Proof of Concept Study of EMBalance Decision Support System to Evaluate Balance Disorders
Condition: Dizziness; Vertigo
MeSH terms: Vertigo; Dizziness
Study type: Interventional

Summary: 
      Balance is crucial for an individual's mobility and independence. Human balance is achieved
      and maintained by a complex set of sensorimotor systems that include sensory input from
      vision, proprioception and the vestibular system (motion, equilibrium, spatial orientation).
      This information is then integrated by the brain. This complexity leads to undiagnosed or
      mistreated patients with balance disorders for long period which can affect their daily
      activities.

      The EMBalance project is a research project funded by the European Union, involving 10
      universities across Europe. Its aim is to create a Decision Support System (DSS) to support
      doctors in diagnosing and treating balance disorders. It will be available to primary and
      secondary care doctors of different specialties, levels of training and in different parts of
      the country.

      The DSS will:

        -  Be used by primary and secondary health care professionals

        -  Assist the doctor on the evaluation and management of dizzy patients

        -  Predict how the balance disorder may progress

        -  Reduce patient waiting time and the onward referrals

        -  Ensure patients receive prompt and efficient treatment plans

      The EMBalance randomised clinical trial (RCT) is a proof-of-concept, multicentre,
      single-blind, and parallel group study, conducted in Belgium, Germany, Greece and United
      Kingdom. At present, the question that this study aims to answer is whether the algorithms
      developed for the EMBalance Platform will yield meaningful information and how these
      algorithms and platform can be improved, performing an offline comparison of the classical
      diagnostic approach and the outcome of the EMBalance platform, without any consequence for
      the patient.

      Patients who present with balance related symptoms at primary care will be randomised to
      either intervention group (non-specialist doctor +DSS) or control group (non-specialist
      doctor -DSS). An overseeing expert will then confirm the diagnosis and management decisions
      made by the non-specialist doctors in order to determine whether the use of the DSS can help
      them in a more precise assessment.
    

Detailed description: 
      Balance is crucial for an individual's mobility and independence. Dizziness and imbalance
      symptoms are one of the most common reasons for visits to a doctor and affect up to 30-40% of
      the population by 60 years of age. The healthcare service provision to address vestibular
      pathology remains inadequate and is regarded as low priority. The complexity of balance
      control mechanisms, the lack of medical expertise, and the absence of specialised equipment
      can be contributory factors to the mismanagement of patients suffering balance disorders.
      However, the mean number for patient visits to their Health Care providers required to
      establish a correct diagnosis and start appropriate treatment, both in the US and the UK, is
      4.5. The overall socio-economic impact of balance disorders on the affected individual,
      patient's families as well as the burden on society and the health services is considerable.

      Advances in computer science and artificial intelligence have allowed the development of
      computer systems that support clinical diagnosis or therapeutic and treatment decisions based
      on individualised patient data. However, a review of existing Decision Support Systems used
      in Medicine demonstrated there are not many successful integrated software systems or
      standalone tools that address the early diagnosis and effective management of balance
      disorders.

      All this said, the EMBalance DSS has been developed as a supplementary and supportive tool
      for non-expert physicians faced with the challenge of addressing vestibular disorders.

      The current study will assess the effectiveness of the EMBalance Decision Support System
      (DSS) for diagnosis and management of balance disorders in a feasibility/proof of concept
      study. Patients who present with balance related symptoms (specifically vertigo or dizziness
      exacerbated by head movements) in primary care, will be seen by a non-specialist doctor
      either with or without the support of the DSS, on a ratio 1:1.

      Non-specialist doctors in each participating country are defined as follow:

        -  UK: General Practitioners

        -  Germany: Neurology residents

        -  Belgium & Greece: ENT residents

      Overseeing experts in each participating country are defined as follow:

        -  UK: Consultant in audiovestibular medicine (AVM)

        -  Germany: Neurologist

        -  Belgium & Greece: ENT specialist with >10 years expertise in AVM/Neuro-otology

      It is anticipated 100 participants will be recruited to each of the two treatment groups,
      giving a total of 200 participants across Europe. Each participating site in Greece, Belgium,
      Germany and United Kingdom will recruit 50 patients. Allocation will be performed based on
      randomisation tables that are produced in advance for each centre.

      Statistical data analysis will be performed by the National and Kapodistrian University of
      Athens. The statistical analysis has been developed by the National and Kapodistrian
      University of Athens and reviewed by the Institute of Communication and Computer Science
      (Greece).

      Quality and ethical assurance are supervised by the Trial Steering Committee (TSC) and Trial
      Management Group (TMG)
    

Intervention name(s): Decision Support System (DSS); Specialist Audiovestibular Consultation; DSS Customised Vestibular Physiotherapy; Standard Physiotherapy Practice; Follow-up
Intervention type(s): Other; Other; Other; Other; Other
Intervention description(s): The EMBalance DSS is a program which summarises and structures clinical information. The structuring of medical information is based on algorithms that have been developed and are employed via the DSS platform. The non-specialist doctors who use the DSS will be asked to exercise their clinical judgement in order to come up with a diagnosis or management plan. The DSS use has the following characteristics:
Doctors can pace the process anyway they see fit (e.g. by switching from history taking to examination, stopping at any point, or going back to medical history) or by stopping the process entirely.
Although the EMBalance platform will propose 2-3 diagnosis (with probability estimation for each), doctors will be asked to either choose one of these or discard and choose their own.; After the initial appointment with the non-specialist doctor, all patients will be invited to attend a specialist neuro-otology clinic where they will be seen by an overseeing expert in order to undergo a "Gold Standard" diagnostic process, and determine the management plan appropriate to the diagnosis, which will be compared to the management plan previously advised by the non-specialist doctor. The overseeing expert will review investigations carried out, results assessed by the non-specialist doctor.; Customised vestibular exercise programme suggested by the DSS. Such exercises are based on the eye, head, and postural exercises that provoke a patient's symptoms.
Adaptation exercises incorporating gaze fixation and head movements and postural exercises are prescribed to promote recovery of the vestibule-ocular reflex (VOR) and vestibulo-spinal reflex function. Up to 5 exercises will be practised by the patient at home for approximately 1-2 minutes each, twice daily initially at a slow speed which gradually increases as symptoms improve.
Patients presenting vestibular migraine will perform a maximum of three exercises. These exercises will be chosen by the DSS from a range of established exercises and chosen according to the patient's symptoms when performing the exercise/type of movement.; Patient will be referred to a local physiotherapy service by his/her non-specialist doctor within 18 weeks from referral. Standard vestibular rehabilitation practice consists of a customised exercise programme, this is service dependent and tailored for patient's symptoms. The rehabilitation programme might include lifestyle advice and education, sometimes accompanied by a leaflet.; All patients will be reviewed after three months follow-up by the overseeing expert.
Other intervention name(s): Decision Making Software; Vestibular Rehabilitation; Standard Rehabilitation Practice
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Diagnostic
Keywords: Decision Support System; Dizziness; Vertigo; Balance