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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 1/3 of older adults report experiencing dizziness and/or loss of equilibrium z 1/5 working age adults experience dizziness z 1/10 working age adults report experiencing dizziness as a handicap z 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 Dizziness contributes to increased incidence of falls due to increased fear of falling precipitating falls z Dizziness leads to decreased social involvement and subsequent increased anxiety and risk of depression z Dizziness contributes to musculo-skeletal problems such as neck stiffness and headache Anxiety & Dizziness z Anxiety and Dizziness are co-morbid conditions in a larger percentage of the population than would be expected from chance z Many patients with anxiety disorders present with abnormal vestibular function z 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 non- randomized 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 post- treatment was found in regards to self- reported 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 & self- controlled 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 cost- effectiveness 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 cost- effective 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. Health-related quality of life and dizziness in old age. J Gerontol 1995;41:286-98. „ Yardley L, Bourgneay J, Andersson G, Owen N, Nazareth I, Luxon L. Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients in the community. Clin Otolaryngol Allied Sci 1998;23:442-48. „ Sloane P, Dallara J, Roach C, Bailey K, Mitchell M, McNutt R. Management of dizziness in primary care. J Am Board Fam Pract 1994;7:1-8. „ Luxon LM. Evaluation and management of the dizzy patient. J Neurol Neurosurg Psychiatry 2004;75(4):45-52. „ Zeeuwe PE, Verhagen AP, Bierma-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;30:6-12. „ 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: Edward Arnold; 1996. p. 251-67. „ Yardley L, Luxon L. Treating dizziness with vestibular rehabilitation. BMJ 1994;308:1252-53. „ Shepard NT, Telian SA, Smith-Wheelock M, Raj A. Habituation and balance retraining. Neurol Clin 1990;8:459-75. „ Beidel DC, Horak FB. Behavior therapy for vestibular rehabilitation. J Anxiety Disord 2001;15:121-30. „ Hawton K, Salkovskis PM, Kirk J, Clark DM. Cognitive behaviour therapy for 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: http://www.cochrane.iwh.on.ca . 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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