Internet-based vestibular rehabilitation for older dizzy adults: does it work? A single blind, three arm, randomised controlled trial in general practice

BACKGROUND Dizziness is a common symptom. The prevalence of dizziness increases with age, ranging from 30% in adults above 65 years of age to 50% in adults above 85. Dizziness can lead to severe limitations in daily functioning. It is a major risk factor for falling, leading to further limitation of activities, fractures, and high healthcare costs. Peripheral vestibular disease is the most common cause of dizziness in primary care (33-38%). Currently, 90% of dizzy patients are managed in primary care, mainly by reassurance and symptomatic drugs. However, none of the prescribed drugs have a well-established curative or preventive effect. According to a recent Cochrane review, there is moderate to strong evidence that vestibular rehabilitation (VR) is a safe and effective treatment for peripheral vestibular disease. VR entails that the patient carries out graded exercises (10-20 minutes daily, 6-12 weeks) that stimulate the vestibular system and promote neurological adaptation. Importantly, most VR trials included a selected population (e.g. patients with acoustic neuroma resection) and were conducted in secondary/tertiary care settings; only few trials included a population representative of patients seen in primary care. Despite empirical evidence for the effectiveness of VR, previous research suggests that less than 3% of eligible dizzy primary care patients ever receive VR. In the Netherlands, 93% of GPs never use VR (by themselves of by referral) for the treatment of dizziness: ‘too time consuming’, ‘not familiar with VR’, ‘doubt about effectiveness’, and ‘not recommended by guideline’. Consequently, it is not only important to generate additional evidence for the effectiveness of VR in primary care, but also to consider alternative models of treatment delivery. An online intervention may provide such an alternative model, as it can be rolled out to a large population at little cost. Importantly, internet use by older adults is growing rapidly. Despite the advantages, unguided internet interventions can be associated with substantial attrition and nonadherence. A combination of online and face-to-face therapy (‘blended care’) may reduce attrition and non-adherence, offering patients the best of both worlds. MAIN OBJECTIVE To investigate the effectiveness of stand-alone internet-based VR and internet-based VR with physiotherapeutic support (blended care) for older dizzy patients in general practice. KEY OBJECTIVES I. To investigate the clinical and cost-effectiveness of internet-based VR (with and without physiotherapeutic support) for older dizzy patients in general practice, compared to usual care. II. To identify predictors of successful treatment. III. To investigate experiences of older dizzy patients receiving internet-based VR. METHODS We will perform a single blind, three arm, randomised controlled trial among patients aged 50 years and over presenting with dizziness in general practice. We will compare stand-alone internet-based VR (trial arm 1, N=100) and internet-based VR with physiotherapeutic support (trial arm 2, N=100) with usual care (trial arm 3, N=100). The internet-based VR intervention closely resembles the effective booklet-based VR by Yardley et al (BMJ 2012). Data will be collected online by sophisticated software (LifeGuide). Measurements will be taken at baseline, 3 and 6 months. The primary outcome, dizziness symptoms at 6 months, will be assessed using the Vertigo Symptoms Scale-Short Form. Health economic outcomes will be measured (iMTA Medical Consumption Questionnaire and 5-level EuroQol 5-dimension questionnaire). Secondary outcome measures will be dizziness-related impairment (Dizziness Handicap Inventory), subjective improvement in dizziness symptoms, anxiety and depression (Patient Health Questionnaire), and adherence to treatment (Problematic Experiences of Therapy Scale). Also, we will investigate predictors of successful treatment with internet-based VR, with and without physiotherapeutic support. Finally, we will perform semi-structured face-to-face interviews among a sample of 20-30 participants to investigate patients’ experiences of internet-based VR. COLLABORATION For the design and execution of this project, we have initiated a unique collaboration with international authorities in the field of online interventions (professor Yardley, University of Southampton) and vestibular disease (professor Bronstein, Imperial College London). DELIVERABLES 1. Easy accessible online VR intervention for patients (www.thuisarts.nl) and GPs (www.nhg.org/nhg-standaarden), to be provided by the Dutch College of GPs (NHG). 2. Clinical decision rule for predictors of successful treatment with internet-based VR. 3. Economic evaluation report on internet-based VR in general practice. 4. At least five international peer-reviewed publications. 5. Contribution to the guideline 'Dizziness' of the NHG. 6. Contribution to the multidisciplinary guideline ‘Dizziness in older patients’.