Internet-Based Vestibular Rehabilitation for Older Adults With Chronic Dizziness: A Randomized Controlled Trial in Primary Care

The purpose of this study was to examine the utility of an internet-based intervention versus usual treatment modalities for older adults with persistent dizziness due to vestibular dysfunction.

The group began the discussion by noting that although this study was performed in the UK, the statistics cited in the introduction were all from the United States. For example, they state that there are 7 million consultations for dizziness in the US and that 68% of Americans 55-64 years old and 38% of those 65 years or older now use the internet. The group discussed two possibilities for this choice: 1) that the data from the United States may be more substantial than that of the UK and 2) the authors cited data that would show the relevance of this topic to a US population also likely to read the article. The group discussed how the authors might have addressed this in the introduction and suggested that providing data from both nations and highlighting the trend in internet use for each country would have been sufficient to reconcile this issue.

The study methods were examined next, with particular interest directed at the inclusion criteria. The study enrolled adults over the age of 50 who had an email address and who were experiencing 2+ years of vestibular dizziness not attributed to another medical condition. There was concern that by including adults aged 50-64 year old that perhaps the study did not adequately capture the older adult (65+) population in this intervention. Several reasons for this choice were discussed, including the possibility that this decision was made in the interest of recruiting more participants, or a concern that fewer participants in the 65+ age group would have access to the internet or continue to use it in the manner prescribed. The group also questioned the utility of an email address as inclusion criteria. While they acknowledged that it was a simple way to screen for internet access they debated whether it was a useful indicator of how this population used the internet, or whether it was a valuable predictor of continued enrollment in the study (i.e. less likely to be frustrated with the technology involved and therefore less likely to drop out). The exclusion criterion was in general felt to be conducive to eliminating confounding factors. Further discussion was directed at the randomization of the patients to either the internet intervention or the usual supportive care groups. The group did not think that there were any ethical concerns due to withholding treatment from one group, as they were still receiving other treatment modalities for their symptoms.

The internet-based intervention itself was the subject of much discussion, as this was a relatively new concept to the group. The intervention consisted of 6 internet sessions completed over 6 weeks with incorporation of psychotherapy techniques such as relaxation, breathing, cognitive restructuring and coping. The psychological impact of unremitting dizziness was acknowledged and the group agreed that vestibular dysfunction may result in increased anxiety, avoidance behaviors, and depression. At the same time the group was unable to determine how much of the intervention was assisting in the actual dizziness versus altering the patient's perception of their condition and coping with it.

The outcomes measured were the 3- and 6-month VSS-SF score and vertigo/autonomic subscores, dizziness handicap inventory, and Hospital Anxiety and Depression Score (HADS). The group questioned the use of HADS versus the standard PHQ-9/GAD-7 tools which are more commonly used. It was noted that HADS did not include suicidal ideation and that this may have made it easier for the researchers to bypass any potential ethical and technical issues that might arise if a participant answered "yes".

Results demonstrated that 61% of participants randomized to the intervention group completed at least the first exercise. At 3 months the VSS-SF score demonstrated no significant difference between the two groups but that the anxiety score was significantly improved in the intervention group. By 6 months the VSS-SF was significantly lower in the intervention group, with particular improvement in those who were 67 years or older. The anxiety scores plateaued after the 3-month mark, and the group explored the possibility that participants no longer actively practiced the CBT techniques several months after the online course was completed and that they had reached the "peak" of any potential improvement.

It was noted that there was a significantly higher dropout rate in the intervention group, but considering the supportive care group was continuing to follow their doctors for routine treatment it was understandable there would likely be some discrepancy in dropout rates between the two groups. Authors discussed 18 non-dizziness related hospitalizations that resulted in drop outs, but the causes were not specified and a determination could not be made about the significance of these hospitalizations without further information. For example, if a patient in the intervention group were hospitalized due to an exacerbation of their anxiety or depression then this would be important information to incorporate in the analysis.

The group acknowledged that this study brought to light a little-known option for primary care providers caring for patients with persistent dizziness due to vestibular dysfunction. Suggestions for improving the study included restricting the study population to those 65 years old and older, including patients who did not have an email address, direct observation of the patient completing the intervention course to assess proper usage by setting up a station in the physician's office where patients could complete the exercises regardless of their internet capabilities. The group agreed that having a CBT only group would be an interesting comparison.

Overall it was felt that internet based interventions had some promise as a more accessible and cost effective treatment for a commonly encountered issue for PCPs. Though this study did not demonstrate any harm, the group would be reluctant to fully advocate such therapy without further data, but it is one of many options for patients who are willing to try new non-medication therapies or who struggle to get to the office.

Competing interests: None declared