chronic vertigo: online vestibular rehab

an intriguing article just came out from the Netherlands showing that Internet-based vestibular rehab works well for adults with chronic vestibular syndrome  (see vertigo online rehab bmj2019 in dropbox, or doi: https://doi.org/10.1136/bmj.l5922)

Details:

-- 59 general practices recruited 322 adults >50yo with chronic vestibular syndrome that had been present for at least one month and was exacerbated or triggered by head movements

-- mean age 67; 61% female; level of education 33% low/27% middle/40% high; 32% living alone; chronic diseases: 58% zero/31% one/10% more; time since vestibular diagnosis: 1 to 6 months in 16%/ 6 months to 2 years 29%/2 to 10 years 38%/>10 years 16%; associated psych conditions: 3% panic disorder/14% generalized anxiety disorder/6% major depressive disorder

-- participants were divided into 3 groups:

    -- stand-alone ventricular rehab (VR): internet-based intervention with weekly online sessions for 6 weeks and daily exercises for 10 minutes twice a day. Patients did receive automated emails to promote adherence.

    -- blended VR: the same Internet-based intervention, supplemented by face-to-face physiotherapy support and home visits in weeks 1 and 3 for 45 minute sessions by a physiotherapist

    -- usual care: standard care from a general practitioner with no restrictions

-- primary outcome: vestibular symptoms after 6 months as measured by the vertigo symptom scale-short form (VSS-SF), a scale with excellent discriminative ability, high internal consistency, and high test-retest reliability, asking about 15 vestibular symptoms on a scale from 0 to 4, scale range 0 to 60, with a difference of at least 3 points being considered clinically relevant. A total score of 12 or more points is considered severe vestibular symptoms

-- Secondary outcomes: dizziness-related impairment; anxiety, depressive symptoms; subjective improvement of vestibular symptoms after 3 and 6 months; and adverse events

Results:

-- for the stand-alone group, 71% completed at least one online session and 48% completed all 6; in the blended VR group 80% completed at least one session, 82% received both home visits, and 53% completed all 6 sessions and were visited twice by the physiotherapist

-- intention-to-treat analysis, at 6 months, as compared to usual care:

    -- stand-alone group: adjusted mean decrease 4.1 points (-5.8 to -2.5)

    -- blended group: adjusted mean decrease 3.5 points (-5.1 to -1.9)

-- similar differences were seen at 3 months in both groups

-- less dizziness-related impairment, less anxiety (GAD-7 improved 1.2 points), and more subjective improvement of vestibular symptoms at 3 and 6 months (at 6 months 53% of the stand-alone group and 52% of the blended VR group reported subjective improvement, vs 39% of the usual care group). No effect on depressive symptoms

-- per-protocol analysis (i.e. assessing those patients who completed the whole program) produced even better results, especially in the stand-alone group:

    -- stand-alone group: adjusted mean decrease 5.4 points (- 7.4 to - 3.4)

    -- blended group: adjusted mean decrease 3.5 points (-5.5 to -1.6)

-- no serious adverse events related to the online VR instruction

Commentary:

-- each year 5% of the general population experience vertigo symptoms, with their prevalence, frequency, and severity increasing with age

-- 4 out of 5 report that their vertigo symptom severely affects their daily functioning

-- 80% of patients with vertigo in the Netherlands, UK, and US are primarily treated by their primary care clinician

-- there seems to be an innate repair mechanism, called vestibular compensation, which helps when a vestibular disorder damages the peripheral vestibular system. When this repair mechanism fails, chronic vestibular syndrome occurs.

-- VR is an exercise-based treatment that gradually stimulates the vestibular system and seems to stimulate vestibular compensation

-- it was notable that those with the stand-alone option above actually did better than those having face-to-face support. It was assumed that the latter would do better given the likelihood of increased adherence and decreased attrition from the program.

-- there are a few online sources for free VR interventions:

    -- https://balance.lifeguidehealth.org/player/play/balance this is the one suggested in the study. The patient needs to develop an account (free), takes a questionnaire to make sure they qualify, then there is some description of vestibular physiology, followed by 6 exercises to do with video demonstrations. In English only

    -- https://www.youtube.com/watch?v=SfuLu46c4Qs is a more extensive exercise program, also beginning with general discussion of the problem and description of what is going on in the inner ear, then video demonstrations of the exercises. In English only.

-- In this study there was also  a patient-specific, personalized approach: each week the patient scored their symptoms, and the exercise difficulty level was increased on an individual basis. For example, the initial exercises were performed sitting down; when the patients had no symptoms, they progressed to exercises while standing and eventually when walking around. This tailored approach might have been important in promoting patient adherence

-- This study’s results are in line with other RCTs in general practice, e.g. a British study.

-- Limitations:

    -- this type of intervention would apply to patients who had computers/Internet access, were comfortable with using computers, were pretty health-literate, and speak English. there may be issues with generalizability to other patient groups.

    -- they included patients with chronic vestibular symptoms though without a specific vestibular disorder: perhaps there might be different outcomes depending on those specifics: e.g. vestibular neuritis, BPPV, vs Ménière’s; though in this study 66% of the patients reported they had never received a diagnosis for a specific vestibular disorder, and this might be the case for most patients seen in primary care

    -- also, the comparison with usual care is a bit fraught, since there was no sham exercise intervention in this group

So, it appears that a pretty minimal, low cost Internet-based intervention (two 10- minutes, twice a day) for just 6 weeks has pretty significant results. My guess is that this intervention would work better if a specific nurse or other personnel were able to call the patient every week, see if there were problems, and adjust the exercises that the patient was doing according to a standardized protocol.

Overall, this intervention might well benefit many patients. And, this is especially true since many of these patients are elderly, functionally impaired by their chronic vertigo (and perhaps more likely to fall), and the vestibular suppressants (meclizine, benzos) have even more serious adverse effects in the elderly…

geoff​

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