Research ArticleOriginal Research

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

Adam W. A. Geraghty, Rosie Essery, Sarah Kirby, Beth Stuart, David Turner, Paul Little, Adolfo Bronstein, Gerhard Andersson, Per Carlbring and Lucy Yardley
The Annals of Family Medicine May 2017, 15 (3) 209-216; DOI: https://doi.org/10.1370/afm.2070

Article Figures & Data

Tables

  • Table 1

    Baseline Characteristics (N = 296)

    CharacteristicIntervention Group (n = 160)Usual Care Group (n = 136)
    Female, No. (%)107 (66.9)90 (66.2)
    Age, mean (SD), y67.3 (9.0)67.5 (11.5)
    Age at leaving school, mean (SD), y16.2 (1.2)16.1 (1.1)
    Time since diagnosis, mean (SD), y6.5 (7.8)8.2 (11.3)
    VSS-SF scores, median (IQR)a
     Total score14 (8–22)13 (7–22)
     Vertigo subscale score8 (5–13)8 (5–12)
     Autonomic symptoms subscale score5 (2–9)5 (2–8)
    DHI score, median (IQR)b32 (22–48)32 (20–55)
    HADS scores, median (IQR)c
     Anxiety score7 (4–10)6 (4–10)
     Depression score4 (2–6)4 (2–7)

    • DHI = Dizziness Handicap Inventory; IQR = interquartile range; VSS-SF = Vertigo Symptoms Scale–Short Form; HADS = Hospital Anxiety and Depression Scale.

    • ↵a Higher scores indicate higher levels of dizziness. Ranges of scores in this trial: total score: 0–48; vertigo subscale score: 0–32; autonomic symptoms subscale score: 0–25.

    • ↵b Higher scores indicate greater dizziness-related disability. Range of scores in this trial: 0–96.

    • ↵c Higher scores indicate higher levels of anxiety and depression. Ranges of scores in this trial: anxiety score: 0–20; depression score: 0–20.

  • Table 2

    Primary and Secondary Outcome Measures at 3 and 6 Months

    Outcome3 Months6 Months
    Intervention, Median (IQR)Usual Care, Median (IQR)Univariate Difference, Median (95% CI)aMultivariate Difference, Median (95% CI)bIntervention, Median (IQR)Usual Care, Median (IQR)Univariate Difference, Median (95% CI)aMultivariate Difference, Median (95% CI)b
    Primary outcome
     VSS-SF total score6 (3–12)9 (5–15)2.52 (1.17 to 3.87; P <.001)2.75 (1.39 to 4.12; P <.001)6 (3–14)7 (4–17)2.38 (0.31 to 4.46; P = .03)2.26 (0.39 to 4.12; P = .02)
    Secondary outcomes
     VSS-SF vertigo subscale score3 (1–7)4 (2–9)1.42 (0.50 to 2.33; P = .003)1.49 (0.54 to 2.43; P = .002)4 (1–6)4 (2–11)1.00 (−0.25 to 2.25; P = .12)0.93 (−0.24 to 2.10; P =.12)
     VSS-SF autonomic symptoms subscale score3 (0–6)4 (2–6)1.19 (0.37 to 2.01; P = .005)1.03 (0.12 to 1.94; P = .03)3 (1–6)4 (1–7)1.38 (0.62 to 2.14; P <.001)1.33 (0.63 to 2.03; P <.001)
     DHI score24 (12.5–38)28 (16–52)5.33 (1.41 to 9.26; P = .008)6.15 (2.81 to 9.49; P <.001)22 (8–40)26 (12–46)5.58 (1.19 to 10.0; P =.01)5.58 (1.19 to 10.0; P =.01)
     HADS anxiety score6 (3–9)6 (3–9)0.88 (0.02 to 1.75; P = .046)0.82 (0.03 to 1.61; P = .04)6 (3–9)6 (3–9)0.17 (−0.83 to 1.16; P = .74)0.10 (−0.97 to 1.16; P =. 86)
     HADS depression score3 (1–5)4 (1–7)0.55 (−0.06 to 1.15; P = .08)0.55 (−0.18 to 1.28; P = .18)2 (1–6)4 (1–6)0.29 (−0.23 to 0.80; P = .27)0.24 (−0.25 to 0.73; P =.33)
     Patient-reported improvement, No. (%)76/122 (62.3)42/128 (32.8)0.28 (0.18 to 0.45; P <.001)0.27 (0.17 to 0.44; P <.001)70/109 (64.2)50/122 (41.0)0.38 (0.25 to 0.59; P <.001)0.41 (0.26 to 0.65; P <.001)

    • DHI = Dizziness Handicap Inventory; IQR = interquartile range; VSS-SF = Vertigo Symptoms Scale–Short Form; HADS = Hospital Anxiety and Depression Scale.

    • ↵a Difference between groups controlling for baseline value and clustering.

    • ↵b Difference between groups controlling for baseline value, clustering, and other significant covariates.

