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Effectiveness of Combined Vestibular Rehabilitation & Cognitive Behavioral Therapy in the Treatment of… Cervant, Bryan; Haker, Erica; Jiwa, Shaila; Jori, Rhonda; Pemble, April; Eng, Janice Oct 5, 2006

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Effectiveness of combined Vestibular Rehabilitation & Cognitive Behavioral Therapy in the treatment of Chronic Dizziness: A Systematic Review Authors: Rhonda Cooper, Erica Haker, Bryan Cervantes, April Pemble, Shaila Jiwa Supervisor: Dr. Janice Eng  Outline „ „ „ „ „ „  Introduction Methods Results & Discussion Physiology Limitations & Future Research Summary  INTRODUCTION  Vestibular Rehabilitation  Cognitive Behavioral Therapy  Canalith Repositioning Maneuvers  Chronic Dizziness z  z  z  z  1/3 of older adults report experiencing dizziness and/or loss of equilibrium 1/5 working age adults experience dizziness 1/10 working age adults report experiencing dizziness as a handicap The prevalence of dizziness may be underestimated as many people living in community have handicapping chronic dizziness that is neither diagnosed or treated  Chronic Dizziness z  z  z  Dizziness contributes to increased incidence of falls due to increased fear of falling precipitating falls Dizziness leads to decreased social involvement and subsequent increased anxiety and risk of depression Dizziness contributes to musculo-skeletal problems such as neck stiffness and headache  Anxiety & Dizziness z  z  z  Anxiety and Dizziness are co-morbid conditions in a larger percentage of the population than would be expected from chance Many patients with anxiety disorders present with abnormal vestibular function Many patients with vestibular disorder suffer from anxiety  Vestibular Rehabilitation & Cognitive Behavioral Therapy  METHODS  Literature Search: Electronic Databases „ „ „ „ „ „ „ „ „ „ „ „  CINHAL Cochrane Central Register of Controlled Trials Cochrane Database of Systematic Reviews EBM Reviews – ACP Journal Club EMBASE Google Scholar PEDro PsycInfo PubMed Web of Science PapersFirst Proquest Dissertations and Theses  Literature Search: Key Words „  „  „  Vestibular rehabilitation Exercise Exercise therapy Kinesiotherapy Cognitive behavioral therapy Cognitive therapy Behavioral therapy Psychotherapy Dizziness Vestibular disease Vestibular disorder Balance disorder Vertigo  Literature Search: Limits „ „ „  „  English Up to June 2006 No limits imposed on the type of study Review papers excluded  Literature Search: PubMed „ „  Large number of search results (783) Clinical queries filter • Limits results to randomized controlled trials (RCTs)  „  Relevant articles link • Does not limit studies based on study design  Literature Search: Other Strategies „  Web of Science • Author search feature: Yardley „ Andersson „ Johansson „ Holmberg „  „  Reference lists search  Literature Search: Hand Searching „  „  All relevant journals were searched thoroughly using electronic databases Not implemented  Inclusion Criteria „  Population: • Adults over 19 years of age with chronic dizziness  „  Intervention: • VR combined with CBT  „  Outcome: • Relevant measures for dizziness, anxiety and depression were considered • i.e. Dizziness handicap inventory (DHI) and vertigo symptom scale (VSS)  Quality Assessment „  Modified version of Downs & Black Checklist for Measuring Study Quality • Applicable to both randomized and nonrandomized studies  „ „  2 independent reviewers Disagreement resolution: • Consensus achieved by discussion among the 2 reviewers • 3rd reviewer available for mediation  Data Extraction „  „ „  Modified version of the Cochrane Back Review Group data extraction form 2 independent reviewers Disagreement resolution: • Consensus achieved by discussion among the 2 reviewers • 3rd reviewer available for mediation  RESULTS & DISCUSSION  Study Selection „  „  „  „  Electronic data bases & examination of reference lists produced 320 studies 6 were selected for abstract or text screening 5 remaining underwent quality assessment & data extraction 4 were selected for this systematic review  A controlled trial of CBT combined with VR in the treatment of dizziness Andersson et al. 2006 „ „ „  „  n = 29 VR & CBT vs. Wait-list control Significant treatment effects were found on self-reported handicap, behavioural measures of exposure to dizziness-provoking movements, & daily registrations of dizziness & distress associated with unsteadiness. No significant change from pre- to posttreatment was found in regards to selfreported measures of general distress.  