe the variations in signs and symptoms in people with persistent dizziness using physical tests and self-reported outcomes across three severity levels of the Dizziness Handicap Inventory (DHI) and investigate their associations with the DHI.MethodParticipants with persistent dizziness (n = 107) were included in this cross-sectional study. The participants underwent (1) physical tests (gait tests, grip strength, body flexibility, and movement-induced dizziness) and completed questionnaires regarding (2) psychological measures (Mobility Inventory of Agoraphobia, Body Sensation Questionnaire, Agoraphobic Cognitions Questionnaire, and Hospital Depression and Anxiety Questionnaire), and (3) fatigue, dizziness severity, and quality of life (Chalders Fatigue Scale, Vertigo Symptom Scale-Short Form, and EQ visual analog scale), in addition to the DHI. Data were presented by descriptive statistics for three DHI severity levels (mild, moderate, and severe). A multiple linear backward regression analysis was conducted for each group of measures in relation to the DHI total score, with additional analyses adjusting for age and sex. Based on these results, significant associations were tested in a final regression model.ResultsWith increasing severity levels of DHI, the participants demonstrated worse performance on most of the physical tests (preferred and fast gait velocity, dizziness intensity after head movements), presented with worse scores on the self-reported measures (avoidance behavior, fear of bodily sensation, fear of fear itself, psychological distress, fatigue, dizziness severity, quality of life). After adjusting for age and sex, significant associations were found between total DHI and avoidance behavior, psychological distress, dizziness severity, and quality of life, but not with any of the physical tests, explaining almost 56% of the variance of the DHI total score.ConclusionThere was a trend toward worse scores on physical tests and self-reported measurements with increasing DHI severity level. The DHI seems to be a valuable tool in relation to several self-reported outcomes; however, several signs and symptoms may not be detected by the DHI, and thus, a combination of outcomes should be utilized when examining patients with persistent dizziness.
Collapse
Affiliation(s)
- Lene Kristiansen
- Department of Health and Function, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngol and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- *Correspondence: Lene Kristiansen
| | - Liv H. Magnussen
- Department of Health and Function, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Kjersti T. Wilhelmsen
- Department of Health and Function, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Silje Maeland
- Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
- Research Unit for General Practice in Bergen, The Norwegian Research Center, Bergen, Norway
| | - Stein Helge G. Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngol and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Anders Hovland
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
- Solli District Psychiatric Centre, Bergen, Norway
| | - Richard Clendaniel
- Physical Therapy Division, Department of Orthopaedics and Department of Head and Neck Surgery and Communication Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Eleanor Boyle
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Birgit Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
3
|
Knapstad MK, Ask T, Skouen JS, Goplen FK, Nordahl SHG. Prevalence and consequences of concurrent dizziness on disability and quality of life in patients with long-lasting neck pain. Physiother Theory Pract 2022; 39:1266-1273. [DOI: 10.1080/09593985.2022.2034077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Mari K. Knapstad
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Tove Ask
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
- Department of Physical Therapy, Haukeland University Hospital, Bergen, Norway
| | - Jan S. Skouen
- Department of Physical Medicine and Rehabilitation, Outpatient Spine Clinic, Haukeland University Hospital, Rådal, Norway
| | - Frederik K. Goplen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Stein Helge G. Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
4
|
