Home-based Vestibular Rehabilitation: A Feasible and Effective Therapy for Persistent Postural Perceptual Dizziness (A Pilot Study)

Abstract

Introduction:

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder where there is persistent dizziness or unsteadiness occurring on most days for more than 3 months duration. Treatment recommendations for PPPD include vestibular rehabilitation therapy (VRT) with or without medications and/or cognitive behavioral therapy.

Objectives:

This paper is a pilot study designed to compare the effects of Bal Ex as a home-based VRT on the quality of life (EQ-5D), dizziness handicap (DHI) and mental health (DASS-21) against hospital-based VRT.

Design:

This was an assessor-blinded, randomized controlled pilot study where PPPD patients were randomly selected to undergo Bal Ex, the home-based VRT (intervention group) or hospital-based (control group) VRT. The participants were reviewed at 4 weeks and 12 weeks after the start of therapy to assess the primary endpoints using the subjective improvement in symptoms as reported by patients, changes in DHI scores, DASS-21 scores and EQ5D VAS scores.

Results:

Thirty PPPD patients successfully completed the study with 15 in each study group. Within 4 weeks, there were significant improvements in the total DHI scores as well as anxiety levels. By the end of 12 weeks, there were significant improvements in the DHI, DASS-21 and EQ5D. The degree of improvement between Bal Ex and the control was comparable.

Conclusion:

VRT is an effective modality in significantly improving quality of life, dizziness handicap, depression, and anxiety levels within 3 months in PPPD. Preliminary results show Bal Ex is as effective as hospital-based VRT and should be considered as a treatment option for PPPD.

Keywords

persistent postural-perceptual dizziness quality of life anxiety vestibular rehabilitation therapy home-based therapy

Introduction

Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder where there is persistent dizziness or unsteadiness on most days for more than 3 months. (Diagnostic criteria listed in Table 1) Usually triggered by a vertiginous event such as vestibular neuritis, benign paroxysmal positional vertigo, panic attacks or even traumatic brain injury, PPPD patients complain of feeling a constant sway or unsteadiness after the initial event has resolved.^1-5

Table 1.

Criteria for the Diagnosis of Persistent Postural-Perceptual Dizziness (PPPD).¹

All 5 criteria must be fulfilled to diagnose PPPD:

A. One or more symptoms of dizziness, unsteadiness or non-spinning vertigo are present on most days for more than 3 month

1. Symptoms last for prolonged (hours-long) periods of time but may wax and wane in severity.

2. Symptoms need not be present continuously throughout the entire day

B. Persistent symptoms occur without specific provocation but exacerbated by upright posture, motion or exposure to visual stimuli.

C. The disorder is precipitated by conditions that cause vertigo, unsteadiness, dizziness or problems with balance including acute, episodic or chronic vestibular syndromes, other neurologic or medical illnesses or psychological distress.

1. When the precipitant is an acute or episodic condition, symptoms settle into the pattern of criterion A as the precipitant resolves, but they may occur intermittently at first and then consolidate into a persistent course.

2. When the precipitant is a chronic syndrome, symptoms may develop slowly at first and worsen gradually.

D. Symptoms cause significant distress or functional impairment.

E. Symptoms not better accounted for by another disease or disorder.

PPPD is commonly seen in females aged 30 to 50 years with a prevalence of 15% to 20% among all patients presenting with vestibular complaints.¹ Often bedside vestibular examination or clinical vestibular function tests for PPPD are normal unless individuals still had residual deficits related to their original triggering or existing conditions.^1,3 PPPD has been shown to affect the personal, social and work life resulting in poorer long-term health outcomes.^6,7 The perceived poor balance in PPPD patients heightens the fear of falling (but never actually falling ) which results in significant limitation of activity which in turn results in significant distress and functional impairment.^1,8

Treatment recommendations for PPPD include vestibular rehabilitation therapy (VRT) with or without medications such as selective serotonin reuptake inhibitors (SSRI) and cognitive behavioral therapy (CBT).^1-3,5,9-11 VRT is a program with graded exercises, consisting of eye, head, and body movements designed to stimulate the vestibular system.⁸ The goals of these movements are to enhance gaze stability, improve postural stability, manage the vertigo symptoms and improve activities of daily living.¹³ Gaze stability is enhanced through vestibular adaptation by improving the vestibulo-ocular reflex (VOR) gain. The error signal from the slippage of visual images on the retina due to a dysfunctional vestibular input is the best stimulus for adaptation.^9,12 However, as PPPD may not have an actual vestibular deficit and instead symptoms are due to chronic hypersensitivity to motion stimuli and visual complexity, desensitization approach through habituation would be more useful.^3,13 Habituation exercises in VRT are repeated monotonous exposure to the specific stimulus that systematically provoke dizziness to create a physiologic fatigue until the patient stops responding completely.^3,10,12-14 In this case, VRT also functions as a behavioral intervention similar to exposure therapy to situations that are challenging which overlaps as a core element in Cognitive Behavioral Therapy (CBT).^10,15 As the noxious stimuli is very patient specific, customized VRT protocols according to the symptoms and functional disability of the individual is encouraged.¹²