Randomized controlled trial of VR combined with CBT for dizziness Johansson et al. 2001 „ „ „  „  n = 19 VR & CBT vs. Wait-list control Statistically significant improvements in the treatment group on walking time, 2 dizziness provocative movements, & on the DHI. No significance found on the Romberg, several of the dizziness provocative movements, or on the questionnaires measuring anxiety & depression.  Feasibility & effectiveness of providing VR for dizzy patients in the community Yardley et al. 1998 „ „  „  „  n = 16 Pre-VR & CBT vs. Post-VR & CBT Improvements were found in the ability to undertake physical activities such as walking & climbing stairs, & how much dizziness interferes with different activities. There is some evidence to show that there is a decrease in postural sway.  Treatment of phobic postural vertigo: A controlled study of CBT & selfcontrolled desensitization Holmberg et al. 2006 „ „ „  „  „  n = 31 VR & CBT vs. VR alone Significant, but small, improvement in experienced vertigo severity & handicap in the self-treatment group. Significant additional effects of psychological treatment showed improvements in patients’ experienced handicap, anxiety, & depression. Results suggest that the treatment effects obtained were less strong overall.  Findings „  „  Combination of VR & CBT was found to be an effective intervention for patients with chronic dizziness in the majority of the outcomes measured by the 4 studies. However, we were unable to conclude that combined VR & CBT is more effective than either VR & CBT alone.  PHYSIOLOGY  Physiological links between balance and anxiety „  „  Physiological connection between balance disorders and anxiety. 4 vestibular nuclei located in the brainstem Æ input from the vestibular portion of C.N. VIII  „  Parabrachial nucleus located in the brainstem  The parabrachial nucleus network Æ emotional, affective, and physiological manifestations of fear and anxiety Æ convergence of vestibular, somatic, and visceral information processing  Physiological links between balance and anxiety „  There is a direct link between the vestibular system and neural networks involved in expressing anxiety and emotions.  LIMITATIONS  Limitations „ „  „  Limited number of studies Limited quality of research examining VR and CBT Factors that contributed to the low quality scores are: ¾ Lack of randomization ¾ Small sample size ¾ Lack of control group ¾ Lack of blinding  Limitations Only one of the studies compared combined VR & CBT to VR alone „ Variability in the research: ¾ patient populations ¾ interventions ¾ outcome measures ƒ Variability in the studies made it difficult to consolidate results and draw valid conclusions „  FUTURE RESEARCH  Future Research „  Research that compares combined VR & CBT to VR alone is needed ¾ to help determine if combined use of VR & CBT is more effective than either intervention alone  Future Research „  Study design needs to be improved: ¾ larger sample sizes ¾ randomization ¾ control groups ¾ homogeneity of patient population ¾ standardized interventions ¾ consistent outcome measures  Future Research „  „  Need to consider the costeffectiveness of combining CBT with VR CBT is an individualized one on one treatment ¾ need to investigate if CBT administered in groups could be as effective in reducing symptoms and be more costeffective than individual treatment  SUMMARY  Summary „  Although combined VR & CBT was found to be an effective intervention for patients with chronic dizziness, we cannot conclude that it is a more effective intervention than either VR or CBT alone.  „  Shortage of research in the area of VR and CBT  „  Lack of standardization for both therapeutic methods.  Summary „  „  Face validity exists for the use of VR & CBT Stronger evidence needed before valid clinical recommendations can be made  References „  „  „  „  „  „  „ „  „  „  Grimby A, Rosenhall U. HealthHealth-related quality of life and dizziness in old age. J Gerontol 1995;41:28698. 