Gustavsen IØ, Wilhelmsen K, Goode AP, Nordahl SHG, Goplen FK, Nilsen RM, Magnussen LH. Dizziness and physical health are associated with pain in dizzy patients-A cross-sectional study. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2021; 26:e1923. [PMID: 34585499 DOI: 10.1002/pri.1923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/14/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND PURPOSE Associations between dizziness, health-related quality of life, and musculoskeletal pain have not been systematically explored in patients with vestibular disorders. Such knowledge may be important for choice of treatments. The study objectives were to examine the extent and localization of musculoskeletal pain and explore whether pain was associated with dizziness and health-related quality of life. METHODS The cross-sectional study investigated anonymized data from an earlier survey on patients with long-lasting dizziness (>3 months) examined in an oto-rhino-laryngological department. The sample includes patient between 18 and 70 years with Ménière's disease, vestibular schwannoma, benign positional paroxysmal vertigo, vestibular neuritis, non-otogenic dizziness, and cervicogenic dizziness. General musculoskeletal, that is, pain in muscles, tendons, and joints was registered by a yes/no question. A pain drawing registered localization of pain. Multiple binary logistic regression models were used to determine the association between pain and vertigo-balance and autonomic-anxiety related dizziness by the short Vertigo Symptom Scale (VSS) and sub-scales (VSS-V, VSS-A), and between pain and health-related quality of life by the SF-36, mental and physical component summary scale (SF-36 MCS, SF-36 PCS). RESULTS The sample consisted of 503 patients, 60.2% were women, the median age was 50 years. General musculoskeletal pain was reported by 72.8% of patients, neck pain by 59.2% and widespread pain by 21.9%. Multiple binary logistic regression models demonstrated that all the pain measures were significantly associated with VSS-V and VSS-A and SF-36 PCS, but not SF-36 MCS. DISCUSSIONS Musculoskeletal pain is prevalent in patients with long-lasting dizziness. The strong associations between pain, VSS, and SF-36 PCS could result in a self-sustaining complex condition. The findings imply that in addition to assessing and treating the vestibular symptoms, musculoskeletal symptoms and physical health should be addressed.
Collapse
Affiliation(s)
- Ingvild Ølfarnes Gustavsen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Kjersti Wilhelmsen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Adam P Goode
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stein Helge Glad Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frederik Kragerud Goplen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Roy Miodini Nilsen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Liv Heide Magnussen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| |
Collapse
|
5
|
Knapstad MK, Nordahl SHG, Skouen JS, Ask T, Goplen FK. Neck pain associated with clinical symptoms in dizzy patients-A cross-sectional study. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2019; 25:e1815. [PMID: 31814286 DOI: 10.1002/pri.1815] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/08/2019] [Accepted: 10/03/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Many patients suffer from concurrent neck pain and dizziness. The aim of this study was to describe the clinical symptoms and physical findings in patients with concurrent neck pain and dizziness and to examine whether they differ from patients with dizziness alone. METHODS Consecutive patients with dizziness and neck pain were recruited from an ear-nose-throat department and a spine clinic. They were divided into three groups: patients with dizziness only (n = 100), patients with dizziness as their primary complaint and additional neck pain (n = 138) and finally, patients with neck pain as their primary complaint accompanied by additional dizziness (n = 55). The patients filled in questionnaires regarding their symptom quality, time-course, triggers of dizziness and the Vertigo Symptom Scale Short Form. The physical examination included Cervical Range of Motion, American College of Rheumatology (ACR) Tender Points, Cervical Pressure Pain Thresholds and Global Physiotherapy Examination 52-Flexibility. RESULTS Both neck pain groups were more likely to have a gradual onset of dizziness symptoms, more light-headedness, visual disturbances, autonomic/anxiety symptoms, decreased cervical range of motion, decreased neck and shoulder flexibility and increased number of ACR tender points compared with patients with dizziness alone. The group having dizziness as their primary complaint and also reporting neck pain had the highest symptom severity and tended to report rocking vertigo and increased neck tenderness. The group with neck pain as their primary complaint was more likely to report headache. CONCLUSION Neck pain is associated with certain dizziness characteristics, increased severity of dizziness and increased physical impairment when compared with dizzy patients without neck pain.