Nada et al¹⁰ recorded significant improvements in the functional and physical aspects in the Dizziness Handicap Inventory (DHI) following VRT among their PPPD patients. Home-based VRT in the form of books and web-based have also been useful as a habituation tool among the PPPD patients.^3,10

There is a Malaysian trademarked product called Bal Ex which is a home-based VRT designed to help individuals with peripheral vestibular disorders by means of manual book (Figure 1a), poster and Digital Video Disc (DVD) designed by Zainun and Bin Fauzan.¹⁶ It is available in 9 different languages including Malay, English, Mandarin, Persian, and Spanish. Bal Ex is adapted from Cawthorne-Cooksey Exercise with the addition of other movements including prayer movements such as bowing (Figure 1b) and kneeling until the palms and forehead touches the ground (prostration) (Figure 1c and d). These movements reflect the routine activities performed by Malaysians specifically during prayers. Bal Ex was effective in improving Vertigo Symptom Scale (VSS), Beck Depression Inventory and Beck Anxiety Inventory with chronic vestibulopathy as early as 1 month of therapy.¹⁷

Figure 1.

Bal Ex as a home-based vestibular rehabilitation therapy: (a) Home based vestibular rehabilitation therapy book used in this study, (b-d) are some of the additional culturally practiced steps incorporated in this module, (b) Prayer movement which includes bending down of the body at the 900 position with hand touching the knee (bowing), (c-d) While kneeling down, patients are advised to bend down until palm and forehead touches the ground (prostration).

Effective therapy requires sustained effort which relies heavily on the patient’s commitment and motivation. A home-based option which includes activities that are familiar to our local setting may be an incentive for better compliance. This paper is a pilot study looking at the effects of VRT in PPPD and the efficacy of Bal Ex on the quality of life, dizziness handicap and mental health when compared to hospital based VRT.

Methods

This was an assessor-blinded, randomized controlled pilot study approved by Medical Research Ethics Committee (NMRR-19-35-45775 (IIR)). Consenting patients from the Otorhinolaryngology Clinic, Hospital Sungai Buloh, Malaysia aged between 18 and 70 years who fulfilled the diagnostic criteria for PPPD (Table 1) were recruited.¹ Those with acute vestibular disorders or symptoms due to other known conditions such as cardiovascular, diseases where vigorous head movements were contraindicated (eg, osteoporosis of the neck) were excluded from the study.

Self-Reported Assessment

Once consented, full clinical history was taken and participants had to complete a series of self-reported questionnaires including Depression Anxiety Stress Scales (DASS-21), Dizziness Handicap Inventory (DHI) and EQ-5D (Quality of life assessment). The Depression, Anxiety and Stress Scales (DASS) is a self-reported instrument designed to assess the unique and related aspects of anxiety, depression, and stress. It was a 42-item questionnaire which later shortened to 21 items, now known as DASS-21.¹⁸ Patients answered either no (score 0), sometimes (score 1), good part of (score 2) or most of the time (score 3) to each statement. At the end of scoring, level of depression, anxiety, and stress is scored separately.¹⁹

DHI is a 25-item self-assessment tool used to measure functional, emotional, and physical effects of dizziness and unsteadiness. Patients were required to answer no (score 0), sometimes (score 2), or always (score 4). The higher the score, the more severe the handicap is with maximum handicap of 100.²⁰

EQ-5D is the most widely used patient reported outcome tool around the world to measure and value health status. It has 1 question for each of the 5 dimensions which include mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Patient scored 1 if had no problems carrying out a task, score 2 if they had some problems, scored 3 if they were unable or had severe pain. It also includes a Visual Analog Scale (VAS) to gauge their perceived health status from 0 (worst health state) to 100 (best health state).²¹

DASS-21, DHI, and EQ-5D were used in this study as they were validated, reliable questionnaires that had Malay version suitable for the local population.^22,23

Vestibular and Audiologic Assessment

Bedside vestibular examination was performed to assess for any neurological weaknesses or hypo-functioning vestibular system. This was followed by tympanometry, audiometry, video nystagmography (VNG), rotary chair, video Head Impulse Test (VHIT), and vestibular evoked myogenic potential (VEMP). If the history was suggestive, some patients underwent radio-imaging to rule out neurological causes for their symptoms. Those with active vestibular problems such as BPPV or uncompensated acute vestibular neuritis are excluded from the study.

Vestibular Rehabilitation

The patients were then randomized using an online randomization software (www.sealedenvelope.com) to either receive Bal Ex (Intervention Group) or the hospital based VRT (Control Group).

Bal Ex consists of 20 movements divided into 3 levels. Level 1 involves head, neck, and eye movements. Level 2 focuses on positioning, movements related to daily activities such as getting up and prayer motion. Level 3 worked on posture and gait (Table 2 lists all the movements in Bal Ex). Patients under the intervention group underwent a directive session ensuring that they understood the correct way to perform the exercises. Stepwise approach was encouraged beginning with slow 10 repetitions for each movement and increasing to 20 repetitions and at a faster rate. Exercises were to be performed 3 times a day. The patients were given a logbook to document compliance and any adverse effects from Bal Ex.

