Toward a Digital Health Intervention for Vestibular Rehabilitation: Usability and Subjective Outcomes of a Novel Platform

Adherence to customized vestibular rehabilitation therapy: influencing factors and clinical implications in vestibulopathy

Objective

Customized vestibular rehabilitation therapy (CVRT) is an effective treatment approach for various vestibular disorders. However, low adherence significantly limits its efficacy, and factors influencing adherence remain underexplored. This study aimed to identify factors affecting adherence to CVRT across major vestibulopathy categories, including acute unilateral vestibular hypofunction (AUVH), chronic unilateral vestibular hypofunction (CUVH), and bilateral vestibular hypofunction (BVH).

Methods

A retrospective analysis of 90 patients who were prescribed four sessions of CVRT and underwent the therapy was conducted. Patients were classified as adherent (≥3 sessions) or non-adherent (≤2 sessions). Demographic characteristics, baseline questionnaire scores, and vestibular function test (VFT) results were compared. Change in questionnaire scores and VFT results before and after CVRT, as well as mid-treatment follow-up questionnaire scores were analyzed.

Results

Adherence rates were highest in CUVH (86.7%) and lowest in BVH (46.2%). Among patients with AUVH, poor functional reach test scores were significantly associated with lower adherence (p = 0.045). In the CUVH category, patients with mild dizziness in the initial questionnaire were non-adherent (p = 0.019). CVRT improved subjective dizziness symptoms and VFT parameters, with the greatest gains observed in AUVH. However, no significant differences in symptom improvement were found between adherent and non-adherent patients. Patients whose symptoms improved rapidly to a mild degree after starting the CVRT were more likely to be non-adherent, with this tendency being especially pronounced in those with AUVH.

Conclusion

Adherence to CVRT varies by vestibulopathy category and is influenced by baseline symptom severity. Tailoring CVRT strategies based on individual clinical profiles may enhance adherence and optimize therapeutic outcomes.

Extended reality technology for alleviating adult dental anxiety: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To assess the effectiveness of extended reality (XR) technology in reducing dental anxiety in adults, through a systematic review and meta-analysis.

METHODS

Comprehensive electronic and manual searches were conducted to identify randomized controlled trials published up to November 23, 2024, with no restrictions on publication year or language. Key outcomes included changes in anxiety and pain levels and cardiovascular indicators, such as blood pressure, heart rate, and oxygen saturation (SpO2). A random-effects model was used to evaluate the combined effects, with subgroup analyses exploring potential influencing factors. The updated Cochrane Risk of Bias 2 tool was used to assess the risk of bias. Meta-analysis was performed using RevMan 5.4.

RESULTS

Of 1,207 screened records, 52 were retrieved for full-text evaluation, resulting in 10 studies meeting the inclusion criteria. The meta-analysis revealed that XR technology significantly reduced anxiety (mean difference [MD]:3.22, 95 % confidence interval [CI]:3.83 to -2.61; I² = 85 %), pain (MD:1.30, 95 % CI:2.07 to -0.53; I² = 84 %), and blood pressure scores (MD:3.34, 95 % CI:4.76 to -1.92; I² = 2 %). For cardiovascular indicators (heart rate, pulse, and SpO₂), the overall effect size was -3.83 (95 % CI:5.54 to -2.13; I² = 83 %).

CONCLUSIONS

Our findings suggest that XR technology effectively alleviates dental anxiety in adults. However, larger, rigorously designed trials to better understand its impact.

CLINICAL SIGNIFICANCE

XR technology reduces patients' blood pressure, heart rate, pain, and anxiety during dental treatments. Rigorous, large-scale trials are needed to confirm its clinical effectiveness.

Wearable sensor and smartphone assisted vestibular physical therapy for multiple sclerosis: usability and outcomes

Introduction

Vertigo, dizziness, gaze instability and disequilibrium are highly prevalent in people with MS (PwMS) and head movement induced dizziness is commonly reported. Vestibular physical therapy (VPT) is a specialised, non-invasive and effective therapy for these problems but usually involves travel for the person to a specialist center with both personal and carbon costs. The use of wearable sensors to track head movement and smartphone applications to deliver and track programs has potential to improve VPT in MS.

Methods

This study investigated the usability and effects of a commercially available digital VPT system (wearable head sensor, smartphone app and clinician software) to deliver VPT to PwMS. A pre/post treatment design was employed and the primary outcome was the System Usability Scale (SUS). Other patient reported outcomes were the Service User Acceptability Questionnaire (SUTAQ), the Patient Enablement Instrument (PEI) and the Dizziness Handicap Inventory (DHI). Physical outcomes measurements included Mini-BESTest (MB), Modified Dynamic Gait Index (mDGI), Gait Speed (GS), Dynamic Visual Acuity (DVA) and head kinematics and symptoms during exercise.

