Emergency Department Vestibular Rehabilitation Therapy for Dizziness and Vertigo: A Nonrandomized Clinical Trial

Abstract

Importance: Dizziness symptoms account for nearly 2 million annual emergency department (ED) visits and present a diagnostic challenge for clinicians. Most dizziness research has focused on improving guideline-concordant care among clinicians, with little focus on developing patient-centered interventions to improve dizziness-related disability.

Objective: To examine the feasibility of ED vestibular rehabilitation therapy (ED-VeRT) using a protocolized diagnostic classification algorithm and collection of longitudinal patient-reported outcomes.

Design, setting, and participants: A pilot nonrandomized clinical trial of ED-VeRT vs usual care for patients presenting to the ED with dizziness at a single urban US ED was conducted from November 16, 2021, to February 6, 2023, with collection of 3-month outcomes through May 1, 2023. Patients were allocated to ED-VeRT or usual care at the discretion of the treating physician.

Interventions: Use of ED-VeRT was delivered by an ED physical therapist via a protocolized diagnostic classification and treatment algorithm based on a diagnosis of benign paroxysmal positional vertigo, triggered undifferentiated dizziness, spontaneous undifferentiated dizziness, or unilateral peripheral hypofunction.

Main outcomes and measures: Feasibility outcomes included participant screening, enrollment, and retention rates to inform the design of a future randomized clinical trial; retention was defined as completing any of 4 follow-up surveys over 3 months. The primary efficacy outcome was change in the Dizziness Handicap Inventory score; the secondary efficacy outcome was change in the Vestibular Activities Avoidance Inventory-9 score.

Results: Of 366 patients screened, 125 participants were enrolled (median age, 52 [IQR, 40-66] years, 73 [58%] female, 61 [49%] White), and 105 retained (84.0%) in longitudinal data collection. Sixty-three participants (50.4%) received ED vestibular therapy and were assigned to primary diagnostic classifications of benign paroxysmal positional vertigo (23 [37.1%]), triggered undifferentiated dizziness (14 [22.6%]), spontaneous undifferentiated dizziness (14 [22.6%]), or unilateral peripheral hypofunction (9 [14.5%]). Despite having higher Dizziness Handicap Inventory and Vestibular Activities Avoidance Inventory scores at baseline, ED-VeRT participants reported lower dizziness handicap (difference: -1.68; 95% CI, -11.30 to 7.90) and vestibular activities avoidance (difference: -2.27; 95% CI, -8.40 to 3.86) at 3 months, although these differences were not statistically significant.

Conclusions and relevance: In this nonrandomized clinical trial, ED vestibular therapy was feasibly delivered to patients presenting to the ED with undifferentiated dizziness symptoms. For participants receiving vestibular therapy the findings for dizziness-related disability over 3 months were not statistically significant, pointing to the need for a fully powered randomized clinical trial.

Trial registration: ClinicalTrials.gov Identifier: NCT05122663.

Figure 1.. Emergency Department Vestibular Rehabilitation Therapy (ED-VeRT) Diagnostic Classification Algorithm

BPPV indicates benign paroxysmal positional vertigo; CRM, canal repositioning maneuvering; HINTS+, head impulse, nystagmus, test of skew plus hearing; PT, physical therapy.

Figure 2.. Study Flow Diagram

Note that the sum of all exclusion criteria exceeds n=366 because some patients met multiple exclusion criteria. ED indicates emergency department; ED-VeRT, ED vestibular rehabilitation therapy.

Figure 3.. Longitudinal Patient-Reported Outcomes

Mean Dizziness Handicap Inventory (DHI) scores (A), Vestibular Activities Avoidance Inventory-9 (VAAI-9) scores (B), and sedating medication use (C) over time. Error bars indicate 95% CIs calculated under the normal distribution assumption. Note that baseline values are calculated directly from observed data, whereas follow-up values are estimated by the generalized linear mixed model. ED-VeRT indicates emergency department vestibular rehabilitation therapy.