Feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy for people with persistent dizziness

Predictors of Chronic Dizziness in Acute Unilateral Vestibulopathy: A Longitudinal Prospective Cohort Study

OBJECTIVE

Chronic dizziness after acute unilateral vestibulopathy (AUVP) causes significant social and economic burdens. This study aims to identify predictors of chronic dizziness.

STUDY DESIGN

Prospective, longitudinal cohort study.

SETTING

ENT departments from secondary and tertiary hospitals.

METHODS

Participants meeting the Barany Society's diagnostic criteria for AUVP were included. Evaluations occurred within 0 to 21 days (T1), and at 4 (T2) and 10 weeks (T3) postonset. The primary outcome measure was the Dizziness Handicap Inventory (DHI) at 6 months, with a score >30 indicating chronic dizziness. Five clusters of predictors were assessed at T1-3: central vestibular compensation, visual dependence, movement exposure, psychological factors, and balance performance. Separate linear regression models for T1, T2, and T3 were constructed to explain the variability in the 6-month DHI score. Receiver operating characteristics analyses were conducted to predict chronic dizziness.

RESULTS

From June 2021 to January 2024, 103 participants (55.2 ± 16.6 years old, 49 women) were included. The regression models explained the variability in the 6-month DHI score by 33.0% at T1, 47.6% at T2, and 64.0% at T3 (P < .001), including psychological factors (T1, T2, T3), visual dependence (T2, T3), and static balance performance (T3). Cutoff values for the Vestibular Activities Avoidance Instrument (23/54), Visual Vertigo Analog Scale (33.5/100), and Hospital Anxiety and Depression Scale-Anxiety (7.5/21) at 10 weeks postonset predicted chronic dizziness.

CONCLUSION

Higher psychological burden, increased visual dependence, and poorer static balance performance were associated with chronic dizziness. Cutoff values were determined to identify individuals with AUVP at risk for chronic dizziness.

[Application of computerized cognitive behavioral therapy in patients with persistent postural-perceptual dizziness]

Objective:A computerized cognitive behavioral therapy intervention program was constructed for patients with persistent postural-perception dizziness（PPPD） and its effects on dizziness symptoms, negative emotions and balance function were investigated. Methods:A randomized controlled trial design was used to select 86 patients with PPPD who were seen in the Department of Otorhinolaryngology Head and Neck Surgery, First Hospital of Shanxi Medical University from July 2020 to July 2021. Randomly assigned to the control group（43 patients） and the experimental group（43 patients）. The control group was routinely treated with medication and vestibular rehabilitation, while the experimental group underwent computerized cognitive behavioral therapy for a total of 9 sessions over 8 weeks; their dizziness symptoms（DHI）, negative affect（GAD-7, PHQ-9） and balance function（BBS） were compared at baseline, 4 and 8 weeks later. Results:After 4 and 8 weeks of intervention, the improvement of dizziness symptoms and negative mood in both groups had a between-group effect, time effect, and interaction effect（P<0.05）. The improvement of balance function had only a time effect and interaction effect（P<0.05）, and no difference in between-group effect was seen（P>0.05）. Conclusion:Computerized cognitive behavioral therapy can be used as an adjunctive treatment to alleviate patients' dizziness, negative affect, and balance function, but no additional benefit has been seen in terms of balance function improvement.

Improving self-motion perception and balance through roll tilt perceptual training

The present study aimed to determine if a vestibular perceptual learning intervention could improve roll tilt self-motion perception and balance performance. Two intervention groups (n = 10 each) performed 1,300 trials of roll tilt at either 0.5 Hz (2 s/motion) or 0.2 Hz (5 s/motion) distributed over 5 days; each intervention group was provided feedback (correct/incorrect) after each trial. Roll tilt perceptual thresholds, measured using 0.2-, 0.5-, and 1-Hz stimuli, as well as quiet stance postural sway, were measured on day 1 and day 6 of the study. The control group (n = 10) who performed no perceptual training, showed stable 0.2-Hz (+1.48%, P > 0.99), 0.5-Hz (-4.0%, P > 0.99), and 1-Hz (-17.48%, P = 0.20) roll tilt thresholds. The 0.2-Hz training group demonstrated significant improvements in both 0.2-Hz (-23.77%, P = 0.003) and 0.5-Hz (-22.2%, P = 0.03) thresholds. The 0.5-Hz training group showed a significant improvement in 0.2-Hz thresholds (-19.13%, P = 0.029), but not 0.5-Hz thresholds (-17.68%, P = 0.052). Neither training group improved significantly at the untrained 1-Hz frequency (P > 0.05). In addition to improvements in perceptual precision, the 0.5-Hz training group showed a decrease in sway when measured during "eyes open, on foam" (dz = 0.57, P = 0.032) and "eyes closed, on foam" (dz = 2.05, P < 0.001) quiet stance balance tasks. These initial data suggest that roll tilt perception can be improved with less than 5 h of training and that vestibular perceptual training may contribute to a reduction in subclinical postural instability.NEW & NOTEWORTHY Roll tilt vestibular perceptual thresholds, an assay of vestibular noise, were recently found to correlate with postural sway. We therefore hypothesized that roll tilt perceptual training would yield improvements in both perceptual precision and balance. Our data show that roll tilt perceptual thresholds and quiet stance postural sway can be significantly improved after less than 5 h of roll tilt perceptual training, supporting the hypothesis that vestibular noise contributes to increased postural sway.

