The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness

Abstract

Background Persistent postural perceptual dizziness (PPPD) is a common and disabling functional neuro-vestibular disorder. We aimed to determine the feasibility and acceptability of conducting a randomised controlled trial of cognitive-behavioural therapy informed vestibular rehabilitation (INVEST intervention) designed for persistent dizziness. Methods A two-armed parallel groups randomised feasibility study of INVEST vs. a time-matched gold standard vestibular rehabilitation (VRT) control. Participants with PPPD were recruited from a specialist vestibular clinic in London, UK. Participants were individually randomised using a minimisation procedure with allocation concealment. Measures of feasibility and clinical outcome were collected and assessed at 4 months. Results Forty adults with PPPD were randomised to six sessions of INVEST (n = 20) or gold standard VRT (n = 20). Overall, 59% of patients screened met the inclusion criteria, of which 80% enrolled. Acceptability of INVEST, as assessed against the theoretical framework of acceptability (TFA), was excellent and 80% adhered to all 6 sessions. There were small to moderate treatment effects in favour of INVEST across all measures, including dizziness handicap, negative illness perceptions, symptom focussing, fear avoidance, and distress (standardised mean difference [SMD]g = 0.45; SMDg = 0.77; SMDg = 0.56; SMDg = 0.50, respectively). No intervention-related serious adverse events were reported. Conclusions The study results give strong support for the feasibility of a full-scale trial. Both arms had high rates of recruitment, retention, and acceptability. There was promising support of the benefits of integrated cognitive-behavioural therapy-based vestibular rehabilitation compared to gold standard vestibular rehabilitation. The study fulfilled all the a-priori criteria to advance to a full-scale efficacy trial. Trial registration number ISRCTN10420559.

Impact and experiences of vestibular disorders and psychological distress: Qualitative findings from patients, family members and healthcare professionals

“…Stakeholders also thought an integrated approach to care would be valuable, whereby physical and psychological aspects are addressed concurrently. Recently, combined approaches delivering cognitive behavioural therapy and vestibular rehabilitation concurrently were found to reduce dizziness handicap, psychological distress, and avoidance amongst patients with persistent dizziness 68,69 . Our findings lend support to this model and suggest that further roll‐out would be worthwhile, as well as future research investigating the longer term impacts of these interventions on daily activities, social engagement and clinical recovery.…”

Exploring the role of attention towards balance in chronic dizziness: Development of the Balance Vigilance Questionnaire

“…Given the links between balance vigilance and chronic dizziness [6, 8], the Balance‐VQ could be a useful tool to help identify patients most likely to benefit from rehabilitation that specifically targets attention during balance (see Herdman et al. [34]). Future work should investigate the prospective utility of the scale for identifying those most at risk of developing chronic dizziness (e.g., PPPD).…”

“…This could then help identify which patients may be most likely to benefit from rehabilitation that specifically targets attention during balance, a strategy that seems particularly effective for improving symptoms in PPPD (see Herdman et al. [34]). Future work should look to explicitly test the sensitivity of the Balance‐VQ for predicting the development of chronic dizziness (particularly following an acute neuro‐otological insult).…”

Introduction to the assessment and management of persistent postural-perceptual dizziness

“…As such, patients tend to benefit from vestibular rehabilitation, as well as cognitive behavioural therapy, and these are best employed concurrently. Thus, cognitive behavioural therapy techniques should inform and augment physical therapy approaches, and vestibular exercises 33 or relaxation techniques should be integrated into cognitive behavioural therapy programmes.…”