Internet-Based Vestibular Rehabilitation for Chronic Dizziness

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.OpenUrlAbstract/FREE Full Text

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?