STEADFAST: Psychotherapeutic Intervention Improves Postural Strategy of Somatoform Vertigo and Dizziness

The Impact of Reich's Vegetotherapy on Emotional Regulation and Postural Balance in Military Personnel: A Non-Pharmacological Approach to Combat Stress

Military operations subject soldiers to intense stress, which can adversely affect both their emotional regulation and physical balance. This study examines the effectiveness of Reich's vegetotherapy (VGT), an alternative non-pharmacological intervention, in improving these critical areas among military personnel. A total of 29 soldiers, with an average age of 30, were randomly assigned to either an experimental group (EG; 15 soldiers) or a control group (CG; 14 soldiers). Over a period of 6 weeks, the EG participated in twice-weekly VGT sessions, while the CG received no intervention. The intervention group showed a significant reduction in anxiety levels, with scores improving from the beginning to the end of the test (p = .001) and a significant time × group interaction (p = .003). The EG experienced a greater improvement (-68%) compared to the CG (-9%) (p = .036). In the open-eyes postural balance test, the EG showed a significant improvement (p = .029), with a time × group interaction effect (p = .04), although no significant difference was found between the groups (p > .05). The EG improved more (-36%) compared to the CG (24%). In addition, anger levels significantly improved post-intervention (p = .001), with a significant time × group interaction (p = .001). These findings suggest that Reich's VGT may serve as an effective method for mitigating stress-related impairments in military personnel. Further research with larger sample sizes is necessary to validate these results and explore its broader applications.

Similarities between explaining dizziness and explaining pain? Exploring common patient experiences, theoretical models, treatment approaches and potential therapeutic narratives for persistent dizziness or pain

Pain and dizziness are common experiences throughout the lifespan. However, nearly a quarter of those with acute pain or dizziness experience persistence, which is associated with disability, social isolation, psychological distress, decreased independence, and poorer quality of life. Thus, persistent pain or dizziness impacts peoples' lives in similarly negative ways. Conceptual models of pain and dizziness also have many similarities. Many of these models are more expansive than explaining mere symptoms; rather they describe pain or dizziness as holistic experiences that are influenced by biopsychosocial and contextual factors. These experiences also appear to be associated with multi-modal bodily responses related to evaluation of safety, threat detection and anticipation, as influenced by expectations, and predictions anticipation, not simply a reflection of tissue injury or pathology. Conceptual models also characterize the body as adaptable and therefore capable of recovery. These concepts may provide useful therapeutic narratives to facilitate understanding, dethreaten the experience, and provide hope for patients. In addition, therapeutic alliance, promoting an active movement-based approach, building self-efficacy, and condition-specific approaches can help optimize outcomes. In conclusion, there are significant overlaps in the patient experience, theoretical models and potential therapeutic narratives that guide care for people suffering with persistent pain or dizziness.

Fear avoidance beliefs, anxiety, and depression in healthy individuals and persons with vestibular disorders across cultures

Background/introduction

In persons with vestibular disorders, disturbed vestibular input and accompanying dizziness can be associated with anxiety or depression. To avoid dizziness, persons with vestibular disorders can develop mal-adaptive fear avoidance behaviors which can negatively influence daily life functioning. The aims of this study were to (1) document different psychological factors in patients with vestibular disorders and healthy adults across cultures and (2) to assess the convergent validity of the 9-item Vestibular Activities Avoidance Instrument (VAAI), which quantifies fear avoidance beliefs.

Methods

Psychological factors and disability were measured in Dutch-speaking healthy adults and English- and Dutch-speaking persons with vestibular disorders using the VAAI, the Dizziness Handicap Inventory (DHI), the Hospital Anxiety and Depression Scale (HADS) and the Activities-Specific Balance Confidence Scale (ABC). The convergent validity of the VAAI was investigated by performing correlation analyses between the VAAI, the DHI, the HADS, and the ABC.