Table 2.

Description of Bal Ex. Each Step is to be Performed 20 Repetitions, 3 Times a Day.

Level 1 All movements are performed with eyes open and then closed. Please imagine a target when performing visual fixation with eyes closed.
1	a. Move your head forward and backward (as if nodding to say yes) without visual fixation on a stationary object b. Turn your head to right and left without visual fixation on a stationary object c. Move your head forward and backward (as if nodding to say yes) with visual fixation on a stationary object d. Turn your head to right and left with visual fixation on a stationary object
Level 2 All movements are performed with eyes open and then closed
1	a. Bend down with hand touching floor from sitting position b. Bend down with hand touching floor from standing position
2	Bend down your body at 90° position and hand touching knee
3	Bend down your body and rotate head left and right
4	Look over your shoulder left and right
5	Lie down and roll from side to side
6	Move from lying position to sitting position
7	While kneeling, bend down your body with palm, forehead, and knee touching the floor
Level 3 Exercise 1-5 are performed with eyes open and then closed
1	Stand with your feet close together without support
2	a. March on the spot b. While standing, raise your heels and the toes
3	a. Touch object on the floor with feet a foot apart b. Touch object on the floor with feet together
4	Stand on one leg
5	a. Stand on a soft pillow and march in one position b. Stand on a soft pillow and rotate upper body and head left and right.
6	Walk forward in straight line with one foot behind the other (tandem gait)
7	Walk sideways left and the right
8	Walk on uneven surface (Pillows or lumpy mattress is placed on the ground)
9	a. Walk in figure of eight b. Walk in a circle c. Walk while making pivot turns
10	Step on and off a step without turning around
11	a. Move head up and down while walking b. Move head side to side while walking
12	Walk while looking over your left and right shoulder alternately

Those who received hospital-based VRT had sessions with a personal physiotherapist who customized the therapy with monthly sessions lasting 30 minutes. The patients in this group had a range of 2 to 3 sessions that consist mainly of Cawthorne-Cooksey exercises and exercises targeting postural stability without any written programs provided as references. Patients were advised to practice what was taught at home for at least 3 times a day. The patients were also provided a logbook to document compliance and any troubles.

The participants were reviewed at 4 weeks and 12 weeks after the start of therapy. During the appointment, subjective improvements (worse, same, better, or completely resolved), self-reported questionnaires and vestibular function were assessed. Compliance and problems faced during exercises were noted. The primary endpoints used in this study were subjective improvement in symptoms and changes in DHI, DASS-21, and EQ-5D VAS.

Statistical analysis

Student t-test was used to compare the continuous variables such as the DHI, EQ-5D VAS and DASS-21 between groups. The chi-squared and Fischer’s exact test methods were used for categorical variables (eg, demographics and EQ-5D). Overall effectiveness of VRT on PPPD was assessed by comparing the endpoints within the first 4 weeks and then 12 weeks. The mean differences in the 4 weeks and 12 weeks of the home-based and hospital-based therapy were then analyzed to compare the effectiveness of each therapy. The level of significance was set at 5% (P = .05).

Results

Between September 2019 and June 2021, 32 PPPD patients were recruited, 16 were randomly enrolled in the home-based VRT and 16 were controls. Two participants dropped out, one from each group. (Figure 2) The Bal Ex group had 4 participants on SSRI and control group had 3 participants on SSRI. The 2 study groups exhibited a homogenous distribution of demographic data and history characteristics (Table 3). Our PPPD patients reported duration of illness between 3 and 180 months with a mean duration of 3 years (39.8 ± 40.7 months). The triggers were mainly peripheral vestibular in origin with BPPV as the most common cause.

Figure 2.

CONSORT 2010 flow diagram.

Table 3.

Demographic and History Characteristics Pre-Treatment.

