Effectiveness of Primary CareBased Vestibular Rehabilitation for Chronic Dizziness

Context Chronic dizziness is a common and difficult to manage symptom among primary care patients. Vestibular rehabilitation exercises improve symptoms in some patients, but primary care settings infrequently use this treatment. Contribution The authors randomly assigned patients to a 30- to 40-minute session during which a nurse in a primary care setting taught them vestibular exercises or to a control group. Patients assigned to the nurse intervention had significantly greater improvement in dizziness symptoms than patients in the control group. Implications Nurse-delivered vestibular rehabilitation is a feasible and effective treatment option for primary care patients with chronic dizziness. The Editors Dizziness is a very common symptom, with a prevalence as high as 25% in the general population (1, 2). One in 10 working-age adults report some degree of handicap due to dizziness (2); 2% experience chronic, frequent, substantially handicapping episodes (3). More than 1 in 5 people older than 60 years of age have current dizziness that has led to substantial disability, medical consultation, or medication use (4). Dizziness is also associated with falls, fear of falling, and loss of independence in older people (5, 6). The most common cause of dizziness presenting in primary care is peripheral vestibular disorder. Psychiatric factors, which often accompany medical disorders, are also common causes. Serious cardiovascular or neurologic disease is rare (1, 7-11). A multifactorial syndrome is common in older people (12). Because of the numerous causes, patients may present in various specialties, but most are managed in primary care (8). Treatment typically consists of reassurance and antivertiginous and antiemetic drugs to relieve symptoms (8, 13-15). However, several reviews of the management of dizziness have concluded that no medication in current use has well-established curative or prophylactic value or is suitable for long-term palliative use. These reviews have called for evaluation of an exercise-based form of treatment known as vestibular rehabilitation (14-16). The central element of vestibular rehabilitation is a program of graded exercises that consist of eye, head, and body movements designed to stimulate the vestibular system. This stimulation promotes central compensation, which is neurologic adaptation to the altered input from the damaged labyrinth (13, 17, 18). These exercises also help patients to overcome fear and avoidance of activities that elicit disorientation and to regain skill and confidence in balance (19). Studies in secondary care (for example, otolaryngology, neurootology, or balance centers) have provided some evidence that vestibular rehabilitation may be an effective treatment for dizziness resulting from various conditions, including peripheral vestibular disorder, benign paroxysmal positional vertigo, anxiety, multifactorial dizziness in the elderly, and head injury (20-26). However, to date, no randomized, controlled trials of vestibular rehabilitation that conform to Consolidated Standards of Reporting Trials (CONSORT) criteria (27) have been reported; therefore, the efficacy and effectiveness of vestibular rehabilitation remain difficult to estimate. For example, some studies do not use intention-to-treat analysis (20, 22-26), some have very few participants in trials (21, 22), and some use unpublished subjective outcome measures rather than measures with known reliability and validity (21, 25, 26). Currently, vestibular rehabilitation is rarely made available to the many patients who are managed at the primary care level. It is a simple therapy with no requirement for equipment; therefore, if effective, it would be highly suitable for more widespread provision in primary care. An earlier nonblinded randomized, controlled trial (28) has provided a preliminary positive evaluation of the efficacy of vestibular rehabilitation in a primary care sample that involved patients with various causes of the disorder. After 2 home visits from a research nurse with specialist training in vestibular rehabilitation, the treatment group demonstrated a decrease in symptom severity, reduced handicap, and better postural control (28). In the present study, we assessed the effectiveness of a single session of vestibular rehabilitation delivered by primary care nurses. Methods Design We used a single-blind randomized, controlled design to compare vestibular rehabilitation with usual medical care. Participants were assessed at baseline and then randomly assigned to the intervention group. At 3 months, a research assistant who was blinded to treatment status reassessed each participant. In a single crossover design (29), during the next 3 months, the usual medical care group received vestibular rehabilitation, and both groups were reassessed by the blinded research assistant at 6 months. The South and West Local Research Ethics Committee and the South