Collapse
Affiliation(s)
- Mari Kalland Knapstad
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Stein Helge Glad Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, The Outpatient Spine Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tove Ask
- Department of Physical Therapy, The Outpatient Spine Clinic, Haukeland University Hospital, Bergen, Norway
| | - Frederik Kragerud Goplen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
6
|
Gerretsen P, Shah P, Logotheti A, Attia M, Balakumar T, Sulway S, Ranalli P, Dillon WA, Pothier DD, Rutka JA. Interdisciplinary integration of nursing and psychiatry (INaP) improves dizziness‐related disability. Laryngoscope 2019; 130:1800-1804. [DOI: 10.1002/lary.28352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/14/2019] [Accepted: 09/19/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Philip Gerretsen
- Multimodal Imaging GroupResearch Imaging Centre, Campbell Mental Health Research Institute, Centre for Addiction & Mental Health Toronto Canada
- Institute of Medical ScienceUniversity of Toronto Toronto Canada
- Department of PsychiatryUniversity of Toronto Toronto Canada
- Centre for Mental HealthUniversity Health Network Toronto Canada
| | - Parita Shah
- Multimodal Imaging GroupResearch Imaging Centre, Campbell Mental Health Research Institute, Centre for Addiction & Mental Health Toronto Canada
- Institute of Medical ScienceUniversity of Toronto Toronto Canada
| | - Anastasia Logotheti
- Multimodal Imaging GroupResearch Imaging Centre, Campbell Mental Health Research Institute, Centre for Addiction & Mental Health Toronto Canada
| | - Mohamed Attia
- Department of PsychiatryUniversity of Toronto Toronto Canada
| | - Thushanthi Balakumar
- Multimodal Imaging GroupResearch Imaging Centre, Campbell Mental Health Research Institute, Centre for Addiction & Mental Health Toronto Canada
| | - Shaleen Sulway
- Department of Otolaryngology–Head and Neck SurgeryToronto General Hospital, University of Toronto Toronto Canada
| | - Paul Ranalli
- Department of Otolaryngology–Head and Neck SurgeryToronto General Hospital, University of Toronto Toronto Canada
| | - Wanda A. Dillon
- Department of Otolaryngology–Head and Neck SurgeryToronto General Hospital, University of Toronto Toronto Canada
| | - David D. Pothier
- Department of Otolaryngology–Head and Neck SurgeryToronto General Hospital, University of Toronto Toronto Canada
| | - John A. Rutka
- Department of Otolaryngology–Head and Neck SurgeryToronto General Hospital, University of Toronto Toronto Canada
| |
Collapse
|
7
|
Knapstad MK, Goplen FK, Ask T, Skouen JS, Nordahl SHG. Associations between pressure pain threshold in the neck and postural control in patients with dizziness or neck pain - a cross-sectional study. BMC Musculoskelet Disord 2019; 20:528. [PMID: 31707980 PMCID: PMC6844061 DOI: 10.1186/s12891-019-2922-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND It is theorized that neck pain may cause reduced postural control due to the known physiological connection between the receptors in the cervical spine and the vestibular system. The purpose of this study was to examine whether the pressure pain threshold in the neck is associated with postural sway in patients with dizziness or neck pain. METHODS Consecutive patients with dizziness (n = 243) and neck pain (n = 129) were recruited from an otorhinolaryngological department and an outpatient spine clinic, respectively. All subjects underwent static posturography. Pressure pain thresholds were measured at four standardized points in the neck, and generalized pain was assessed using the American College of Rheumatology tender points. The relationship between postural sway and pressure pain threshold was analyzed by linear regression, and the covariates included age, sex, and generalized pain. RESULTS In the dizzy group, there was a small, inverse relationship between pressure pain thresholds and sway area with eyes closed, after adjusting for age, sex, and generalized pain (bare platform; lower neck, p = 0.002, R2 = 0.068; upper neck, p = 0.038, R2 = 0.047; foam rubber mat; lower neck, p = 0.014, R2 = 0.085). The same inverse relationship was found between pressure pain thresholds in the neck and the Romberg ratio on a bare platform after adjusting for age, sex and generalized pain (upper neck, p = 0.15, R2 = 0.053; lower neck, p = 0.002, R2 = 0.069). Neither of these relationships were present in the neck pain group. CONCLUSION Our findings indicate that the pressure pain threshold in the neck is associated with postural sway in patients suffering from dizziness after adjusting for age, sex, and generalized pain, but only with closed eyes. The association was small and should be interpreted with caution. TRIAL REGISTRATION Trial registration: Clinicaltrial.gov NCT03531619. Retrospectively registered 22 May 2018.