Characteristics	All (30)	Hospital VRT (15)	Bal Ex (15)	P value
Age	46.27 ± 9.82	48.52 ± 8.72	44 ± 10.61	.150
Gender (Females)	19 (63.3%)	10 (66.7%)	9 (60%)	.705
Duration of symptoms
3-6 month	6 (20%)	5 (33.3%)	1 (6.7%)	.166
6-12 month	6 (20%)	3 (20%)	3 (20%)
1-5 year	11 (36.7%)	3 (20%)	8 (53.3%)
>5 year	7 (23.3%)	4 (26.7%)	3 (20%)
Symptoms
Unsteadiness	28 (93.3)	14 (93.3)	14 (93.3)	1
Dizziness	20 (66.7)	11 (73.3)	9 (60)	.699
Headache	10 (33.3)	5 (33.3)	5 (33.3)	1
Non-spinning vertigo	9 (30)	5 (33.3)	4 (26.7)	1
Diagnosis
BPPV	11 (36.7%)	4 (26.7%)	7 (46.7%)	.739
Vestibular Neuritis	5 (16.7%)	3 (20%)	2 (13.3%)
Labyrinthitis	3 (10%)	2 (13.3%)	1 (6.7%)
Panic attacks	2 (6.7%)	1 (6.7%)	1 (6.7%)
Stroke and head injury	6 (20%)	4 (26.7%)	2 (13.3%)
Co-morbidities
Hypertension	10 (33.3)	6 (40)	4 (26.7)	.699
Diabetes	6 (20)	2 (13.3)	4 (26.7)	.651
Ischemic heart disease	1 (3.3)	0 (0)	1 (6.7)	1
Dyslipidemia	10 (33.3)	5 (33.3)	5 (33.3)	1
Cerebrovascular disease	4 (13.3)	3 (20)	1 (6.7)	.598
Anxiety/depression Disorder	1 (3.3)	0 (0)	1 (6.7)	1
EQ5D (Persons scoring 2 or 3)
Mobility	17 (56.7%)	9 (60%)	8 (53.3%)	.713
Self-care	6 (20%)	3 (20%)	3 (20%)	1
Usual activities	23 (76.7%)	13 (86.7%)	10 (66.7%)	.195
Pain/discomfort	21 (70%)	10 (66.7%)	11 (73.3%)	.690
Anxiety/depression	20 (66.7%)	8 (53.3%)	12 (80%)	.121
Mean EQ5D VAS	65.3 ± 17.2	63.67 ± 18.66	67 ± 16.01	.32
DHI (mean scores)
Physical	14.3 ± 7.5	14.4 ± 8.18	14.2 ± 7.11	.453
Functional	20.7 ± 9.6	22 ± 9.23	19.33 ± 10.1	.228
Emotional	14.4 ± 9.7	13.2 ± 9.19	15.6 ± 10.40	.311
Total	49.7 ± 24	50.27 ± 22.93	49.13 ± 25.85	.385
DASS-21 (mean scores)
Depression	6.1 ± 5	5.8 ± 5.33	6.4 ± 4.81	.4
Anxiety	7.8 ± 5.1	6.33 ± 4.67	9.2 ± 5.32	.087
Stress	7.4 ± 4.9	6.87 ± 4.44	8 ± 5.37	.277
Total	21.3 ± 14.2	18.93 ± 13.92	23.6 ± 14.57	.215

From the EQ-5D, the self-care was least affected when compared to managing their usual activities, mobility, pain, or anxiety/depression. Mean VAS was at 65.3 ± 17.2. Mean DHI scores was recorded as 49.7 ± 24 and DASS-21 was reported as mild (6.1 ± 5) for depression, moderate (7.8 ± 5.1) for anxiety and mild (7.4 ± 4.9) for stress.

Review of the logbooks confirmed compliance in both arms. During the second and third visit, Bal Ex group reported it easy to perform the exercises and were able to demonstrate the steps practiced at home. While the physiotherapist in the control arm only saw them once a month, the participants similarly felt the exercises were easy to perform and were able to perform them during the clinic visits.

Effects of VRT

Twenty-nine (96.7%) PPPD patients found regardless of the type of VRT to be beneficial. Fourteen subjects (93.3%) in the Bal Ex group found the exercises beneficial including 2 who reported complete resolution of symptoms. One subject (6.7%) however claimed no improvements but not worsening. In the hospital-based group, 100% found it beneficial with 2 experiencing complete resolution of symptoms.

There was significant improvement in the anxiety levels seen on EQ5D and DASS-21 as well as the total DHI scores improving from 49.7 ± 24 at pre-treatment to 37.4 ± 24.3 within 4 weeks (P = .033). (Table 4) The total DHI scores continued to improve significantly at the end of 12 weeks to 33.6 ± 23.4 (P = .005) including all individual aspects of DHI (physical, functional, and emotional). EQ5D VAS increased by almost 10 points in 12 weeks from 65.3 ± 17.2 to 74.7 ± 15.9 (P = .016). There were also significant improvements in the depression, anxiety, and total DASS-21 scores.

Table 4.

Overall Effects of Vestibular Rehabilitation Therapy in PPPD.

	Results at pre-treatment and at 4 week			Results at 12th week and difference from pre-treatment
	Visit 1	Visit 2	P value	Visit 3	P value
EQ5D (Persons scoring 2 or 3)
Mobility	17 (56.7%)	19 (63.3%)	.580	9 (30%)	.037*
Self-care	6 (20%)	6 (20%)	.735	5 (16.7%)	.739
Usual activities	23 (76.7%)	20 (66.7%)	.678	16 (53.3%)	.058
Pain/discomfort	21 (70%)	22 (73.3%)	.892	20 (66.7%)	.781
Anxiety/depression	20 (66.7%)	11 (36.7%)	.046*	12 (40%)	.038*
Mean EQ5D VAS	65.3 ± 17.2	69.7 ± 19.9	.192	74.7 ± 15.9	.016*
DHI (mean score)
Physical	14.3 ± 7.5	11.8 ± 7.1	.111	9.9 ± 6.5	.010*
Functional	20.7 ± 9.6	15.6 ± 9.8	.029	14.4 ± 9.2	.006*
Emotional	14.4 ± 9.7	10.4 ± 9.7	.067	8.7 ± 7.9	.008*
Total	49.7 ± 24	37.4 ± 24.3	.033*	33.6 ± 23.4	.005*
DASS-21 (mean score)
Depression	6.1 ± 5	4.2 ± 5.1	.058	4.1 ± 4.5	.004*
Anxiety	7.8 ± 5.1	5.3 ± 4.6	.035*	6.4 ± 4.3	.025*
Stress	7.4 ± 4.9	6 ± 4.7	.095	6.6 ± 4.6	.055
Total	21.3 ± 14.2	15.5 ±13.3	.054	17.4 ± 13.3	.016*