East Local Research Ethics Committee approved the study, and all participants gave signed informed consent. Participants We recruited participants in 2001 and 2002 from 20 general practices within a 30-mile radius of Southampton, United Kingdom, and included inner-city, suburban, and rural practices. Participating practices had participants with varying levels of social deprivation, as assessed from census data (Jarman scores [30] ranged from 6.49 to 29.11; mean, 8.65). Practice staff used the medical records in the practice to identify all patients with dizziness during the past 2 years. After we screened for exclusion criteria, patients were invited by letter to participate in the study. Practices used the following search terms to identify potentially suitable patients from their computerized databases (terms used varied according to how patient data were recorded by the practice): vertigo, dizziness, Mnire disease, ENT [ear, nose, throat] referral, balance problems, vestibular, prochlorperazine, cinnarizine, betahistine, and diuretics. Patients could also be directly recruited by their general practitioner, and posters displayed in practices informed patients that they could ask to participate. Exclusion criteria were as follows: identifiable nonlabyrinthine cause of dizziness in patient records, duration of dizziness less than 2 months during the past 2 years, medical contraindications for making required head movements (for example, severe cervical disorder), and serious comorbid conditions (for example, life-threatening condition or progressive central disorder). Before randomization, we also excluded patients if they were no longer found to be dizzy at the baseline assessment or if none of the rehabilitation exercises provoked dizziness. In this context, the rehabilitation exercises served as a screening test to identify patients with movement-provoked dizziness, which is typical of vestibular imbalance and should therefore respond to vestibular rehabilitation. After baseline assessment to confirm eligibility and obtain data for stratification, participants were randomly assigned by an administrative assistant with no previous contact with the patient. Allocation, concealed in opaque sealed envelopes, was based on block randomization within practice (block size, 4) after stratification for severity of symptoms on the Vertigo Symptom ScaleShort Form (28) (Figure 1) (low severity, <12 points; high severity, 12 points). On the basis of findings from the previous primary care study (28), we estimated that with a sample size of 86 patients per group, we should be able to detect an effect size of 0.5 on the Vertigo Symptom ScaleShort Form with a 2-tailed significance level of 5% and 90% power. After we made the exclusions (Figure 2), 87 patients were randomly assigned to the usual medical care group and 83 were assigned to the treatment group. Figure 1. Vertigo Symptom Scale (short form). Figure 2. Participants at each stage of the trial. Intervention The nurses (n= 23) attended a single half-day group training session at which they learned how to teach patients to carry out vestibular rehabilitation exercises at home (Table 1 and Appendix 1 video). For a full description of the materials used by nurses, see Appendix 2A (rationale for nurse and patient education), Appendix 2B (workshop structure for nurse training), Appendix 2C (schedule for vestibular rehabilitation sessions), and the Appendix Figure (patient therapy monitoring sheet). The vestibular rehabilitation program was focused on a professionally designed treatment booklet for patients (Appendix 3A [booklet] and Appendix 3B [supplement to booklet for patients with Mnire disease]) and was developed by using principles of behavior change derived from theory and research on adherence (techniques included eliciting and addressing concerns, providing evidence of efficacy, requiring the patient to make a specific goal plan and written commitment, monitoring and reinforcing progress, and teaching skills to cope with setbacks) (31, 32). Patients were actively involved in adapting the exercise program to suit their symptoms, capabilities, and lifestyle. Nurses saw patients individually for 30 to 40 minutes to take them through the booklet and gave additional support and advice by telephone at 1 and 3 weeks after this initial session (Appendix 2C). Participants in both groups remained free to continue their usual medical care, including use of medications and referral to specialties. Appendix 3A. Treatment booklet for patients titled "Balance Retraining: Exercises Which Speed Recovery from Dizziness and Unsteadiness. " The booklet was written by Dr. Lucy Yardley, who retains copyright for this booklet. Appendix Figure. Patient therapy monitoring sheet. Table 1. Steps of Nurse-Delivered Vestibular Rehabilitation Outcome Measures The primary outcome measures were self-reported spontaneous and provoked symptoms of dizziness, dizziness-related quality of life, and objective measurement of postural st