Results

Sixteen PwMS (14 female), mean age 44(±14) years were recruited to the study and twelve completed VPT. Mean adherence to exercise, measured digitally was 60% (±18.4). SUS scores were high at 81 (±14) and SUTAQ scores also demonstrated high levels of satisfaction and acceptability of the system. Statistically significant improvements in MB (mean change 2.25; p = 0.004), mDGI (median change 1.00; p = 0.008), DVA (median change -1.00; p = 0.004) were found. Head frequencies significantly improved with concurrent decreased intensity of dizziness during head movements (mean change across 4 gaze stabilization exercises was 23 beats per minute; p < 0.05). Non-significant improvements were seen in DHI (p = 0.07) and GS (p = 0.15). 64.5% of follow up visits were conducted remotely (video or phone), facilitated by the system.

Discussion

This study had two main outcomes and benefits for PwMS. Firstly, we showed that the system used was both acceptable and could be used by PwMS. Secondly, we demonstrated an improvement in a range of dizziness, balance and gait metrics with remotely delivered care. This system has the potential to positively impact on MS physiotherapy service provision with the potential to deliver effective remote care.

Remote assessment and management of patients with dizziness: development, validation, and feasibility of a gamified vestibular rehabilitation therapy platform

Introduction

Dizziness is a growing public health concern with as many as 95 million adults in Europe and the United States experiencing vestibular hypofunction, which is associated with reduced quality of life, poorer health, and falls. Vestibular rehabilitation therapy (VRT) is effective in reducing symptoms and improving balance; however, limited access to qualified clinicians and poor patient adherence impedes optimal delivery. The goal of this study was to develop and evaluate the feasibility of a remote therapeutic monitoring VRT Platform application (APP) for the assessment and treatment of vestibular dysfunction.

Methods

User-centered iterative design process was used to gather and integrate the needs of users (clinicians and patients) into the design at each stage of development. Commonly used vestibular patient-reported outcome measures (PROs) were integrated into the APP and adults with chronic dizziness were enrolled to evaluate validity and reliability of the APP compared to standard clinical measures (CLIN). Gaze stabilization exercises were gamified to provide an engaging experience and an off-the-shelf sensor captured eye and head movement to provide feedback on accuracy of performance. A prospective, pilot study design with pre-and post-treatment assessment assessed feasibility of the APP compared to standard VRT (CLIN).

Results

Participants with dizziness wanted a summary rehabilitation report shared with their clinicians, felt that an app could help with accountability, and believed that a gaming format might help with exercise adherence. Clinicians felt that the app should include features to record and track eye and head movement, monitor symptoms, score accuracy of task performance, and measure adherence. Validity and reliability of the digital PROs (APP) were compared to scores from CLIN across two sessions and found to have good validity, good to excellent test-retest reliability, and excellent usability (≥88%ile). The pilot study demonstrated feasibility for use of the APP compared to CLIN for treatment of vestibular hypofunction. The mean standard system usability score of the APP was 82.5 indicating excellent usability.

Discussion

Both adult patients with chronic dizziness and VRT clinicians were receptive to the use of technology for VRT. The HiM-V APP is a feasible alternative to clinical management of adults with chronic peripheral vestibular hypofunction.

Effectiveness of Telerehabilitation in Dizziness: A Systematic Review with Meta-Analysis

Dizziness can be a debilitating condition with various causes, with at least one episode reported in 17% to 30% of the international adult population. Given the effectiveness of rehabilitation in treating dizziness and the recent advancements in telerehabilitation, this systematic review aims to investigate the effectiveness of telerehabilitation in the treatment of this disorder. The search, conducted across Medline, Cochrane Central Register of Controlled Trials, and PEDro databases, included randomized controlled trials assessing the efficacy of telerehabilitation interventions, delivered synchronously, asynchronously, or via tele-support/monitoring. Primary outcomes focused on dizziness frequency/severity and disability, with secondary outcomes assessing anxiety and depression measures. Seven articles met the eligibility criteria, whereas five articles contributed to the meta-analysis. Significant findings were observed regarding the frequency and severity of dizziness (mean difference of 3.01, p < 0.001), disability (mean difference of -4.25, p < 0.001), and anxiety (standardized mean difference of -0.16, p = 0.02), favoring telerehabilitation. Telerehabilitation shows promise as a treatment for dizziness, aligning with the positive outcomes seen in traditional rehabilitation studies. However, the effectiveness of different telerehabilitation approaches requires further investigation, given the moderate methodological quality and the varied nature of existing methods and programs.

Leveraging Technology for Vestibular Assessment and Rehabilitation in the Operational Environment: A Scoping Review

INTRODUCTION

The vestibular system, essential for gaze and postural stability, can be damaged by threats on the battlefield. Technology can aid in vestibular assessment and rehabilitation; however, not all devices are conducive to the delivery of healthcare in an austere setting. This scoping review aimed to examine the literature for technologies that can be utilized for vestibular assessment and rehabilitation in operational environments.

MATERIALS AND METHODS

A comprehensive search of PubMed was performed. Articles were included if they related to central or peripheral vestibular disorders, addressed assessment or rehabilitation, leveraged technology, and were written in English. Articles were excluded if they discussed health conditions other than vestibular disorders, focused on devices or techniques not conducive to the operational environment, or were written in a language other than English.