Results

A total of 151 Dutch-speaking healthy adults, 404 English-speaking participants with vestibular disorders, and 126 Dutch-speaking participants with vestibular disorders were included. Participants with vestibular disorders presented with higher levels of fear avoidance beliefs (VAAI), perceived disability (DHI), anxiety and depression (HADS), and lower confidence during balance activities (ABC) compared to healthy adults. Regarding the convergent validity of the VAAI, there were moderate to strong correlation coefficients (r = 0.39-0.74) between fear avoidance and the DHI, HADS, and ABC in participants with vestibular disorders.

Conclusions

Participants with vestibular disorders report a higher psychological burden compared to healthy adults. These results emphasize the importance of assessing psychological factors in persons with vestibular disorders. In addition, evidence was provided for convergent validity, supporting the VAAI as a valid outcome measure across cultures.

Treating Psychiatric Symptoms in Persistent Postural Perceptual Dizziness

Persistent postural perceptual dizziness (PPPD) is a functional neurological disorder characterized by troublesome feelings of dizziness and might be precipitated by vestibular events, postural changes, psychopathologies, and/or a person's perceptual experiences. The diagnosis is confirmed by assessing a patient's history. A variety of psychiatric symptoms are associated with PPPD; anxiety and depression are the most common. Psychotherapy and pharmacotherapy can be clinically helpful in reducing psychiatric symptoms and dizziness. Early intervention improves prognosis.

Nationwide Utilization of Computerized Dynamic Posturography in an Era of Deimplementation

Computerized dynamic posturography (CDP) provides multisensory assessment of balance. Consensus is lacking regarding CDP utility and coverage determinations vary. To inform best practices and policy, this cross-sectional study quantifies provider use of CDP among Medicare beneficiaries over time (2012-2017), by geographic region (hospital referral region [HRR]), and specialty. We observed 195,267 beneficiaries underwent 212,847 CDP tests totaling $15,780,001 in payments. Number of CDPs billed per 100,000 beneficiaries varied 534-fold across HRRs. Over 6 years, CDP use grew by 84% despite stagnant reimbursement. More utilization was attributable to primary care clinicians than specialties focused on care for dizziness and balance disorders. The observed growth and variation illustrate the potential for policy and provider preferences to drive unexpected practice patterns and underscore the need to engage a broad network of providers to develop optimal guidelines for use. CDP may offer a use case for deimplementation of low-value diagnostic services.

The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness

BACKGROUND

Persistent postural perceptual dizziness (PPPD) is a common and disabling functional neuro-vestibular disorder. We aimed to determine the feasibility and acceptability of conducting a randomised controlled trial of cognitive-behavioural therapy informed vestibular rehabilitation (INVEST intervention) designed for persistent dizziness.

METHODS

A two-armed parallel groups randomised feasibility study of INVEST vs. a time-matched gold standard vestibular rehabilitation (VRT) control. Participants with PPPD were recruited from a specialist vestibular clinic in London, UK. Participants were individually randomised using a minimisation procedure with allocation concealment. Measures of feasibility and clinical outcome were collected and assessed at 4 months.

RESULTS

Forty adults with PPPD were randomised to six sessions of INVEST (n = 20) or gold standard VRT (n = 20). Overall, 59% of patients screened met the inclusion criteria, of which 80% enrolled. Acceptability of INVEST, as assessed against the theoretical framework of acceptability (TFA), was excellent and 80% adhered to all 6 sessions. There were small to moderate treatment effects in favour of INVEST across all measures, including dizziness handicap, negative illness perceptions, symptom focussing, fear avoidance, and distress (standardised mean difference [SMD]g = 0.45; SMDg = 0.77; SMDg = 0.56; SMDg = 0.50, respectively). No intervention-related serious adverse events were reported.

CONCLUSIONS

The study results give strong support for the feasibility of a full-scale trial. Both arms had high rates of recruitment, retention, and acceptability. There was promising support of the benefits of integrated cognitive-behavioural therapy-based vestibular rehabilitation compared to gold standard vestibular rehabilitation. The study fulfilled all the a-priori criteria to advance to a full-scale efficacy trial.

