Vestibular Rehabilitation VR

1
Vestibular Rehabilitation (VR)

• The effectiveness of and psychological issues
  associated with VR self-treatment booklets

Dr Maggie Donovan-Hall and Dr Sarah Kirby
Acknowledging Professor Lucy YardleyIrish
Audiology Society Conference, 7th Nov 2008
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Overview

• Background to Vestibular Rehabilitation (VR)
• Understanding issues related to the adherence of
  VR
• Booklet and training programmes
• The delivery of VR within your own practice
• Main conclusions

3
Background to Vestibular Rehabilitation (VR)

• Overview of the rationale for VR
• Exploring different modes of delivering VR
• Therapeutic and theoretical rational of VR
  booklets

4
Background vestibular related dizziness

• Vestibular related dizziness is very common
• 1 in 10 in the working population and 1 in 5 in
  people older than 65 years (Yardley et al, 1998)
• Dizziness is normally treated at the Primary Care
  level and has been shown to account for 2 of all
  GP consultations (Kroenke et al, 1992)
• However, only 40 of people reporting dizziness
  consult their GP
• Only 40 of those that do consult their GP
  receive any type of treatment or diagnosis
  (Yardley et al, 1998)

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Vestibular Related Dizziness Usual Treatment
Pathway

• At the Primary Care level the treatment normal
  involves reassurance and the prescription of
  drugs (e.g. vestibular sedatives and diuretics)
• Such prescriptions have been shown to be
  ineffective in reducing symptoms
• Can cause unpleasant symptoms and hinder recovery
  
• (Kroenke et al, 1992 Yardley et al, 1998)

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Vestibular Rehabilitation

• Vestibular Rehabilitation is a simple exercise
  based treatment and was first introduced by
  Cawthorne Cooksey in 1946
• Noticed patients with balance problems often
  refrain from moving their heads
• Developed a simple series exercises known as
  Cawthorne-Cooksey exercises or Vestibular
  Rehabilitation (VR)

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Aims of Vestibular Rehabilitation

• VR involves eye, head, and body movements that
  aim to achieve two main goals
• To stimulate the vestibular system and retrain
  the brain to cope with movements that initially
  caused the dizziness
• Patient achieves this by making slow head
  movements and than slowly increases speed
• At first exercises will induce dizzy symptoms but
  need to be carried out repeatedly to work
• To encourage patients to actively cope with their
  dizziness
• Gain confidence and over come fears of making
  head movement

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Exploring different modes of delivering VR (1)

• Trials of vestibular rehabilitation (VR) in
  primary care have shown that patients with
  dizziness of mixed aetiology can successfully
  undertake VR when nurse delivered
• Yardley, Beech, Zander et al. (1998) British
  Journal General Practice 481136-40
• Individual VR, nurse delivered (trained for two
  weeks).
• Two x 30-40 min sessions, six weeks apart,
  supplemented with written material.
• Yardley, Donovan-Hall, Smith et al. (2004) Annals
  of Internal Medicine 141598-605
• Self-management booklet talked through by nurse
  (trained for half a day).
• Booklet to use for 3 months, plus one 30 minute
  session and 2 follow-up phone calls from a nurse.

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Exploring different modes of delivering VR (2)

• A trial of VR among members of the Ménières
  Society has shown that people with symptoms of
  Ménières disease can successfully undertake VR
  using a self-management booklet without support.
• Yardley Kirby (2006) Psychosomatic Medicine
  68762-769
• Booklet to use for 3 months with no additional
  support.
• Comparison booklet on symptom control
• relaxation (to reduce arousal-related symptoms)
• controlled breathing (to reduce nausea and
  arousal)
• distraction (to reduce attention to symptoms)
• stress reduction (to promote better coping)

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Yardley et al., 1998
Yardley et al., 2004
Yardley Kirby 2006
Patients
n 67 (76 Cs) mixed aetiology
n 83 (87 Cs) mixed aetiology
n 120 (120 Cs) Ménières disease
Design setting
RCT Primary care
RCT Primary care
RCT Self help group
Treatment Delivery Mode Training
Individual therapy by nurse trained for 2 weeks
VR booklet delivered by nurse trained for ½ day
VR booklet (no additional support)
Outcome (at 6 months)
?symptoms (obj subj), anxiety, depression
? symptoms (obj subj), handicap
? symptoms (subj), negative beliefs, handicap
Adherence
75 adhered, but few induced symptoms adequately
55 adhered for at least 9/12 weeks or no symptoms
37.5 adhered for at least 9/12 weeks or no
symptoms
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Therapeutic rationale for VR booklet