The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness

BACKGROUND

Persistent postural perceptual dizziness (PPPD) is a common and disabling functional neuro-vestibular disorder. We aimed to determine the feasibility and acceptability of conducting a randomised controlled trial of cognitive-behavioural therapy informed vestibular rehabilitation (INVEST intervention) designed for persistent dizziness.

METHODS

A two-armed parallel groups randomised feasibility study of INVEST vs. a time-matched gold standard vestibular rehabilitation (VRT) control. Participants with PPPD were recruited from a specialist vestibular clinic in London, UK. Participants were individually randomised using a minimisation procedure with allocation concealment. Measures of feasibility and clinical outcome were collected and assessed at 4 months.

RESULTS

Forty adults with PPPD were randomised to six sessions of INVEST (n = 20) or gold standard VRT (n = 20). Overall, 59% of patients screened met the inclusion criteria, of which 80% enrolled. Acceptability of INVEST, as assessed against the theoretical framework of acceptability (TFA), was excellent and 80% adhered to all 6 sessions. There were small to moderate treatment effects in favour of INVEST across all measures, including dizziness handicap, negative illness perceptions, symptom focussing, fear avoidance, and distress (standardised mean difference [SMD]g = 0.45; SMDg = 0.77; SMDg = 0.56; SMDg = 0.50, respectively). No intervention-related serious adverse events were reported.

CONCLUSIONS

The study results give strong support for the feasibility of a full-scale trial. Both arms had high rates of recruitment, retention, and acceptability. There was promising support of the benefits of integrated cognitive-behavioural therapy-based vestibular rehabilitation compared to gold standard vestibular rehabilitation. The study fulfilled all the a-priori criteria to advance to a full-scale efficacy trial.

TRIAL REGISTRATION NUMBER

ISRCTN10420559.

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.

[Vestibular rehabilitation in patients with vestibular peripheral vertigo]

Objective:To evaluate the efficacy of vestibular rehabilitation in patients with anterior peripheral vertigo and analyze its influencing factors. Methods:From January 2018 to June 2021, 153 cases with peripheral vertigo diseases（including 47 cases of benign positional paroxysmal vertigo, 38 cases of Meniere's disease, 26 cases of sudden deafness with vertigo, 23 cases of vestibular migraine and 19 cases of vestibular neuritis） were enrolled. One hundred and three cases were treated with vestibular rehabilitation combined with drugs, and 50 cases only treated with drugs were used as controls. Self-rating scale and vertigo disorder scale were evaluated at the beginning of treatment, 4 weeks and 8 weeks, respectively. The curative effects of the two groups were tested by t-test, and the independent risk factors affecting the curative effects were analyzed by multiple linear regression. Results:There was no difference in clinical data, self-assessment scale and vertigo disorder scale between the two groups（P>0.05）. At 4 and 8 weeks, the scores of self-assessment scale and vertigo disorder scale in the experimental group were better than those in the control group（all P<0.01）, and the curative effect at 8 weeks was better than that at 4 weeks, especially the decrease of emotional score during walking and the proportion of severe vertigo disability（all P<0.01）. The scores of self-rating scale and vertigo disorder scale of the cases with benign positional paroxysmal vertigo and vestibular neuritis were better than Meniere's disease, vestibular migraine and sudden deafness with vertigo（P<0.05）. Headache（P<0.05） and severe vertigo disorder before intervention（P<0.01） were independent risk factors affecting the efficacy of vestibular rehabilitation. Conclusion:Vestibular rehabilitation combined with anti-vertigo drugs in the treatment of vestibular peripheral vertigo is better than that of only using drugs, especially in improving the degree of emotional disorder and vertigo disability. It is more suitable for benign positional paroxysmal vertigo and vestibular neuritis, while the effect of combined headache or severe vertigo is relatively poor.

Dizziness and physical health are associated with pain in dizzy patients-A cross-sectional study

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.

Protocol for a randomised controlled feasibility study of psychologically informed vestibular rehabilitation for people with persistent dizziness: INVEST trial

Background

Dizziness is a common complaint that often persists and leads to disability and distress. Several cognitive and behavioural responses may contribute to the neurobiological adaptations that maintain persistent vestibular symptoms. This paper will present the protocol of a two-arm parallel group feasibility randomised controlled trial designed to determine whether a fully powered efficacy trial is achievable by examining the feasibility of recruitment, acceptability and potential benefits of an integrated cognitive behavioural therapy and vestibular rehabilitation (CBT-VR) treatment for people with persistent dizziness.

