Novel ways of providing vestibular rehabilitation: booklet-based and internet

1. Novel ways of providing vestibular rehabilitation: booklet-based and internet This presentation outlines independent research commissioned by the National Institute for Health Research (NIHR) under its RfPB Programme (Grant Reference PB-PG-0107-12069). Dr Sarah Kirby: sek@soton.ac.uk Acknowledgements: Gerhard Andersson, Fiona Barker, Adolfo Bronstein, Per Carlbring, Maggie Donovan-Hall, Adam Geraghty, Paul Little, Anna Morris, Mark Mullee, Ingrid Muller, Beth Stuart, David Turner, Lucy Yardley

2. Vestibular related dizziness Dizziness affects up to 25% of adults 1 in 10 in working population, and 1 in 5 in those 65+ Can lead to disability, medical consultation or medication use. Risk factor for falling and fear of falling. Anxiety frequently present in people with chronic dizziness.

3. Management of dizziness • 90% of UK dizzy patients treated in primary care. • 40% of those consulting GP receive any diagnosis or treatment (typically reassurance and medication). • No medication has established value, or suitable long-term. • Vestibular rehabilitation (VR) is recommended treatment for chronic dizziness, but only available in secondary or tertiary care. • Of those who are referred, only a small proportion of dizzy patients are willing to attend secondary care.

4. Models of delivering VR • Yardley, Beech, Zander et al. (1998) British Journal General Practice 48:1136-40 • 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 141:598-605 • 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. • Yardley & Kirby (2006) Psychosomatic Medicine 68:762-769 • Booklet to use for 3 months with no additional support.

5. Models of delivering VR • Yardley, Barker, et al. Clinical and cost-effectiveness of booklet-based vestibular rehabilitation for chronic dizziness in primary care: pragmatic randomised controlled. BMJ (in press) 1 • Yardley, Geraghty, Kirby, et al. Online dizziness intervention for older adults.2 • Funded by NIHR, RfPB Programme (Grant Reference PB-PG-0107-12069) • Funded by Dunhill Medical Trust (Grant Reference R222/1111)

6. ‘Balance Retraining’ VR booklet • Programme of daily graded VR exercises that aim to: • Stimulate the vestibular system and through repetition and increase speed, promote neurological adaptation and partial or complete resolution of symptoms. • Promote psychological adaptation and reduced anxiety by demonstrating that provoked symptoms are predictable, controllable, and tolerable.

7. VR Exercises in booklet • Basic exercises: • Shake & Nod; eyes open, eyes closed, visual fixation • Progress from sitting, standing, then walking (starting slowly if necessary, increasing speed) • General activities: • ball games, walking on different surfaces or in different places, sports dance and exercise, travel • Special exercises: • for unsteadiness, turning over in bed, reaching, dealing with different visual patterns / environments

8. Psychological content of booklet • Addresses attitudes, beliefs and concerns • Increases confidence in ability to carry out the exercises • Increases commitment and action plans • Motivation and experience

9. Cost effectiveness RCT: • 337 participants from 35 GP surgeries were randomised to receive: • Routine care • Booklet only • Booklet with telephone support • Participants in active treatment arms were sent the VR booklet to follow for 12 weeks. • Participants in the booklet with telephone support arm also received 3 telephone calls from a VR therapist. • Outcomes were measured at baseline, 12 weeks and 1 year.

10. Trial results Graph showing % of each group that felt better than they did before the trial began (subjective)

11. Results – primary outcome: Vertigo symptoms (VSS-SF)

12. Results - secondary outcomes 12 weeks effectiveness analyses • Booklet with telephone support significantly improved on autonomic anxiety symptoms compared to routine care. 1 year effectiveness analysis • Compared with routine care, both treatment groups significantly improved on autonomic anxiety and dizziness handicap. • Booklet with telephone support group also had significantly lower anxiety and depression compared to routine care only

13. Cost-effectiveness analysis • Booklet arm cost the same as routine care, booklet with telephone support arm cost about £30 more. • Cost effectiveness acceptability curve show both interventions to be highly cost- effective, with the telephone support group being more cost-effective at values of a QALY greater than £1200. • The threshold NICE uses is £20,000-30,000, meaning that if a QALY is worth less than £20,000 then it is considered worth paying for.

14. Cost-effectiveness analysis

15. Older adults and the Internet • Internet interventions are increasingly being used as an alternative to paper- based self-management materials • Older adults’ use of the Internet for health information is increasing rapidly: • growth in Internet access from 2006 to 2010 was 113% in 65+ • In 2010, 72% aged 55-64 and 32% aged 65+ accessed the Internet within the last three months in the UK • 59% of those aged 65+ used it “almost everyday”

16. Online dizziness intervention for older adults • Aims: • To develop, build and qualitatively pilot an Internet intervention for dizziness in close collaboration with older adults with dizziness. • To carry out a trial to determine the effectiveness of the Internet intervention within an NHS primary care context, compared to usual care. • To determine the cost-effectiveness of the intervention.

17. Phase 1 - Development • LY has developed ‘LifeGuide’, free open source software (www.lifeguideonline.org) to develop complex Internet interventions with minimal programming support. • Translate paper based materials from previous trials into online format for older adults. • Modular structure (6-8 wks). • Map specific tailoring opportunities. • Images and videos. • User involvement and piloting.

18. Phase 2 - Trial • NHS primary-care based trial (N = approx 262) • Online intervention + usual care vs. usual care only. • Login and complete modules on a weekly basis. • Stand-alone and fully automated. • Automated email reminders. • Option to receive text messages (SMS) related to the intervention content. • Sub-sample – qualitative interviews of experiences and perceptions. • Effectiveness and cost-effectiveness analyses.

19. Conclusions • Booklet-based VR is a simple and highly cost-effective way of managing chronic dizziness in primary care. • Booklet-based VR with and without telephone support significantly improved subjective dizziness and vertigo symptoms at 1 year follow-up. • Telephone support led to greater improvement in anxiety and depression • however 1 in 4 did not take up telephone support

20. Conclusions • Internet-based VR has potential to be more readily implemented in NHS: • reduced costs. • absence of training to deliver the support. • provides the opportunity for wide access if made available to the general public. • Booklet-based and internet-based VR models have the potential to be used within a stepped care approach: • maximising benefit to patients & available resources. • may reduce number of patients requiring referral to secondary care.

21. Booklet availability • www.menieres.org.uk • To date the Meniere’s Society have supplied over 13,760 copies • nearly 10,000 to patients and the others to health professionals

22. Thank you