• Carry out daily graded head movements that
  stimulate balance organs in order to
• Promote neurophysiological adaptation of the
  balance system to movement
• Promote psychological adaptation by demonstrating
  that provoked symptoms are predictable,
  controllable, and tolerable

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Theoretical rationale for VR booklet
Trigger Movement stimulates balance organs,
provokes dizziness
Outcomes Handicap Anxiety/depression
Beliefs about dizziness Sign of serious attack,
intolerable unpredictable, uncontrollable
Behaviour Avoid movements that provoke dizziness
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Understanding issues related to the adherence of
VR

• Psychological diagnoses to take into account
• Patients beliefs about their symptoms, and
  taking part in the study
• What predicts the outcome of VR?
• Applying strategies to increase adherence
• Measuring adherence

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Psychological diagnoses to take into account

• Anxiety depression
• Panic agoraphobia
• heart rate, sweating, shaking, nausea, chest
  pain, dizziness, fear, unreality, detached from
  self, numbness, tingling, hot/cold
• anxiety avoidance of going out alone, crowds,
  travelling.
• Health anxiety (Kirby Yardley, in press)
• Generic worry about illness and concern about
  symptoms and feelings in body (beyond normal
  concerns when you have an illness)
• Post-traumatic stress disorder (PTSD) (Kirby
  Yardley, in press)
• in response to a traumatic event re-experiencing
  invasive memories thoughts avoidance of
  activities, places, feeling distant sleep
  concentration problems, irritable, being super
  alert

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Patients beliefs about their symptoms

• Fears associated with dizziness
• Dizziness will result in physical harm or serious
  illness
• Concern about letting people down and the social
  embarrassment of becoming dizzy in public
• Any dizziness is the start of a severe attack
• Behaviours resulting from fears
• Handicap / disability
• Avoidance of situations activities
• Increased dependence on friends family

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What predicts the outcome of VR?

• Kirby Yardley (in press) Journal of
  Psychosomatic Research
• Do pre-VR symptoms, beliefs, and concerns affect
  anxiety post-VR (in people with Ménière's
  disease)? YES

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Issue of adherence

• As VR is a self-management treatment, the success
  of the treatment crucially depends on the
  patients motivation to complete treatment
• No previous research has explored the factors
  relating to adherence and patient motivation to
  VR
• Research employing a social psychological model
  as a theoretical guide to understand adherence to
  VR
• To help understand patients beliefs about taking
  part in the treatment

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Theory of Planned Behaviour (Ajzen
Madden,1986)
Beliefs about the behaviour evaluation of
these beliefs (i.e. advantages disadvantages
of VR)
Attitudes
Perception of normative beliefs and motivation
to comply (i.e. husbands Beliefs about VR)
Intention (to carry out VR)
Behaviour (adherence to VR)
Subjective Norm
Patients perception that they have the ability
or resources to carry out behaviour (i.e. time
health issues related to VR)
Perceived Behavioural Control
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Examples of the participants responses 1

• Attitudes
• Advantages of carrying out VR
• Improve / stop/ recover symptoms or illness
• Improve / regain / help with balance
• Non-drug / natural treatment
• Gain confidence
• Disadvantages of carrying out VR
• Adverse effects of exercises
• Time usage
• Chore and dislike

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Examples of the participants responses 2

• Subjective norm Who may hold an opinion as to
  whether you should or should not carry out VR?
• Spouse / Partner
• Children
• Help to do VR exercises
• Support / Encouragement
• Routine / Being reminded
• Self-motivation
• PBC Prevent doing VR exercises
• Illness / Exercises causing illness
• Forgetting
• Time commitment / daily Schedule

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The use of implementation intentions (I-I)

• Part of therapy programme involved asking
  participants to choose and record two times they
  would carry out VR
• I-I normally involve stating a time and a place
  where the behaviour will be carried out
  (Gollwitzer, 1993)

• Previous studies have shown that for specific
  types of behaviour the format of I-I needs to be
  flexible (e.g. Sheeran Orbell, 1999 Rise et
  al, 2003)
• VR is promoted as a simple self-management
  treatment that needs to be carried out on a daily
  basis regardless of location

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Implementation Intention Study

• All participants in the study were categorised
  into 3 naturally occurring groups
• Specific time plan (e.g. 8.00am 6.00pm)
• Vague time plan (e.g. AM PM)
• No plan
• These groups were analysed to explore if there
  were differences in adherence .
• The results showed that participants were less
  likely to adhere if they hadnt made a plan.
• These participants also had lower levels of
  intention.
• Therefore, participants with lower levels of
  intention were less likely to form a plan.
  Planning is important!