p value <.05.

When analyzed individually, both study groups showed improvements in EQ5D VAS, DHI, and DASS-21 at the end of 12 weeks (Figure 3). Larger improvement in the anxiety levels at week 4 was seen in Bal Ex group but was no longer seen at the 12-week visit. The other mean improvements of EQ5D, DHI, and DASS-21 between Bal Ex and hospital-based VRT were comparable (Table 5).

Figure 3.

Comparison of mean scores between Visit 1, 2, and 3 for each modality of treatment.

Table 5.

Mean Improvement Between Different VRT Modalities in PPPD.

	Mean improvement in the first 4 week			Mean improvement in 12 week
	Bal Ex	Hospital	P value	Bal Ex	Hospital	P value
EQ-5D	5.7 ± 9.5	2.9 ± 15.6	.142	11.3 ± 16.2	7.3 ± 21.9	.356
DHI
Physical	2.3 ± 2.7	1 ± 8	.255	4.2 ± 4.2	4.5 ± 7	.476
Functional	3.1 ± 3.1	4.9 ± 9.5	.125	4.1 ± 5	7.6 ± 5.6	.061
Emotional	2.2 ± 3.5	3.6 ± 4.9	.184	5.7 ± 6.5	5.6 ± 6	.484
Total	8.5 ± 5.3	10.1 ± 19.9	.352	14.1 ± 11.7	18.1 ± 15.5	.386
DASS-21
Depression	1.7 ± 4.6	1.4 ± 1.5	.468	1.9 ± 3.8	2.1 ± 2.5	.468
Anxiety	2.5 ± 2.6	1 ± 1.9	.019*	1.9 ± 5.3	0.9 ± 4.1	.203
Stress	0.5 ± 4.4	1.3 ± 2.5	.394	0.6 ± 3.8	1.1 ± 2.5	.356
Total	4.8 ± 8.5	3.6 ± 4.6	.142	4.3 ± 11.6	3.5 ± 7.7	.268

p value <.05.

Discussion

Study Design and Demographics

For a pilot study, the recruitment and adherence to the study were satisfactory with a completion rate of 93.8% where only 2 participants dropped out after the first visit citing COVID-19 fears in hospitals. All other participants could complete the questionnaires and found the testing as well as treatment relevant. The patients had been searching for a diagnosis for an average of 3 years which were similar to those reported^24,25 and this contributed to the good compliance as they were eager to try anything which may help with their symptoms. As such, there were no major alterations to the study protocol required.

The symptoms and demographic characteristics of our PPPD patients were no different from those published where they were predominantly females with the mean age values ranging between 30 and 50 years.^9,24,26-32 The common symptoms reported in our study were unsteadiness (93.3%) and dizziness (66.7%) which corresponded to the findings of Habs et al.²⁴ The most common triggers were also vestibular in origin similar to other published data.^30,33,34 While Habs et al had almost 55% of the PPPD patients with no obvious triggers,²⁴ we did not have such high percentage with only 3 (10%) patients. Our pre-treatment DHI scores of 49.7 was within the documented mean range of 44 to 56^{9,24,26,28,32,35} which had the functional aspects most affected more so than physical or emotional. Our mean EQ-5D VAS score was not far off from the reported range of 42 to 62.^11,24

Overall Effects of VRT

While VRT is accepted as a safe and effective treatment for acute and chronic peripheral vestibulopathy,^5,12 there is lacking in high-quality randomized controlled studies to evaluate which form of VRT is better and which is more effective in PPPD. David et al³⁶ used gaze stability and balance retraining exercises in a double blinded placebo control randomized trial in patients with peripheral vestibular dysfunction and showed improvement in locomotor stability. Strupp et al in a prospective, randomized study showed that patients with acute unilateral vestibular loss treated with habituation and Cawthorne-Cooksey exercises had significantly improved postural stability compared to untreated control group after 1 month.³⁷ Venosa and Bittar showed that their patients required less medication when taught adaptation exercises at the time of presentation in the emergency department.³⁸ VRT also facilitated recovery in postural stability and vestibulospinal compensation in post acoustic neuroma surgeries.^39,40 However, all these cases had some form of vestibular asymmetry where compensation could be achieved through VRT.