Collapse
Affiliation(s)
- Mari K Knapstad
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Frederik K Goplen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tove Ask
- Department of Physical Therapy, Haukeland University Hospital, Bergen, Norway
| | - Jan S Skouen
- Department of Physical Medicine and Rehabilitation, The Outpatient Spine Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Stein Helge G Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
8
|
van Vugt VA, van der Wouden JC, Essery R, Yardley L, Twisk JWR, van der Horst HE, Maarsingh OR. Internet based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice: three armed randomised controlled trial. BMJ 2019; 367:l5922. [PMID: 31690561 PMCID: PMC6829201 DOI: 10.1136/bmj.l5922] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice. DESIGN Pragmatic, three armed, parallel group, individually randomised controlled trial. SETTING 59 general practices in the Netherlands. PARTICIPANTS 322 adults aged 50 and older with a chronic vestibular syndrome. INTERVENTIONS Stand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions. MAIN OUTCOME MEASURES The primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events. RESULTS In the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference -4.1 points, 95% confidence interval -5.8 to -2.5; and -3.5 points, -5.1 to -1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial. CONCLUSION Stand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice. TRIAL REGISTRATION Netherlands Trial Register NTR5712.
Collapse
Affiliation(s)
- Vincent A van Vugt
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
| | - Rosie Essery
- Department of Psychology, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Henriëtte E van der Horst
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
| | - Otto R Maarsingh
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
| |
Collapse
|
9
|
Kristiansen L, Magnussen LH, Wilhelmsen KT, Mæland S, Nordahl SHG, Clendaniel R, Hovland A, Juul-Kristensen B. Efficacy of intergrating vestibular rehabilitation and cognitive behaviour therapy in persons with persistent dizziness in primary care- a study protocol for a randomised controlled trial. Trials 2019; 20:575. [PMID: 31590692 PMCID: PMC6781377 DOI: 10.1186/s13063-019-3660-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/14/2019] [Indexed: 01/13/2023] Open
Abstract
Background Dizziness is a common complaint, and the symptom often persists, together with additional complaints. A treatment combining Vestibular Rehabilitation (VR) and Cognitive Behaviour Therapy (CBT) is suggested. However, further research is necessary to evaluate the efficacy of such an intervention. The objective of this paper is to present the design of a randomised controlled trial aiming at evaluating the efficacy of an integrated treatment of VR and CBT on dizziness, physical function, psychological complaints and quality of life in persons with persistent dizziness. Methods/design The randomised controlled trial is an assessor-blinded, block-randomised, parallel-group design, with a 6- and 12-month follow-up. The study includes 125 participants from Bergen (Norway) and surrounding areas. Included participants present with persistent dizziness lasting for at least 3 months, triggered or exacerbated by movement. All participants receive a one-session treatment (Brief Intervention Vestibular Rehabilitation; BI-VR) with VR before being randomised into a control group or an intervention group. The intervention group will further be offered an eight-session treatment integrating VR and CBT. The primary outcomes in the study are the Dizziness Handicap Inventory and preferred gait velocity. Discussion Previous studies combining these treatments have been of varying methodological quality, with small samples, and long-term effects have not been maintained. In addition, only the CBT has been administered in supervised sessions, with VR offered as home exercises. The current study focusses on the integrated treatment, a sufficiently powered sample size, and a standardised treatment programme evaluated by validated outcomes using a standardised assessment protocol. Trial registration www.clinicaltrials.gov, ID: NCT02655575. Registered on 14 January 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3660-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lene Kristiansen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.
