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Topic of the Month: Biobehavioral Aspects of Vestibular Rehabilitation

No 468: April 17, 2019

Hsu CL, Tsai SJ, Shen CC, Lu T, Hung YM, Hu LY.  Risk of benign paroxysmal positional vertigo in patients with depressive disorders: a nationwide population-based cohort study.  BMJ Open. 2019 Mar 30;9(3):e026936. doi: 10.1136/bmjopen-2018-026936.  

OBJECTIVE: The association between depression and benign paroxysmal positional vertigo (BPPV) remains debated. This study aimed to investigate the risk of BPPV in patients with depressive disorders.

DESIGN: Longitudinal nationwide cohort study.

SETTING: National health insurance research database in Taiwan.

PARTICIPANTS: We enrolled 10,297 patients diagnosed with depressive disorders between 2000 and 2009 and compared them to 41,188 selected control patients who had never been diagnosed with depressive disorders (at a 1:4 ratio matched by age, sex and index date) in relation to the risk of developing BPPV.

METHODS: The follow-up period was defined as the time from the initial diagnosis of depressive disorders to the date of BPPV, censoring or 31 December 2009. Cox proportional hazard regression analysis was used to investigate the risk of BPPV by sex, age and comorbidities, with HRs and 95% CIs.

RESULTS: During the 9-year follow-up period, 44 (0.59 per 1000 person-years) patients with depressive disorders and 99 (0.33 per 1000 person-years) control patients were diagnosed with BPPV. The incidence rate ratio of BPPV among both cohorts calculating from events of BPPV per 1000 person-years of observation time was 1.79 (95% CI 1.23 to 2.58, p=0.002). Following adjustments for age, sex and comorbidities, patients with depressive disorders were 1.55 times more likely to develop BPPV (95% CI 1.08 to 2.23, p=0.019) as compared with control patients. In addition, hyperthyroidism (HR=3.75, 95% CI 1.67-8.42, p0.001) and systemic lupus erythematosus (SLE) (HR=3.47, 95% CI 1.07 to 11.22, p=0.038) were potential risk factors for developing BPPV in patients with depressive disorders.

CONCLUSIONS: Patients with depressive disorders may have an increased risk of developing BPPV, especially those who have hyperthyroidism and SLE.

PMID: 30928959

No 467: April 11, 2019

Sullivan KA, Kaye SA, Blaine H, Edmed SL, Meares S, Rossa K, Haden C.  Psychological approaches for the management of persistent postconcussion symptoms after mild traumatic brain injury: a systematic review.  Disabil Rehabil. 2019 Feb 11:1-9. doi: 10.1080/09638288.2018.1558292. 

BACKGROUND: To evaluate the evidence for psychological treatments for persistent postconcussion symptoms following mild traumatic brain injury. There is scant evidence from limited clinical trials to direct the psychological management of persistent symptoms.

METHOD: Databases were searched for studies that: (1) included adults (≥ aged 16 years) following injury (from any cause); (2) tested interventions for postconcussion symptoms after the acute injury period (e.g., after hospital discharge), but prior to established chronicity (e.g., not more than 12 months post-injury), and; (3) applied one of five broadly-defined psychological interventions (cognitive behavioural therapy, counselling, psychoeducation, education/reassurance, or mindfulness). All controlled trials were eligible for inclusion.

RESULTS: Of the 20,945 articles identified, 10 underwent risk-of-bias analysis by two independent reviewers. Nine were retained for data extraction. They used: cognitive behaviour therapy (n=2), counselling (n=2), psychoeducation (n=2), education/reassurance (n=2), or compared cognitive behaviour therapy to counselling (n=1).

CONCLUSION: Counselling or cognitive behaviour therapy have the most support but the evidence remains limited. We encourage further randomized controlled trials of early interventions in samples at risk for persistent symptoms, including closer study of psychological risk-factors and the 'active' ingredient. To advance the field, future trials must include additional methodological controls and improved reporting. Implications for rehabilitation Persistent symptoms following mild traumatic brain injury can be disabling and psychological management for rehabilitation may be proposed. However, Controlled trials show that while some psychological approaches hold promise for this purpose, there are significant gaps in the underpinning evidence. The best results are seen when postconcussion programs use counselling or cognitive behaviour therapy and are targetted for people with an increased risk of persistent symptoms.

PMID: 30741023

No 466: April 3, 2019

Walker A, Kantaris X, Chambers M. Understanding therapeutic approaches to anxiety in vestibular rehabilitation: a qualitative study of specialist physiotherapists in the UK.  Disabil Rehabil. 2018 Apr;40(7):829-835. doi: 10.1080/09638288.2016.1277393. Epub 2017 Jan 27.

PURPOSE: People with vestibular disorders are typically treated by physiotherapists in vestibular rehabilitation. Anxiety is strongly associated with vestibular disorders; however, there is a lack of understanding about how physiotherapists respond to people presenting with anxiety within vestibular rehabilitation. This study aimed to explore physiotherapists' current practice in assessing and treating patients with anxiety in vestibular rehabilitation.

MATERIALS AND METHODS: A qualitative study using semi-structured interviews with 10 specialist physiotherapists in vestibular rehabilitation in three university teaching hospitals in England. Data were analyzed using thematic analysis.

RESULTS: Four themes were identified: (i) The therapeutic relationship, (ii) Adapting assessment and treatment, (iii) Psychological intervention and support, and (iv) Physiotherapists' education and training. Physiotherapists reported using a range of behavioral and cognitive techniques and adapting their therapeutic approach by placing greater emphasis on education, building trust and pacing treatment. Physiotherapists highlighted the need for more specialist psychological support for patients during vestibular rehabilitation and tailored training and guidance on addressing anxiety within vestibular rehabilitation.

CONCLUSIONS: Physiotherapists working in vestibular rehabilitation consider managing aspects of anxiety within their scope of practice and describe taking a psychosocial therapeutic approach. There is limited access to expert psychological support for patients with anxiety within vestibular rehabilitation. Implications for rehabilitation Anxiety is strongly associated with vestibular disorders and it is common for these patients to be managed by physiotherapists in vestibular rehabilitation. Vestibular rehabilitation services could improve access to psychological expertise through dedicated psychological input, more effective signposting and referral pathways, and better access to inter-professional support from psychologists and/or CBT practitioners in managing more complex patients. Physiotherapists requested tailored training and guidance to enhance their ability to manage patients with anxiety more effectively in vestibular rehabilitation.

PMID:   28129508

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