RESULTS

Our search strategy yielded 32 articles: 8 articles met our inclusion and exclusion criteria whereas the other 24 articles were rejected.

DISCUSSION

There is untapped potential for leveraging technology for vestibular assessment and rehabilitation in the operational environment. Few studies were found in the peer-reviewed literature that described the application of technology to improve the identification of central and/or peripheral vestibular system impairments; triage of acutely injured patients; diagnosis; delivery and monitoring of rehabilitation; and determination of readiness for return to duty.

CONCLUSIONS

This scoping review highlighted technology for vestibular assessment and rehabilitation feasible for use in an austere setting. Such technology may be leveraged for prevention; monitoring exposure to mechanisms of injury; vestibular-ocular motor evaluation; assessment, treatment, and monitoring of rehabilitation progress; and return-to-duty determination after vestibular injury.

FUTURE DIRECTIONS

The future of vestibular assessment and rehabilitation may be shaped by austere manufacturing and 3D printing; artificial intelligence; drug delivery in combination with vestibular implantation; organ-on-chip and organoids; cell and gene therapy; and bioprinting.

A gaming app developed for vestibular rehabilitation improves the accuracy of performance and engagement with exercises

Introduction

Vestibular hypofunction is associated with dizziness, imbalance, and blurred vision with head movement. Vestibular rehabilitation is the gold standard recommendation to decrease symptoms and improve postural stability. The Clinical Practice Guidelines for vestibular hypofunction suggest home exercises 3-5 times daily, but patient adherence is a problem, with compliance rates often below 50%.

Methods

An app was developed to increase engagement with home exercises by providing exercises as games. This study compared the accuracy of exercise performance in a one-time session using the app versus no-app and gathered participant feedback on using the app for vestibulo-ocular reflex (VOR) and balance exercises. The app was tested with 40 adults (20 women), mean age of 67 ± 5.7 years, with symptomatic unilateral or bilateral vestibular hypofunction. Participants completed VOR exercises in pitch and yaw planes, weight-shift, and single-leg balance exercises using an inertial motion unit to move the character on the tablet screen. Participants were randomly assigned to begin the exercises with or without the app.

Results

Results show that during VOR exercises, participants achieved the prescribed frequency of head motion for the yaw plane (p ≤ 0.001) and reduced variability of head movement frequency in both the yaw (p ≤ 0.001) and pitch plane (p ≤ 0.001) in the app compared to the no-app condition. During weight-shifting exercises, a larger range of body motion was noted in the anteroposterior and mediolateral directions in the app compared to the no-app condition (p < 0.05). During single-leg balance exercises, pelvic motion was lower in the app versus no-app condition (p = 0.02). Participants modified their exercise performance and corrected their mistakes to a greater extent when they used the app during the VOR exercises. Participants agreed that they felt motivated while playing the games (97%) and felt motivated by the trophies (92%). They agreed that the app would help them perform the exercises at home (95%), improve their rehab performance (95%) and that it was fun to do the exercises using the app (93%).

Discussion

The results of this study show that technology that is interactive and provides feedback can be used to increase accuracy and engagement with exercises.

How do patients with chronic dizziness experience a web-based home rehabilitation programme for customised vestibular therapy ('WeBaVeR')? A qualitative study

BACKGROUND

Vestibular rehabilitation therapy (VRT) is the first choice approach for chronic dizziness. However, current home treatment programmes often lack attention to the individual needs of the patient and the integration of visual desensitisation therapy. We therefore developed a customised web-based VRT programme containing visual desensitisation exercises.

OBJECTIVE

To assess the user experience (usability, satisfaction, acceptability, and quality) of patients with chronic dizziness with the customised WEb-BAsed VEstibular Rehabilitation, further called 'WeBaVeR'.

METHODS

Patients with chronic dizziness, attending the Department of Otorhinolaryngology of the Antwerp University Hospital (period September 2021 to May 2022), received a customised programme, i.e. exercises supported by our web application and booklet. The programme lasted 6 weeks, with weekly supervision by phone. Patients' user experience was examined with the System Usability Scale (SUS), Client Satisfaction Questionnaire (CSQ), Service User Technology Acceptability Questionnaire (SUTAQ), and the User version of the Mobile Application Rating Scale (uMARS).

RESULTS

Twelve patients with chronic dizziness (mean age: 45.33 ± 13.26 years) participated. The overall rated level of perceived usability (mean SUS score: 78.75 ± 8.95 points), satisfaction (mean CSQ score: 33.08 ± 3.37 points), acceptability (mean SUTAQ score: 105.67 ± 13.40 points) and quality (mean uMARS score: 94.58 ± 10.69 points) was good. The main remarks concerned the user interface and the interactive capabilities of the web application, and that WeBaVeR does not increase health awareness, or accessibility to health care providers.

CONCLUSION

Patients with chronic dizziness consider WeBaVeR as useful, acceptable, satisfactory and of good quality. To facilitate implementation in practice, further optimisation of WeBaVeR based on the feedback received, is useful.