| | - L H Magnussen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - K T Wilhelmsen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - S Mæland
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - S H G Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - R Clendaniel
- Doctor of Physical Therapy Division, Department of Orthopedics, Duke University School of Medicine, Durham, NC, USA
| | - A Hovland
- Department of Clinical Psychology, University of Bergen, Bergen, Norway.,Solli District Psychiatric Centre (DPS), Nesttun, Norway
| | - B Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
10
|
Kristiansen L, Magnussen LH, Juul-Kristensen B, Mæland S, Nordahl SHG, Hovland A, Sjøbø T, Wilhelmsen KT. Feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy for people with persistent dizziness. Pilot Feasibility Stud 2019; 5:69. [PMID: 31139431 PMCID: PMC6528375 DOI: 10.1186/s40814-019-0452-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 05/06/2019] [Indexed: 01/16/2023] Open
Abstract
Purpose To evaluate the feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy (VR-CBT) for people with persistent dizziness in primary care. Design Prospective single-group pre- and post-test study. Participants Adults (aged 18–70) with acute onset of dizziness and symptoms lasting a minimum 3 months, recruited from Bergen municipality. Methods Participants attended eight weekly group sessions of VR-CBT intervention. Feasibility outcomes consisted of recruitment and testing procedures, intervention adherence, and participant feedback, besides change in primary outcomes. The primary outcomes were Dizziness Handicap Inventory (DHI) and preferred gait velocity. Results Seven participants were recruited for the study. All participants completed the pre-treatment tests, five participants completed the intervention and answered post-treatment questionnaires, and three completed post-treatment testing. Of the five participants, three attended at least 75% of the VR-CBT sessions, and two 50% of the sessions. Participants reported that the VR-CBT was relevant and led to improvement in function. DHI scores improved beyond minimal important change in two out of five participants, and preferred gait velocity increased beyond minimal important change in two out of three participants. Conclusion The current tests and VR-CBT treatment protocols were feasible. Some changes are suggested to optimise the protocols, before conducting a randomised controlled trial. Trial registration NCT02655575. Registered 14 January 2016—retrospectively registered
Collapse
Affiliation(s)
- Lene Kristiansen
- 1Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, P.O. box 7030, 5020 Bergen, Norway
| | - L H Magnussen
- 1Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, P.O. box 7030, 5020 Bergen, Norway
| | - B Juul-Kristensen
- 2Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - S Mæland
- 1Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, P.O. box 7030, 5020 Bergen, Norway
| | - S H G Nordahl
- 3Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngol and Head Neck Surgery, Haukeland University Hospital, Bergen, Norway.,4Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - A Hovland
- Solli District Psychiatric Centre (DPS), Nesttun, Norway.,6Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - T Sjøbø
- Solli District Psychiatric Centre (DPS), Nesttun, Norway
| | - K T Wilhelmsen
- 1Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, P.O. box 7030, 5020 Bergen, Norway
| |
Collapse
|
11
|
Kalland Knapstad M, Goplen F, Skouen JS, Ask T, Nordahl SHG. Symptom severity and quality of life in patients with concurrent neck pain and dizziness. Disabil Rehabil 2019; 42:2743-2746. [PMID: 30739502 DOI: 10.1080/09638288.2019.1571640] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: There is little knowledge on how neck pain impacts dizzy patients, and if different diagnoses of dizziness associate with neck pain. The aim was to examine differences in dizziness severity, quality of life and demographics in dizzy patients with and without neck pain. Additionally, we examined if neck pain was associated with a non-vestibular or vestibular diagnosis.Methods: We included 236 consecutive patients referred to an otorhinolaryngological university clinic for vertigo and balance problems. The patients were divided in two groups: Patients with and without neck pain. Patient-reported outcomes measures were the Dizziness Handicap Inventory, RAND-12, neck pain and symptom duration.Results: A total of 59% of the patients reported neck pain. Patients with neck pain reported poorer quality of life (p < .001) and worse handicap due to dizziness (p < .001). There were no associations between reported neck pain and dizziness of non-vestibular or vestibular origin (p = .29).Conclusion: Neck pain is a common complaint among dizzy patients. Patients with concurrent dizziness and neck pain should warrant attention due to poorer general and dizziness-related quality of life. This finding appears unrelated to whether or not they receive a peripheral vestibular diagnosis.IMPLICATION FOR REHABILITATIONNeck pain is common in patients with dizziness and associated with higher dizziness handicap and lower quality of life.Neck pain should be addressed specifically in patients assessed for dizziness, irrespective of diagnosis.Further research is needed to better understand the interactions between neck pain and dizziness.