Our study investigated the effects of VRT in a functional disorder specifically PPPD. Studies showed VRT to be beneficial in terms of VSS, fall risk, balance, and emotional status^3,41 and improved posturography abnormalities in patients with PPPD.^42,43 Similarly, our patients responded well to VRT with a significant overall improvement of the DHI within 4 weeks (12.3 points drop) and this continued to increase to 16.1 point drop after 12 weeks. Significant improvements of the individual elements of DHI (physical, functional, and emotional) were only seen at 12 weeks indicating that time was an important factor to elicit effects of therapy. This further supports the previous findings that VRT gave rise to subjective improvements and in DHI scores.^5,9,42 Nada et al however only showed improvements in the physical and functional elements in DHI but not the emotional aspect.¹⁰ However, their study only followed-up with their patients for 6 weeks whereas in this research, the study period was doubled to 12 weeks. The element of time may have contributed to the emotional improvements seen in our study.

The DASS-21 scores in our study population were just above the cutoff levels for mild in depression levels and moderate in anxiety levels. Anxiety levels improved significantly within 4 weeks and depression, anxiety and overall DASS-21 scores significantly improved after 12 weeks of VRT. Our PPPD patients also had significant improvement of EQ-5D scores post VRT from 65.3 to 74.7 at the end of 12 weeks. This further supports the fact that depressive mood and having anxiety is not a barrier to achieving a positive response to VRT.^3,9,12,44

Bal Ex in PPPD

In principle, VRT should be tailored to a person’s limitation and abilities and this is best performed under the watchful eye of a physiotherapist.¹² However, is there a role in non-customized home VRT for patients with PPPD?

Bal Ex has shown equivalent efficacy when compared to hospital-based VRT. However, there was observed larger variability in the control group in the DHI and VAS scores while the Bal Ex group had a larger variability in the DASS-21 score. It would seem that Bal Ex had more consistent improvement in the balance symptoms but less so in the emotional states. As Bal Ex is a book which helps a patient focus solely on the simple exercises with a clear path to what the end looks like. This may be the factor which helps keep the patient motivated and on track and hence less variability in the DHI and VAS scores. Whereas with a physiotherapist, there is the human presence which aids in emotional support which is absent with Bal Ex. However, the physiotherapist threads a fine line needing to support the emotional needs of the patient as well as giving the adequate push for adequate exercise which may result in the larger variability in the DHI scores in the hospital-based VRT. These findings now alerts us the importance of juggling the consistency in performing the exercises as well as the emotional support of VRT in PPPD.

While Bal Ex aims at gaze stabilization, posture control and mobility, it can be used as a habituation tool. During the first directive session, the PPPD patients were observed for exercises that triggered dizziness which were mainly the Level 1 exercises. They were encouraged to repeatedly perform them to initiate the habituation process. Habituation can be achieved though visual stimulation or head and body movements and Thompson et al had demonstrated that the head and body movements were most effective in PPPD.³ This may explain why our patients responded positively with improved tolerance to the repeated movements of the head and body.

Looking at a larger picture, patients with dizziness usually seek treatment at the primary care level which may not have neurotology or VRT facilities. A non-customized home VRT such as Bal Ex may be able to provide relief in a PPPD patient without the added financial burden as well as logistical hassle for the patient to travel miles away for therapy. Motivated by the needs of a population living far from a tertiary medical center, Yardley et al had demonstrated in a randomized controlled study the effectiveness of a non-customized VRT being delivered by a trained nurse. The study showed that booklet VRT reduced symptoms, anxiety, handicap, emotional distress in the Hospital Anxiety and Depression Scale and was cost effective.⁸ Intervention at the primary care level using Bal Ex could reduce the number of patients needing referrals⁸ and even more so, since it is as effective as a hospital-based VRT. Furthermore, Bal Ex performed better in alleviating the anxiety levels compared to hospital based VRT in the first 4 weeks of treatment and this may just be the motivation the PPPD patients need to continue to be compliant with the therapy.

This study had its limitations where it was not possible to blind participants to the intervention group that they were in. However, patients from both arms were motivated to seek relief and endpoints were based on self-assessed questionnaires looking at relative improvements within one-self. There were also non-specific psychological effects of treatment, such as assurance and positive outcome expectations especially while being seen by a physical physiotherapist. We had expected that it would contribute to a better outcome but as the outcomes were comparable, it further demonstrates how Bal Ex could be an effective option without the need for constant physical interaction. Undeniably, the sample size is small as it is part of a pilot study. As there is no major alteration to the study protocol, this study is still ongoing, and we are collecting data to include a 6- and 12-month follow-up.

In conclusion, vestibular rehabilitation therapy in Persistent Postural-Perceptual Dizziness is an effective modality in significantly improving quality of life, dizziness handicap, depression, and anxiety levels. While customized VRT is encouraged, Bal Ex is a non-customized home-based VRT that is as effective as hospital based VRT and can be considered as part of a treatment option for PPPD.