TRIAL REGISTRATION NUMBER

ISRCTN10420559.

Persistent Postural-Perceptual Dizziness Interventions—An Embodied Insight on the Use Virtual Reality for Technologists

Persistent and inconsistent unsteadiness with nonvertiginous dizziness (persistent postural-perceptual dizziness (PPPD)) could negatively impact quality of life. This study highlights that the use of virtual reality (VR) systems offers bimodal benefits to PPPD, such as understanding symptoms and providing a basis for treatment. The aim is to develop an understanding of PPPD and its interventions, including current trends of VR involvement to extrapolate and re-evaluate VR design strategies. Therefore, recent virtual-reality-based research work that progressed in understanding PPPD is identified, collected, and analysed. This study proposes a novel approach to the understanding of PPPD, specifically for VR technologists, and examines the principles of effectively aligning VR development for PPPD interventions.

Compensatory image of the stability of people with multiple sclerosis and atrial vertigo based on posturography examination

Pathophysiology of balance disorders due to multiple sclerosis (MS) and atrial vertigo (AV) is different. We evaluated posture stability when maintaining balance in people with MS presenting symptoms of ataxia and those with AV. We included 45 women (15 with MS; 15 with AV; 15 controls). A posturography platform was used to measure balance parameters. To characterize the image of stability and the compensation of balance disorders, the surface area of the stabilogram (SAS), vision control index (VCI) and the vision-motion control index (VMCI) were used. The stability image of people with MS and AV with eyes open (p = 0.002), with eyes closed (p = 0.080) and with visual biofeedback (p = 0.0008) differed significantly. SAS depended on visual biofeedback regardless of the occurrence of balance disorders and was the basis for determining the compensatory share of vision-motor coordination. Differences in VCI between groups were insignificant. VMCI was significantly higher in people with balance disorders than in those without, but similar in the MS and AV groups. The image of stability is different in people with MS and AV. Thanks to visual biofeedback, it becomes possible to launch effective vision-motor coordination when compensating balance disorders. VCI may become the measure of compensation for balance disorders.

[Clinical diagnosis and treatment of chronic dizziness]

Chronic dizziness is defined as a complex of symptoms lasting months or years, including oscillopsia, nystagmus, and postural instability. Diagnostic search includes peripheral vestibulopathy - chronic unilateral vestibulopathy resulting from vestibular neuronitis, schwannoma of the 8th pair of cranial nerves, medical or surgical ablation of the labyrinth, and bilateral vestibulopathy; central vestibulopathy - syndromes accompanied by central vertical nystagmus, small vessel disease in patients with chronic cerebral ischemia; general somatic diseases, peripheral polyneuropathy, side-effects of medications as well as persistent postural-perceptual dizziness. Often, when collecting an anamnesis, it is not possible to identify specific features of dizziness and instability, therefore, clinical and instrumental examination of the patient is of particular importance. In the otoneurological examination, the greatest attention is paid to static/coordination tests, oculomotor tests aimed at identifying signs of damage to the vestibulo-ocular reflex. The principles of treatment depend on the diagnosed cause of dizziness and instability and can, to varying degrees, combine pharmacotherapy, vestibular rehabilitation and psychotherapy, as well as correction of therapy for the underlying disease that caused vestibulopathy.

Vestibular deficits and psychological factors correlating to dizziness handicap and symptom severity

OBJECTIVE

To determine the relative contribution of demographic variables, objective testing and psychological factors in explaining the variance in dizziness severity and handicap.

METHODS

One-hundred and eighty-five consecutive patients on the waiting list to attend a diagnostic appointment in a tertiary neuro-otology clinic with a primary complaint of vertigo or dizziness completed a cross-sectional survey. Primary outcomes were the Dizziness Handicap Inventory and the vertigo subscale of the Vertigo Symptom Scale-Short Form. Psychological questionnaires assessed anxiety and depressive symptoms, illness perceptions, cognitive and behavioural responses to symptoms, beliefs about emotions and psychological vulnerability. Patients also underwent standardised audio-vestibular investigations and tests to reach a diagnosis at appointment.

