van Vugt VA, van der Wouden JC, Essery R, et al. 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: British Medical Journal. 2019;367.
Background. Chronic vestibular syndrome, or persistent vestibular dysfunction may result from mal-adaptation or ineffective compensation after the peripheral vestibular insult, producing vertigo, dizziness, vestibulovisual and postural symptoms. Vestibular Rehabilitation (VR), a safe and effective treatment for chronic vestibular syndrome, is, however, underutilized.
Purpose. This study compared the clinical effectiveness and safety of stand-alone versus blended internet-based VR versus usual care in adults over 50 with chronic vestibular syndrome.
Methods. Study design included a pragmatic, three group (stand-alone internet VR vs blended internet VR vs usual care), parallel arm, randomized controlled trial. Adults aged 50 and older who had visited their general practitioner with a vestibular symptom in the past two years were identified from the electronic medical records of general practices. Participants with good command of the Dutch language, access to internet, and persisting vestibular symptoms present for >1month triggered by head movements, no reports of comorbid conditions or any other head movement contraindications were included. Participants were further screened to include individuals with chronic vestibular syndrome versus an acute or episodic vestibular syndrome, stratified by the symptom severity and randomized into the 3 groups. Stand-alone group received Vertigo Training, an internet-based VR intervention (Dutch translation of free Balance Retraining) which included weekly online sessions for 6 weeks, 2×10 minutes of daily 6 core VR exercises tailored for each individual progressing from sitting to walking, and advice on coping and symptom control. Participants also received usual care from their doctor. Blended group received the 6-week Vertigo Training intervention and 2 home physiotherapy visits in weeks 1 & 3 for 45 minutes each. The physiotherapist provided information on vestibular symptoms and VR, taught how to use the online intervention, and advised on how to anticipate and cope with symptoms or obstacles. Participants also received usual care from their doctor. Usual care group received standard level of care by their doctor. Measurements were collected at baseline, 3 & 6-month follow-up. The primary outcome measure was the vertigo symptom scale-short form (VSS-SF) which includes frequency of 15 vestibular symptoms on a scale from 0 (no symptoms) to 4 (symptoms most days) during the past month (total range 0-60 points), where >=12 points is classified as severe vestibular symptoms, and a 3-point change is clinically significant. Secondary measures included dizziness handicap inventory (DHI), subjective improvement in vestibular symptoms, patient health questionnaire (PHQ) for anxiety & depression, and perceived barriers to adherence with problematic experiences of therapy scale (PETS). Descriptive statistics were used to compare baseline characteristics. Intention-to-treat analysis was conducted for stand-alone group versus usual care, and blended group versus usual care comparisons using linear mixed models and generalized estimating equation analysis. Per-protocol analysis were also performed.
Results. 322 participants were randomized: 98 to stand-alone, 104 to blended, & 120 to the usual care group. Follow-up data on primary outcome at 3 and 6 months was collected for 292 (91%) and 286 (89%) of participants. Participants in stand-alone VR group reported significantly less vestibular symptoms than usual care at 3 months (mean VSS-SF=4.3, 95%CI=−5.9 to −2.6) and 6 months (mean VSS-SF=4.1, 95%CI=−5.8 to −2.5). Participants in the blended VR group reported significantly less vestibular symptoms than usual care at 3 months (mean VSS-SF=3.9, 95%CI=−5.5 to −2.3) and 6 months (mean VSS-SF=3.5, 95%CI=−5.1 to −1.9). Participants in stand-alone and blended VR versus usual care group experienced less dizziness at three (mean=-4.9, 95%CI=−8.4 to −1.3) and six months (mean=-4.5, 95%CI=−8.0 to −0.9); less anxiety at three (mean=-1.2, 95%CI=−2.0 to −0.4) and six months (mean=-1.2, 95%CI=−2.0 to −0.4). At six months 46/87 (53%) participants in the stand-alone, 48/93 (52%) in the blended and 43/110 (39%) in the usual care group reported subjective improvement of vestibular symptoms.
No differences in depression were found. Per-protocol analysis done as well (the treatment effects of stand-alone VR were notably better). Study is limited by Selection bias, use of broad chronic vestibular syndrome diagnosis, lack of between group comparison.
Conclusion. This three-armed randomized controlled trial determines the effectiveness of stand-alone and blended online VR versus usual care in adults with chronic vestibular syndrome at 6-weeks, 3 and 6 months of receiving intervention. Individuals reported less vestibular symptoms, dizziness impairment and anxiety, and more subjective improvement than the usual group.