Footnotes

Abbreviation

BPPV = Benign Paroxysmal Positional Vertigo

CBT = Cognitive Behavioral Therapy

DASS-21 = Depression, Anxiety, Stress Scale (21 Items)

DHI = Dizziness Handicap Inventory

EQ-5D = EuroQOL 5 Dimension

PPPD = Persistent Postural-Perceptual Dizziness

SSRI = selective serotonin reuptake inhibitors

VAS = Visual Analog Scale

VEMP = Vestibular Evoked Myogenic Potential

VHIT = Video Head Impulse Test

VNG = Video Nystagmography

VSS = Vertigo Symptom Scale

VOR = vestibulo-ocular reflex

VRT = Vestibular Rehabilitation Therapy

Author Contributions

All authors contributed equally to this work. CS Teh, Z Zainun, I Fadzilah and N Prepageran were involved in the conception and design of the study. NA Abdullah, NR Kamarudcin, K Mohd Judi and CS Teh was involved in the data acquisition, analysis and interpretation of data. CS Teh wrote the main paper. All authors discussed the results and implications and commented on the manuscript at all stages. N Prepageran revised it critically.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was self-funded.

Ethical Approval

This study is registered National Medical Research Register and approved by the Malaysian Medical Research and Ethics Committee (MREC) with the registration number NMRR-19-35-45775 (IIR).

ORCID iD

Carren Sui-Lin Teh

References

Staab

Eckhardt-Henn

Horii

, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the committee for the classification of Vestibular Disorders of the Bárány Society. J Vestib Res. 2017;27(4):191-208.

Popkirov

Staab

Stone

Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018;18(1):5-13.

Thompson

Goetting

Staab

Shepard

NT.

Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: a pilot study. J Vestib Res. 2015;25:97-104. doi:10.3233/VES-150551

Powell

Derry-Sumner

Rajenderkumar

Rushton

Sumner

Persistent postural perceptual dizziness is on a spectrum in the general population. Neurology. 2020;94(18):e1929-e1938.

Choi

KD.

Effect of vestibular exercise and optokinetic stimulation using virtual reality in persistent postural-perceptual dizziness. Sci Rep. 2021;11(1):14437.

Sezier

AEI

Saywell

Terry

Taylor

Kayes

. Working-age adults’ perspectives on living with persistent postural-perceptual dizziness: a qualitative exploratory study. BMJ Open. 2019;9(4):e024326.

Teh CS

Prepageran

The impact of disease duration in persistent postural-perceptual dizziness (PPPD) on the quality of life, dizziness handicap and mental health. J Vestib Res. 2021 Dec 17. doi: 10.3233/VES-210087. Epub ahead of print.

Yardley

Barker

Muller

, et al. Clinical and cost effectiveness of booklet based vestibular rehabilitation for chronic dizziness in primary care: single blind, parallel group, pragmatic, randomised controlled trial. BMJ. 2012;344:e2237-e2237.

Kuwabara

Kondo

Kabaya

, et al. Acceptance and commitment therapy combined with vestibular rehabilitation for persistent postural-perceptual dizziness: a pilot study. Am J Otolaryngol. 2020;41(6):102609.

10.

Nada

Ibraheem

Hassaan

MR.

Vestibular rehabilitation therapy outcomes in patients with persistent postural-perceptual dizziness. Ann Otol Rhinol Laryngol. 2019;128(4):323-329.

11.

Eldøen

Kvalheim

Thesen

, et al. Web-based vestibular rehabilitation in persistent postural-perceptual dizziness. Brain Behav. 2021;11(10):e2346. doi:10.1002/brb3.2346

12.

Eleftheriadou

Skalidi

Velegrakis

GA.

Vestibular rehabilitation strategies and factors that affect the outcome. Eur Arch Otorhinolaryngol. 2012;269(11):2309-2316.

13.

Hall

Herdman

Whitney

, et al. Vestibular rehabilitation for peripheral vestibular hypofunction: an updated clinical practice guideline from the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022;46(2):118-177. doi:10.1097/NPT.0000000000000382

14.

Lacour

Bernard-Demanze

Interaction between vestibular compensation mechanisms and vestibular rehabilitation therapy: 10 recommendations for optimal functional recovery. Front Neurol. 2015;5:285. doi:10.3389/fneur.2014.00285

15.

Han

Song

Kim

JS.

Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol. 2011;7(4):184-196.

16.

Zainun

Bin Fauzan

Rapid recovery of a patient with chronic balance disorders treated with combination of home-based therapy and regular physiotherapist follow-up: A case report. Medeniyet Med J. 2017;32(3):191-194.

17.

Zainun

Sy Saifuddin

SN.

Effectiveness and psychological improvement in chronic vestibular problem using home-based balance rehabilitation with step 1 (head and neck movement): A case report. Int J Sci Med Ed. 2021;15(2):35-37.

18.

Norton

PJ.

Depression anxiety and stress scales (DASS-21): psychometric analysis across four racial groups. Anxiety Stress Coping. 2007;20(3):253-265.

19.