Collapse
Affiliation(s)
- Mari Kalland Knapstad
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frederik Goplen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jan Sture Skouen
- Department of Physical Medicine and Rehabilitation, The Outpatient Spine Clinic, Haukeland University Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tove Ask
- Department of Physical Therapy, Haukeland University Hospital, Bergen, Norway
| | - Stein Helge Glad Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
12
|
Knapstad MK, Nordahl SHG, Naterstad IF, Ask T, Skouen JS, Goplen FK. Measuring pressure pain threshold in the cervical region of dizzy patients-The reliability of a pressure algometer. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2018; 23:e1736. [PMID: 30088327 PMCID: PMC6221019 DOI: 10.1002/pri.1736] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 05/07/2018] [Accepted: 07/11/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES A tool for measuring neck pain in patients with dizziness is needed to further investigate the relationship between the two symptoms. The objective of this study was to examine the reliability and validity of a hand-held pressure algometer in measuring pressure pain threshold (PPT) in different cervical regions of dizzy patients. METHODS PPT was measured at two bilateral standardized sites of the neck by a trained physiotherapist in 50 patients with dizziness. Intraclass correlation coefficients (ICC) were calculated for intrarater and test-retest reliability. Concurrent validity was assessed by measuring the association between PPT and the American College of Rheumatology (ACR) tender points at each site and with the numeric pain rating scale (NPRS). RESULTS Almost perfect intrarater (ICC = 0.815-0.940) and within-session test-retest (ICC = 0.854-0.906) reliability was found between the measures. On each site, a low PPT predicted a positive ACR tender point at each site (OR = 0.864-0.922). Last, we found a statistical inverse relationship between the PPT and the NPRS (R = -0.52 to -0.66). CONCLUSION The study shows that a pressure algometer is a reliable tool for measuring PPT in the neck of dizzy patients. Further, the PPT correlates significantly with other subjective measures of pain indicating that it may be a useful tool for further research.
Collapse
Affiliation(s)
- Mari Kalland Knapstad
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Stein Helge Glad Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Tove Ask
- The Outpatient Spine Clinic, Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway
| | - Jan Sture Skouen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,The Outpatient Spine Clinic, Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
| | - Frederik Kragerud Goplen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology/Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
13
|
Dayal M, Perez-Andujar A, Chuang C, Parsa AT, Barani IJ. Management of vestibular schwannoma: focus on vertigo. CNS Oncol 2015; 2:99-104. [PMID: 25054360 DOI: 10.2217/cns.12.30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
This article reviews published literature on vertigo and a 'sense of imbalance' affecting patients who are treated with radiosurgery (RS) for vestibular schwannoma. This is a relatively understudied complaint, along with tinnitus, in this patient population, despite its significant impact on quality of life. It is also a symptom that is most inconsistently impacted by either RS or surgery. This article aims to highlight the importance of this symptom in patients managed for vestibular schwannoma primarily with RS to encourage a more systematic study of vertigo as an outcome measure and to help elucidate its potential etiology.