RESULTS

Objective disease characteristics were not associated with handicap and only the presence of vestibular dysfunction on one test (caloric) was associated with symptom severity. Almost all the psychological factors were correlated with dizziness outcomes. The total hierarchical regression model explained 63% of the variance in dizziness handicap, and 53% was explained by the psychological variables. The regression model for symptom severity explained 36% of the variance, and 30% was explained by the psychological factors. In adjusted models, factors associated with dizziness handicap included age, female gender, distress, symptom focusing, embarrassment, avoidance, and beliefs about negative consequences. Fear avoidance was the only independent correlate in the fully adjusted model of symptom severity.

CONCLUSION

Self-reported dizziness severity and handicap are not correlated with clinical tests of vestibular deficits but are associated with psychological factors including anxiety, depression, illness perceptions, cognitive and behavioural responses.

Treatment of Persistent Postural-Perceptual Dizziness (PPPD) and Related Disorders

PURPOSE OF REVIEW

Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder of functional dizziness that in the International Classification of Diseases in its 11th revision (ICD-11) supersedes phobic postural vertigo and chronic subjective dizziness. Despite efforts to unify the diagnosis of functional (somatoform) dizziness, patients will present with a variety of triggers, perpetuating factors, and comorbidities, requiring individualized treatment. This article will review different treatment strategies for this common functional neurological disorder and provide practical recommendations for tailored therapy.

RECENT FINDINGS

An emerging understanding of the underlying pathophysiology that considers vestibular, postural, cognitive, and emotional aspects can enable patients to profit from vestibular rehabilitation, as well as cognitive-behavioral therapy (CBT). Crucially, approaches from CBT should inform and augment physiotherapeutic techniques, and, on the other hand, vestibular exercises or relaxation techniques can be integrated into CBT programs. Antidepressant medication might further facilitate rehabilitation, though the mechanisms are yet to be elucidated, and the level of evidence is low. In PPPD and related disorders, vestibular rehabilitation combined with CBT, and possibly supported by medication, can help patients escape a cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in everyday life.

Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness

PURPOSE OF REVIEW

Functional dizziness is the new term for somatoform or psychogenic dizziness. The aim of this study is to review arguments for the new nomenclature, clinical features, possible pathomechanisms, and comorbidities of functional dizziness.

RECENT FINDINGS

The prevalence of functional dizziness as a primary cause of vestibular symptoms amounts to 10% in neuro-otology centers. Rates of psychiatric comorbidity in patients with structural vestibular syndromes are much higher with nearly 50% and with highest rates in patients with vestibular migraine, vestibular paroxysmia, and Ménière's disease. Pathophysiologic processes seem to include precipitating events that trigger anxiety-related changes in postural strategies with an increased attention to head and body motion and a cocontraction of leg muscles. Personality traits with high levels of neuroticism and low levels of extraversion appear as risk factors for anxiety and depressive disorders and increased morbidity in functional disorders.

SUMMARY

Correct and early diagnosis of functional dizziness, as primary cause or secondary disorder after a structural vestibular syndrome, is very important to prevent further chronification and enable adequate treatment. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically.

Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness

Persistent postural-perceptual dizziness (PPPD) is a newly defined diagnostic syndrome that unifies key features of chronic subjective dizziness, phobic postural vertigo and related disorders. It describes a common chronic dysfunction of the vestibular system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness. The disorder constitutes a long-term maladaptation to a neuro-otological, medical or psychological event that triggered vestibular symptoms, and is usefully considered within the spectrum of other functional neurological disorders. While diagnostic tests and conventional imaging usually remain negative, patients with PPPD present in a characteristic way that maps on to positive diagnostic criteria. Patients often develop secondary functional gait disorder, anxiety, avoidance behaviour and severe disability. Once recognised, PPPD can be managed with effective communication and tailored treatment strategies, including specialised physical therapy (vestibular rehabilitation), serotonergic medications and cognitive-behavioural therapy.

Functional (psychogenic) dizziness

Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.