Bakir

Kinis

Bez

, et al. Mental health and quality of life in patients with chronic otitis media. Eur Arch Otorhinolaryngol. 2013;270(2):521-526.

20.

Yorke

Ward

Vora

Combs

Keller-Johnson

Measurement characteristics and clinical utility of the dizziness handicap inventory among individuals with Vestibular Disorders. Arch Phys Med Rehabil. 2013;94(11):2313-2314.

21.

Devlin

Brooks

EQ-5D and the euroqol group: Past, present and Future. Appl Health Econ Health Policy. 2017;15:127-137.

22.

Musa

Fadzil

Zain

Translation, validation and psychometric properties of Bahasa Malaysia version of the depression anxiety and stress scales (DASS). ASEAN J Psychiatry. 2007;8(2):82-89.

23.

Zainun

Saat Ga

. Translation and validation study of Malay version of dizziness handicap inventory (MYDHI). Medeniyet Med J. 2017;32(3):170-174.

24.

Habs

Strobl

Grill

Dieterich

Becker-Bense

Primary or secondary chronic functional dizziness: does it make a difference? A DizzyReg study in 356 patients. J Neurol. 2020;267(Suppl 1):212-222.

25.

Jeong

, et al. Correction to: cerebral perfusion abnormalities in patients with persistent postural-perceptual dizziness (PPPD): a SPECT study. J Neural Transm. 2019;126(5):697-699.

26.

Bittar

Lins

EM.

Clinical characteristics of patients with persistent postural-perceptual dizziness. Braz J Otorhinolaryngol. 2015;81(3):276-282.

27.

Yan

Cui

Liang

Wang

Chen

Analysis of the characteristics of persistent postural-perceptual dizziness: a clinical-based study in China. Int J Audiol. 2017;56(1):33-37.

28.

Xue

Zhang

Zhou

Cognitive Behavior Therapy as augmentation for sertraline in treating patients with persistent postural-perceptual dizziness. Biomed Res Int. 2018;2018:8518631. doi:10.1155/2018/8518631

29.

Zachou

Anagnostou

Diagnostic value of key signs in persistent postural-perceptual dizziness. J Neurol. 2020;267(6):1846-1848.

30.

Adamec

Juren Meaški

Krbot Skorić

, et al. Persistent postural-perceptual dizziness: clinical and neurophysiological study. J Clin Neurosci. 2020;72:26-30.

31.

Breinbauer

Contreras

Lira

, et al. Spatial navigation is distinctively impaired in persistent postural perceptual dizziness. Front Neurol. 2020;10:1361.

32.

Ertugrul

Söylemez

Soylemez

Determination of predictors for persistent postural-perceptual dizziness. KBB-Forum. 2019;18(3):249-256.

33.

Nigro

Indovina

Riccelli

, et al. Reduced cortical folding in multi-modal vestibular regions in persistent postural perceptual dizziness. Brain Imaging Behav. 2019;13(3):798-809.

34.

Dimitriadis

Saad

Igra

, et al. White matter lesions in magnetic resonance imaging of the brain in 56 patients with visual vertigo. J Laryngol Otol. 2018;132(6):550-553.

35.

Kristiansen

Magnussen

Juul-Kristensen

, et al. Feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy for people with persistent dizziness. Pilot Feasibility Stud. 2019;5(1):69.

36.

David

Kathleen

MGB

Stephen

Jose

Mara

WR.

Vestibular rehabilitation: useful but not universally so. Otolaryngol Head Neck Surg. 2003;128(2):240-250.

37.

Strupp

Arbusow

Maag

Gall

Brandt

Vestibular exercises improve central vestibulospinal compensation after vestibular neuritis. Neurology. 1998;51(3):838-844.

38.

Venosa

Bittar

RS.

Vestibular rehabilitation exercises in acute vertigo. Laryngoscope. 2007;117(8):1482-1487.

39.

Vereeck

Wuyts

Truijen

De Valck

Van de Heyning

PH.

The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection. Clin Rehabil. 2008;22(8):698-713.

40.

Herdman

Clendaniel

Mattox

Holliday

Niparko

JK.

Vestibular adaptation exercises and recovery: acute stage after acoustic neuroma resection. Otolaryngol Head Neck Surg. 1995;113(1):77-87.

41.

Kundakci

Sultana

Taylor

Alshehri

MA.

The effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness: a systematic review. F1000Res. 2018;7:276.

42.

Morisod

Mermod

Maire

Posturographic pattern of patients with chronic subjective dizziness before and after vestibular rehabilitation. J Vestibular Res. 2018;27(5-6):305-311.

43.

Baydan

Yigit

Aksoy

Does vestibular rehabilitation improve postural control of subjects with chronic subjective dizziness?

PLoS One. 2020;15(9):e0238436.

44.

Axer

Finn

Wassermann

Guntinas-Lichius

Klingner

Witte

OW.

Multimodal treatment of persistent postural-perceptual dizziness. Brain Behav. 2020;10(12):e01864. doi:10.1002/brb3.1864