Methods

Forty adult patients will be recruited from a tertiary vestibular clinic with persistent movement–triggered dizziness for 3 months or longer who have moderate–high levels of dizziness handicap. Participants will be 1:1 randomised, using a minimisation procedure, to six sessions of either CBT-VR (intervention arm) or VR only (control arm). Measures will be collected at baseline and 4 months post randomisation. The primary feasibility outcomes include descriptive data on numbers meeting eligibility criteria, rates of recruitment, numbers retained post randomisation, treatment adherence and an acceptability questionnaire. Treatment effects on self-report outcomes will be estimated to determine that 95% confidence intervals for the effects are consistent with anticipated effects and minimum clinically important differences, and to provide information needed for the power calculation of an efficacy trial. A nested qualitative study will be conducted post-intervention (intervention group only) to explore the acceptability of the intervention and identify any areas in need of improvement.

Discussion

If a trial of CBT-VR is feasible, acceptability data will be used to enhance the intervention if needed and refine the multicentre RCT protocol. Future studies will need to consider the training required for other physiotherapists to deliver the intervention.

Trial registration

ClinicalTrials.gov, ISRCTN 10420559

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00896-y.

A Randomized Controlled Trial Evaluating Integrative Psychotherapeutic Group Treatment Compared to Self-Help Groups in Functional Vertigo/Dizziness

We tested the efficacy of an integrative psychotherapeutic group treatment (IPGT) in reducing vertigo/dizziness-related impairment along with depression, anxiety, and somatization by conducting a randomized controlled superiority trial comparing IPGT to self-help groups moderated by a clinical psychologist (SHG). Adult patients with functional vertigo and dizziness symptoms were randomly allocated to either the IPGT or SHG as active control group. Outcomes were assessed at baseline (t0), after treatment lasting 16 weeks (t1), and 12 months after treatment (t2). A total of 81 patients were assigned to IPGT and 78 patients were assigned to SHG. Vertigo-related impairment was reduced in both conditions (IPGT: t0–t1: d = 1.10, t0–t2: d = 1.06; SHG: t0–t1: d = 0.86, t0–t2: d = 1.29), showing the efficiency of both IPGT and SHG. Clinically relevant improvements were also obtained for depression in both groups. Linear mixed model analyses revealed no differences between groups for all outcomes (effect of group for the primary outcome: b = −1.15, SE = 2.13, t = −0.54, p = 0.59). Attrition rates were higher in SHG (52.6%) than in IPGT (28.4%). Both conditions improved primary and secondary outcomes while IPGT was better accepted by patients than SHG. Trial registration: ClinicalTrials.gov, Identifier: NCT02320851.

Primary or secondary chronic functional dizziness: does it make a difference? A DizzyReg study in 356 patients

In 2017, the term “persistent postural-perceptual dizziness” (PPPD) was coined by the Bárány Society, which provided explicit criteria for diagnosis of functional vertigo and dizziness disorders. PPPD can originate secondarily after an organic disorder (s-PPPD) or primarily on its own, in the absence of somatic triggers (p-PPPD). The aim of this database-driven study in 356 patients from a tertiary vertigo center was to describe typical demographic and clinical features in p-PPPD and s-PPPD patients. Patients underwent detailed vestibular testing with neurological and neuro-orthoptic examinations, video-oculography during water caloric stimulation, video head-impulse test, assessment of the subjective visual vertical, and static posturography. All patients answered standardized questionnaires (Dizziness Handicap Inventory, DHI; Vestibular Activities and Participation, VAP; and Euro-Qol-5D-3L). One hundred and ninety-five patients (55%) were categorized as p-PPPD and 162 (45%) as s-PPPD, with female gender slightly predominating (♀:♂ = 56%:44%), particularly in the s-PPPD subgroup (64%). The most common somatic triggers for s-PPPD were benign paroxysmal positional vertigo (27%), and vestibular migraine (24%). Overall, p-PPPD patients were younger than s-PPPD patients (44 vs. 48 years) and showed a bimodal age distribution with an additional early peak in young adults (about 30 years of age) beside a common peak at the age of 50–55. The most sensitive diagnostic tool was posturography, revealing a phobic sway pattern in 50% of cases. s-PPPD patients showed higher handicap and functional impairment in DHI (47 vs. 42) and VAP (9.7 vs. 8.9). There was no difference between both groups in EQ-5D-3L. In p-PPPD, anxiety (20% vs. 10%) and depressive disorders (25% vs. 9%) were more frequent. This retrospective study in a large cohort showed relevant differences between p- and s-PPPD patients in terms of demographic and clinical features, thereby underlining the need for careful syndrome subdivision for further prospective studies.

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

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.