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Theory of Planned Behaviour (Ajzen
Madden,1986)
Implementation intentions
Beliefs about the behaviour evaluation of
these beliefs (i.e. advantages disadvantages
of VR)
Attitudes
Perception of normative beliefs and motivation
to comply (i.e. husbands Beliefs about VR)
Intention (to carry out VR)
Behaviour (adherence to VR)
Subjective Norm
Patients perception that they have the ability
or resources to carry out behaviour (i.e. time
health issues related to VR)
Perceived Behavioural Control
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Measuring adherence

• The Problematic Experiences of Therapy Scale
  (PETS)
• Assumes people will encounter difficulties in
  relation to specific rather than general issues
• Symptoms too severe or aggravated by therapy
• Uncertainty about how to carry out the treatment
• Doubts about treatment efficacy
• Practical problems (such as lack of time or
  opportunity, forgetting)
• Important to include PETS before asking actual
  adherence questions
• Provides a more socially acceptable foundation on
  which to base a more open and honest discussion
  about adherence

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Booklet and training programmes

• Breakdown of the VR booklet
• Developing a VR training
  programme for different groups
  of clinicians

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Breakdown of the VR booklet

• Addresses attitudes, beliefs and concerns
• Why dizziness occurs

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Breakdown of the VR booklet

• Addresses attitudes, beliefs and concerns
• Why dizziness occurs
• Causes of dizziness

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Breakdown of the VR booklet

• Addresses attitudes, beliefs and concerns
• Why dizziness occurs
• Causes of dizziness
• Whether symptoms are controllable
• Evidence of how effective the treatment is (e.g.
  who improve, other patients experiences)
• High quality presentation influences attitudes
  (e.g. pictures, colour)

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Breakdown of the VR booklet

• Increases confidence in ability to carry out the
  exercises
• Give very clear, simple instructions

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Breakdown of the VR booklet

• Increases confidence in ability to carry out the
  exercises
• Give very clear, simple instructions
• A graded approach ensures that the patient
  experiences early success with the easy initial
  stages

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Breakdown of the VR booklet

• Increases confidence in ability to carry out the
  exercises
• Give very clear, simple instructions
• A graded approach ensures that the patient
  experiences early success with the easy initial
  stages
• Include instructions on how to cope with setbacks
  (modifying programme if tired, busy or ill,
  drawing on social support)

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Breakdown of the VR booklet

• Increases commitment and action plans
• Provides scope for patient to design programme to
  suit particular needs/lifestyle
• Includes an action plan for patient to decide on
  and commit to (when, where, what, how much
  rehabilitation will carry out)

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Breakdown of the VR booklet

• Motivation and experience
• Design procedures that allow patient to monitor
  and chart their own adherence and gradual
  improvement

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Breakdown of the VR booklet

• Motivation and experience
• Design procedures that allow patient to monitor
  and chart their own adherence and gradual
  improvement
• Generalisation of exercises to real life
  situations (ball games, walking, sport, dance or
  exercise, travel, and specific activities that
  cause dizziness)

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Developing a VR training programme for different
groups of clinicians Practice Nurses

• Objective To evaluate the effectiveness of
  nurse-delivered Vestibular Rehabilitation in
  primary care for patients with chronic dizziness.
• Nurses received half day training on how to teach
  patients VR exercises in one 30-40 min. session
  plus telephone follow-up
• Patients carry out exercises daily at home
• Booklet answers patient concerns, instructs on
  how to tailor exercises to patients problems and
  capabilities

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Developing a VR training programme for different
groups of clinicians Physiotherapists

• VR exercises were first developed by
  physiotherapists, yet are not regularly included
  in clinical practice.
• Mainly used by specialists who have undergone
  higher level training.
• We are in the process of developing a one day
  continuing professional development (CPD)
  training programme for physiotherapists
• Our aim is for the exercises to be used at a
  basic level in a wide range of clinical settings
  where specialist training is not available or is
  too time consuming to undertake.