Collapse
Affiliation(s)
- Manisha Dayal
- Department of Radiation Oncology, University of California at San Francisco, 505 Parnassus Avenue, Room L-08 (Box 0226), San Francisco, CA 94143-0226, USA
| | | | | | | | | |
Collapse
|
14
|
Examination and treatment of patients with unilateral vestibular damage, with focus on the musculoskeletal system: a case series. Phys Ther 2014; 94:1024-33. [PMID: 24557651 DOI: 10.2522/ptj.20130070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND AND PURPOSE Persistent dizziness and balance problems have been reported in some patients with unilateral vestibular pathology. The purpose of this case series was to address the examination and treatment of musculoskeletal dysfunction in patients with unilateral vestibular hypofunction. CASE DESCRIPTION The musculoskeletal system was evaluated with the Global Physiotherapy Examination, dynamic balance was measured during walking with triaxial accelerometers positioned on the lower and upper trunk, and symptoms and functional limitations were assessed with standardized self-report measures. The 4 included patients had symptoms of severe dizziness that had lasted more than 1 year after the onset of vestibular dysfunction and a moderate level of perceived disability. Musculoskeletal abnormalities typically included postural misalignment, restricted abdominal respiration, restricted trunk movements, and tense muscles of the upper trunk and neck. The patients attended a modified vestibular rehabilitation program consisting of body awareness exercises addressing posture, movements, and respiration. OUTCOMES After the intervention, self-reported symptoms and perceived disability improved. Improvements in mobility and positive physical changes were found in the upper trunk and respiratory movements. The attenuation of mediolateral accelerations (ie, body oscillations) in the upper trunk changed; a relatively more stable upper trunk and a concomitantly more flexible lower trunk were identified during walking in 3 patients. DISCUSSION The recovery process may be influenced by self-inflicted rigid body movements and behavior strategies that prevent compensation. Addressing physical dysfunction and enhancing body awareness directly and dizziness indirectly may help patients with unilateral vestibular hypofunction break a self-sustaining cycle of dizziness and musculoskeletal problems. Considering the body as a functional unit and including both musculoskeletal and vestibular systems in examination and treatment may be important.
Collapse
|
15
|
Trinidade A, Yung M. Consultant-led, multidisciplinary balance clinic: process evaluation of a specialist model of care in a district general hospital. Clin Otolaryngol 2014; 39:95-101. [DOI: 10.1111/coa.12236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2014] [Indexed: 11/28/2022]
Affiliation(s)
| | - M.W. Yung
- Ipswich General Hospital; Heath Rd; Ipswich UK
| |
Collapse
|
16
|
Tamber AL, Bruusgaard KA, Bruusgaard D. Different outcome measures and domains of functioning: 18 months follow-up of persons with dizziness. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2014. [DOI: 10.3109/21679169.2014.886721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
17
|
Neurotology symptoms at referral to vestibular evaluation. J Otolaryngol Head Neck Surg 2013; 42:55. [PMID: 24279682 PMCID: PMC4176296 DOI: 10.1186/1916-0216-42-55] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 11/23/2013] [Indexed: 12/30/2022] Open
Abstract
Background Dizziness-vertigo is common in adults, but clinical providers may rarely diagnose vestibular impairment and referral could be delayed. To assess neurotology symptoms (including triggers) reported by patients with peripheral vestibular disease, during the year just before their referral to vestibular evaluation. Methods 282 patients with peripheral vestibular disease and 282 control subjects accepted to participate. They had no middle ear, retinal, neurological, psychiatric, autoimmune or autonomic disorders. They reported their symptoms by a standardized questionnaire along with their anxiety/depression symptoms. Results Patients were referred after months or years from the onset of their symptoms, 24% of them reported frequent falls with a long clinical evolution; 10% of them reported no vertigo but instability related to specific triggers; 86% patients and 12% control subjects reported instability when moving the head rapidly and 79% patients and 6% control subjects reported instability when changing posture. Seven out of the 9 symptoms explored by the questionnaire allowed the correct classification of circa 95% of the participants (Discriminant function analysis, p < 0.001). High blood pressure, dyslipidemia and anxiety/depression symptoms showed a mild correlation with the total score of symptoms (multiple R2 =0.18, p < 0.001). Conclusions Late referral to vestibular evaluation may underlie a history of frequent falls; some patients may not report vertigo, but instability related to specific triggers, which could be useful to prompt vestibular evaluation. High blood pressure, dyslipidemia and anxiety/depression symptoms may have a mild influence on the report of symptoms of vestibular disease in both, patients and control subjects.