1995;41:286 Yardley L, Bourgneay J, Andersson G, Owen N, Nazareth I, Luxon L. Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients patients in the community. Clin Otolaryngol Allied Sci 1998;23:4421998;23:442-48. Sloane P, Dallara J, Roach C, Bailey K, Mitchell M, McNutt R. Management of dizziness dizziness in primary care. J Am Board Fam Pract 1994;7:11994;7:1-8. Luxon LM. Evaluation and management of the dizzy patient. patient. J Neurol Neurosurg Psychiatry 2004;75(4):452004;75(4):45-52. Zeeuwe PE, Verhagen AP, BiermaBierma-Zeinstra SM, van Rossum E, Faber MJ, Koes BW. The effect of Tai Chi Chuan in reducing falls among elderly people: design of a randomized clinical trial in the Netherlands. BMC Geriatr 2006;30:62006;30:6-12. Yardley L, Hallam R. Psychosocial aspects of balance disorders. In: Bronstein A, Brandt T, Woolacot M, editors. Clinical Aspects of Balance and Gait Disorders. London: London: Edward Arnold; 1996. p. 251251-67. Yardley L, Luxon L. Treating dizziness with vestibular rehabilitation. BMJ 1994;308:1252 1994;308:1252--53. Shepard NT, Telian SA, SmithSmith-Wheelock M, Raj A. Habituation and balance retraining. Neurol Clin 1990;8:4591990;8:459-75. Beidel DC, Horak FB. Behavior therapy for vestibular rehabilitation. J Anxiety Disord 2001;15:1212001;15:121-30. Hawton K, Salkovskis PM, Kirk J, Clark DM. Cognitive behaviour therapy for psychiatric psychiatric problems. Oxford: Oxford University Press; 1989.  References „  „  „  „  „  „  „  „  „  „  Barlow DH. Clinical handbook of psychological disorders: a step-by-step treatment manual. 3rd ed. New York: Guildford Press; 2001. Brandt T, Huppert D, Dieterich M. Phobic Postural Vertigo: a first follow up. J Neurol 1994;241:191-95. Yardley L, Owen N, Nazareth I. Prevalence and presentation of dizziness in a general practice community sample of working age. Br J Gen Pract 1998;148:1131-35. Jacob RG, Whitney SL, Detweiler-Shostak G, Furman JM. Vestibular rehabilitation for patients with agoraphobia and vestibular dysfunction. J Anxiety Disord 2001;15:131-46. Jacob RG, Furman JM, Durrant JD, Turner SM. Panic, agoraphobia, and vestibular dysfunction. Am J Psychiatry 1996;153:503-12. Yardley L, Luxon L, Lear S. Vestibular and posturographic test results in people with symptoms of panic and agoraphobia. J Audiol Med 1994;3:48-65. Hsu LC, Hu HH, Wong WJ, Wang SJ, Luk YO, Chern CM. Quality of life in elderly patients with dizziness: analysis of the Short-Form Health Survey in 197 patients. Acta Otolaryngol 2005;125(1):55-9. Goisman RM, Warshaw MG, Keller MB. Psychosocial treatment prescriptions for generalized anxiety disorder, panic disorder, and social phobia, 1991-1996. Am J Psychiatry 1999;156(11):1819-21. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377-84. Cochrane Back Review Group [homepage on the Internet]. Toronto, ON: Institute for Work & Health [cited 2006 August 25]. Available from: .  References „  „  „  „  „  „  „  „  Andersson G, Yardley L. Combined cognitive-behavioural and physiotherapy treatment of dizziness: a case report. Behavioural and Cognitive Physiotherapy 1998;26:365-69. Andersson G, Asmundson G, Denev J, Nilsson J, Larsen HC. A controlled trial of cognitive-behavior therapy combined with vestibular rehabilitation in the treatment of dizziness. Behav Res Ther 2006;4(9):1265-73. Johansson M, Akerlund D, Larsen HC, Andersson G. Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people. Otolaryngol Head Neck Surg 2001;125(3):151-56. Holmberg J, Karlberg M, Harlacher U, Rivano-Fischer M, Magnusson M. Treatment of phobic postural vertigo: a controlled study of cognitive-behavioral therapy and self-controlled desensitization. J Neurol 2006;253:500-6. Balaban CD, Thayer JF. Neurological basis for balance-anxiety links. J Anxiety Disord 2001;15:53-79. Telian SA, Shepard NT. Update on vestibular rehabilitation. Otolaryngol Clin North Am 1996;29:359-71. Luxon LM, Davies LM, eds. Handbook of vestibular rehabilitation . London: Whurr Publishers Ltd; 1997. Shepard NT, Talian SA. Programmatic vestibular rehabilitation. Otolaryngol Head Neck Surg 1995;112:173-82.  Acknowledgements „  We would like to thank Dr. Janice Eng, Dr. Susan Harris and Ms. Charlotte Beck for their mentorship throughout this review  Questions?  


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