Dizziness is especially common among persons older than 60 years, and can result in significant disability, fear of falling, and loss of independence. The underlying causes encountered most frequently in primary care offices are peripheral vestibular disorders and psychiatric factors; in older patients, multiple issues may be responsible. Significant cardiovascular and neurologic disorders rarely cause dizziness alone. Usual treatment in primary care includes reassurance with anti-vertigo and antiemetic drugs. Results of several reviews, however, show that medications do not have a well-established efficacy in the treatment of dizziness and call for further evaluation of the role of exercise-based treatment. Vestibular rehabilitation regimens use eye, head, and body movement exercises to stimulate the vestibular system, resulting in central compensation. The exercises also help decrease patient anxiety and increase confidence in balance. Yardley and colleagues used a single-blinded, randomized controlled trial to evaluate the efficacy of vestibular rehabilitation offered in a primary care setting.
Patients with dizziness were recruited from 20 urban and rural general practices in southern England in 2001 and 2002 and were assigned randomly to vestibular rehabilitation or usual care for three months. Patients with a nonlabyrinthine cause for their dizziness were excluded, as were those who could not safely perform the required head movements. Patients assigned to rehabilitation had a 30- to 40-minute meeting with a trained nurse who explained vestibular exercises and took them through an explanatory treatment booklet. Nurses also provided a follow-up phone call at weeks 1 and 3 to offer support and answer questions. After three months, participants were assessed by a blinded assistant. The groups were then crossed over for another three months before being reassessed. Dizziness symptoms were evaluated using the Vertigo Symptom Scale Short Form, a balance performance monitor, and by participant self-reports. All patients continued to use their regular medications.
At the three-month follow-up, the vestibular rehabilitation intervention group showed significantly greater improvement on all primary outcome measures compared with the usual care group. At the six-month follow-up, the group who initially had been given vestibular rehabilitation maintained their symptom improvement, whereas the group who received vestibular rehabilitation during the second three-month period improved significantly on six of the eight outcome measures. Side effects reported with the exercises were minor and transient.
The authors conclude that vestibular rehabilitation offered in a primary care setting with minimal follow-up support can reduce heterogeneous dizziness symptoms and resultant disability. The program should include targeted exercises for specific forms of dizziness, and daily activities (e.g., walking, traveling) to encourage adaptation to dizziness in ordinary situations.
editor’s note: In an editorial1 in the same journal, Dieterich points out that physical therapy for balance control is a useful tool for managing dizziness and vertigo regardless of the cause. She notes that the simple exercise used in the Yardley study––moving the head from one side to the other and lowering or raising the head with the eyes open or closed with increasing rapidity––can be highly useful in alleviating symptoms and fall anxiety. The central nervous system is flexible enough to compensate for certain peripheral and central neurologic deficits, although the effects of aging and pathology worsen equilibrium problems. The best therapy for dizziness consists of treatment for any underlying cause, as well as encouragement of physical exercise and balance training.—r.s.