  • Table 3

    Post Hoc Exploratory Analysis of Intervention Effectiveness by Age

    VSS-SF Total ScoreAged ≤67 YearsAged >67 Years
    Intervention, Median (IQR)Usual Care, Median (IQR)Univariate Difference, Median (95% CI)aMultivariate Difference, Median (95% CI)bIntervention, Median (IQR)Usual Care, Median (IQR)Univariate Difference, Median (95% CI)aMultivariate Difference, Median (95% CI)b
    6 months8 (4–15)9 (5–20)1.00 (−1.77 to 3.77; P = .48)1.08 (−1.66 to 3.82; P = .44)5 (1–12)6 (3–15)3.00 (0.14 to 5.86; P = .04)NAc
    3 months8 (5–15)10 (6–19)2.79 (0.74 to 4.83; P = .008)3.03 (0.99 to 5.08; P = .004)6 (1–10)8 (4–12)3.19 (1.03 to 5.35; P = .004)3.33 (1.29 to 5.38; P = .002)

    • IQR = interquartile range; VSS-SF = Vertigo Symptoms Scale–Short Form; NA = not applicable.

    • ↵a Difference between groups controlling for baseline values and clustering.

    • ↵b Difference between groups controlling for baseline value, clustering, and other significant covariates.

    • ↵c No other covariates were significant.

Additional Files

  • The Article in Brief

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

    Adam W.A. Geraghty , and colleagues

    Background Chronic dizziness is commonly seen in US primary care and is often due to vestibular dysfunction (dysfunction in parts of the inner ear and brain that process sensory information involved with controlling balance and eye movements). This study tested the effectiveness of fully automated Internet-based vestibular rehabilitation in improving dizziness symptoms in patients aged 50 and over.

    What This Study Found A publicly-available, self-directed Internet-based vestibular rehabilitation program effectively reduces dizziness and dizziness-based disability in older primary care patients without requiring clinical support. The randomized controlled trial involving 296 patients aged 50 years and older with dizziness exacerbated by head movements found that compared with the usual care group, patients in Internet-based rehabilitation group had less dizziness on the Vertigo Symptom Scale-Short Form at three months and six months. Dizziness-related disability was also lower in that group at three months and six months.

    Implications

    • Given the increasing Internet use being seen in older adults, the authors conclude Internet-based interventions may provide a promising means of greatly increasing the provision of evidence-based self-management strategies for adults in primary care.

  • Annals Journal Club

    May/June 2017: Internet-Based Vestibular Rehabilitation for Chronic Dizziness


    The Annals of Family Medicine encourages readers to develop a learning community to improve health care and health through enhanced primary care. Participate by conducting a RADICAL journal club. RADICAL stands for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. We encourage diverse participants to thinking critically about important issues affecting primary care and act on those discussions.1

    HOW IT WORKS

    In each issue, the Annals selects an article and provides discussion tips and questions. Take a RADICAL approach to these materials and post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion: Submit a comment.") Discussion questions and information are online at: http://www.AnnFamMed.org/site/AJC/.

    CURRENT SELECTION

    Article for Discussion

    Geraghty AW, Essery R, Kirby S, et al. Internet-based vestibular rehabilitation for older adults with chronic dizziness: A randomized controlled trial in primary care. Ann Fam Med 2017;15(3):209-216.

    Twitter Journal Club

    Join us for our first Twitter journal club on Wednesday, May 31 from 12:00-1:00 PM EST (4:00 PM GMT), hashtag #AJC. This moderated Twitter chat will pose questions about the selected article at regular intervals.

    Discussion Tips

    Pragmatic randomized controlled trials are conducted in real-world clinical practice. Classic teaching in these trials is that you exchange some internal validity for external generalizability. Given the increasing number of these trials and their link to practice, an understanding of how to analyze and interpret them is important.

    Discussion Questions

    • What question is asked by this study and why does it matter?
    • What is known about vestibular rehabilitation?2 Why does this matter to the reading of this trial? How could this study advance current clinical practice?
    • How strong is the study design for answering the question? Why is it important that the authors published the study design prior to the start of the trial? What limitations are seen in pragmatic clinical trials (higher loss to follow-up/less robust data collection)?
    • What does it mean that the randomization was "stratified by severity"?
    • How do intention to treat and per protocol analyses differ? Why do these matter? How was per protocol defined in this study?
    • To what degree can the findings be accounted for by: How patients were selected or excluded; the percentage of patients lost to follow-up (and was this different between study arms?); how the main variables were measured; how the findings were interpreted; and by chance?
    • What are the main study findings? Were the results clinically relevant?
    • How were harms measured?
    • Why was loss to follow-up higher in the intervention arm? What does it mean to impute results? What measures provide reassurance about the conclusions related to the rate of loss to follow-up?
    • What was found in the exploratory analysis by age? What is your impression of this subgroup analysis? Was this analysis an a priori or a post hoc analysis?
    • How comparable is the study sample to patients in your practice? How transportable are the findings?
    • How might this study change your practice? Education? Research?
    • What are the next steps in interpreting or applying the findings?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197 http://annfammed.org/content/4/3/196.full.
    2. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015;1:CD005397.

  • Supplemental Table and Figure

    Supplemental Table and Figure.

    Files in this Data Supplement:
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