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Developing a VR training programme for different
groups of clinicians Audiologists

• We are currently running a trial in primary care
  to evaluate the effectiveness and cost
  effectiveness of providing a self-management
  booklet with and without telephone support from a
  qualified vestibular therapist.
• 3 vestibular therapists (2 x audiologists, 1 x
  hearing therapist who delivers VR)
• Half day training session to standardise how the
  telephone support is delivered
• Support is given in one 30 minute session (by
  phone) and two x 15 minute follow ups, 1 week and
  3 weeks later

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Content of training programme

• Explanation of standardised approach and giving
  rationale for therapy
• Role play exercise 1 fostering appropriate
  attitudes and expectations
• Explanation of section on implementation of basic
  exercises
• Explanation of section on special exercises and
  general activities
• Discussion of psychological aspects of therapy
  and encouraging adherence
• Role play exercise 2 Encouraging adherence
• General discussion and questions

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Content of support first session (30-45 mins)

• Understanding and attitudes (10-15 mins)
  Ask whether patient
• understands how their dizziness may relate to
  balance system functioning?
• believes that exercises can improve their balance
  functioning?
• believes that exercise therapy is
  necessary/beneficial for them?
• has realistic expectations for short and
  longer-term consequences of exercises?
• believes that therapy will not harm them?
• understands contraindications to exercising?

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Content of support first session (30-45 mins)

• Implementation (15-25 minutes)
  Ensuring that the
  patient
• has made a written commitment to specific (safe)
  place and (appropriate) time which suits them for
  carrying out exercises?
• understands how to use the scoring test to choose
  appropriate exercises for them?
• understands how to carry out the exercises safely
  and appropriately (particularly pacing)?
• has agreed on exercises to be practised
  (including special exercises and general
  activities if time)? feels they have adequate
  access to social/professional support?
• understands the purpose and timing of monitoring
  and follow-up of their progress?

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Content of support first session (30-45 mins)

• Relapse prevention (5-10 minutes)
• Ask patient what problems they anticipate.
• Do not dismiss these but discuss ways to
  minimise costs of therapy, encouraging patient to
  generate solutions, and weigh up relative costs
  and benefits of options for action.
• Alert patient that symptoms may temporarily
  increase with over-vigorous exercising, physical
  or emotional stress, fatigue, illness.
• Re-emphasise strategy to cope with this of a)
  decreasing exercise intensity but NOT regularity,
  b) seeking social support and professional
  advice.

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Content of support first session (30-45 mins)

• Relapse prevention (5-10 minutes)
  Then ask whether the
  patient
• Can foresee setbacks that may occur specific to
  their circumstances?
• Knows what to do if these setbacks occur, to
  prevent serious disruption of therapy?
• Has any other questions?

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Content of support 1st 2nd follow-up (15 mins)

• Check general adherence first (i.e. discourage
  symptom focus)
• Congratulate on any adherence (i.e. praise
  adherence rather than criticise non-adherence).
• Ask about any barriers to adherence
• Help patient to generate solutions to these (see
  previous sections)
• Get patient to make new specific commitment to
  new solutions (what/when/where)
• Congratulate patient on creating and committing
  to these solutions.
• Check and record patient monitoring and updating
  of exercise programme, including special
  exercises and general activities.
• Ask if any other questions/concerns, and respond
  positively.

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The delivery of VR within your own practice

• Group work task
• Feedback discussion

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The delivery of VR within your own practice

• Group work (working in pairs) to consider the
  benefits and barriers of implementing some of
  these strategies/training ideas within your own
  clinical practice
• Feed back to the group

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Main Conclusions
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Main conclusions

• Specially developed booklets alone can be used to
  deliver VR safely and effectively.
• A wide range of health professionals can be
  trained to deliver basic VR in a range of
  clinical settings.
• Psychological factors are important to include
  when delivering VR.
• You can promote adherence to booklet-based VR by
  
• minimal additional support by a health
  professional
• planning when VR will be carried out
• Asking specific (not general) questions about
  adherence