Collapse
|
18
|
Abstract
OBJECTIVE The study examines categorical responses to questions on a comprehensive dizziness questionnaire, to find the overall predictive power of the questionnaire, and to identify which question(s) are most predictive of each diagnosis. STUDY DESIGN Retrospective chart review. SETTING Specialized dizziness and balance center at a tertiary care hospital. PATIENTS A total of 619 patients (aged 19-89 yr, of whom 60% are women and 40% are men) diagnosed with 1 of 23 types of dizziness or postural instability. INTERVENTION All patients were administered a standard 163-item dizziness questionnaire (including 77 review of systems items). OUTCOME MEASURES Predicted diagnoses from the questionnaire, as determined by binary and multinomial logistic regressions, are compared with an ultimate clinical diagnosis made by an expert neurotologist based on full interview, examination, and clinical tests. RESULTS Significant question groupings exist for each of the main diagnoses. A subset of 47 questions under multinomial logistic regression gave high predictive accuracies for migraine (92%), benign paroxysmal positional vertigo (90%) and Ménière's disease (86%), and fair predictive power for vestibular neuritis (63%), contributing to an overall predictive accuracy of 84%. A smaller subset of 32 questions gave an overall predictive accuracy of 71%. CONCLUSION The capability of historical data to accurately predict the ultimate diagnosis for dizziness emphasizes the importance of a structured questionnaire in the evaluation of such patients. Future developments include the formulation of a computer-based program to generate a differential diagnosis for the practitioner to consider.
Collapse
|
19
|
Abstract
AIM AND OBJECTIVES To provide an overview of vertigo and its management and identify its impact on individuals to offer strategies for managing the condition. BACKGROUND Dizziness and vertigo are symptoms common to many pathologies/dysfunctions ranging from the benign to the potentially serious; many are poorly understood. Although rarely life-threatening, vertigo is debilitating and significantly affects quality of life; it may be as disabling as paralysis or loss of a limb. Although 40-80% of cases remain unexplained, referral for specific investigation is rare. DESIGN A narrative literature review including descriptive, theoretical and empirical material reliant on the keywords 'dizziness' and 'vertigo' and the phrase 'vestibular disorders'. This provided diverse information that was used to address the research questions. RESULTS Vertigo is a widespread and potentially distressing symptom that may arise at any age and be acute or chronic. For most, it resolves spontaneously; for others, dizziness persists, causing significant distress. Its management is challenging, especially when the underlying cause is unclear. Pharmacological interventions, physiotherapy, psychotherapy or, rarely, surgery can be used in its management. Few nursing studies are available, suggesting that nursing knowledge may be limited. RELEVANCE TO CLINICAL PRACTICE Although nurses may frequently encounter patients with vertigo, there are few relevant nursing studies in this area; few consider appropriate nursing interventions or approaches to patient care. The information provided reveals that understanding the full impact of the condition and identification of patients' needs are essential to effective care. Some strategies to help affected patients are outlined. CONCLUSIONS Vertigo, a widespread, often intractable condition, affects significant numbers of people; diagnosis and management can be challenging. Treatment, care and support must be selected on an individual basis taking individuals into account. The primary goals are to maintain physical status, psychosocial interaction and quality of life.
Collapse
Affiliation(s)
- Susan Holmes
- Faculty of Health and Social Care, Canterbury Christ Church University, Canterbury, Kent CT1 1QU, UK.
| | | |
Collapse
|