Online treatment for older dizzy patients in general practice

INTRODUCTION:

Dizziness is a common symptom in general practice with a high prevalence among older adults. The most common cause of dizziness in general practice is peripheral vestibular disease. Vestibular rehabilitation (VR) is a safe and effective treatment for peripheral vestibular disease that entails specific exercises to maximise the central nervous system compensation for the effects of vestibular pathology. An internet-based VR intervention has recently been shown to be safe and effective. Online interventions are low cost and easily accessible, but prone to attrition and non-adherence. A combination of online and face-to-face therapy, known as blended care, may balance these advantages and disadvantages.

METHODS AND ANALYSIS:

A single-blind, three-arm, randomised controlled trial among patients aged 50 years and over presenting with dizziness of vestibular origin in general practice will be performed. In this study, we will compare the clinical and cost-effectiveness of stand-alone internet-based VR and internet-based VR with physiotherapeutic support ('blended care') with usual care during 6 months of follow-up. We will use a translated Dutch version of a British online VR intervention. Randomisation will be stratified by dizziness severity. The primary outcome measure is the Vertigo Symptoms Scale-Short Form. Intention-to-treat analysis will be performed, adjusting for confounders. The economic evaluation will be conducted from a societal perspective. We will perform an additional analysis on the data to identify predictors of successful treatment in the same population to develop a clinical decision rule for general practitioners.

Stand-alone internet-based Vestibular Rehabilitation (VR) and internet-based VR with physiotherapeutic support is more (cost-)effective than usual care when treating dizziness in older patients in general practice.

Inclusion: June 2017 -May 2018.
Follow-up: September 2017 - November 2018.
Measurements: at baseline, 3 months, and 6 months follow-up.

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 on the effective booklet-based VR by Yardley et al (BMJ 2012).
VR entails specific exercises with the aim of maximising central nervous system compensation for vestibular pathology. Recently, specific components have been defined, namely compensation (using motion to habituate or reduce responsiveness to repetitive stimuli and to re-balance tonic activity within the vestibular nuclei), adaptation (using repetitive and provocative movements of the head and/or eyes to reduce error and restore vestibule-ocular reflex gain), substitution (promoting the use of individual or combinations of sensory inputs), and motor learning principles (changing movement behaviour).