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Internet based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice: three armed randomised controlled trial

BMJ 2019; 367 doi: (Published 05 November 2019) Cite this as: BMJ 2019;367:l5922

Linked Opinion

Treat dizziness and vertigo with vestibular rehabilitation

  1. Vincent A van Vugt, general practice registrar1,
  2. Johannes C van der Wouden, associate professor1,
  3. Rosie Essery, research fellow in health psychology2,
  4. Lucy Yardley, professor of health psychology2,
  5. Jos W R Twisk, applied biostatistician3,
  6. Henriëtte E van der Horst, head of department of general practice and elderly care medicine1,
  7. Otto R Maarsingh, general practitioner and researcher1
  1. 1Department of General Practice and Elderly Care Medicine, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
  2. 2Department of Psychology, University of Southampton, Southampton, UK
  3. 3Department of Epidemiology and Biostatistics, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
  1. Correspondence to: V A van Vugt v.vanvugt{at}
  • Accepted 24 September 2019


Objective To investigate the clinical effectiveness and safety of stand alone and blended internet based vestibular rehabilitation (VR) in the management of chronic vestibular syndromes in general practice.

Design Pragmatic, three armed, parallel group, individually randomised controlled trial.

Setting 59 general practices in the Netherlands.

Participants 322 adults aged 50 and older with a chronic vestibular syndrome.

Interventions Stand alone VR comprising a six week, internet based intervention with weekly online sessions and daily exercises (10-20 minutes a day). In the blended VR group, the same internet based intervention was supplemented by face-to-face physiotherapy support (home visits in weeks 1 and 3). Participants in the usual care group received standard care from a general practitioner, without any restrictions.

Main outcome measures The primary outcome was vestibular symptoms after six months as measured by the vertigo symptom scale-short form (VSS-SF range 0-60, clinically relevant difference ≥3 points). Secondary outcomes were dizziness related impairment, anxiety, depressive symptoms, subjective improvement of vestibular symptoms after three and six months, and adverse events.

Results In the intention-to-treat analysis, participants in the stand alone and blended VR groups had lower VSS-SF scores at six months than participants in the usual care group (adjusted mean difference −4.1 points, 95% confidence interval −5.8 to −2.5; and −3.5 points, −5.1 to −1.9, respectively). Similar differences in VSS-SF scores were seen at three months follow-up. Participants in the stand alone and blended VR groups also experienced less dizziness related impairment, less anxiety, and more subjective improvement of vestibular symptoms at three and six months. No serious adverse events related to online VR occurred during the trial.

Conclusion Stand alone and blended internet based VR are clinically effective and safe interventions to treat adults aged 50 and older with a chronic vestibular syndrome. Online VR is an easily accessible form of treatment, with the potential to improve care for an undertreated group of patients in general practice.

Trial registration Netherlands Trial Register NTR5712.


  • Contributors: ORM obtained the funding and coordinated the study. ORM, VAvV, JCvdW, HEvdH, and LY designed the study. RE and LY advised on the development of the vertigo training intervention. VAvV collected the data. VAvV and JWRT analysed the data. VAvV wrote the first substantial draft of the article and is the guarantor. ORM, JCvdW, RE, LY, HEvdH, and JWRT critically revised the manuscript. All authors read and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from the Netherlands Organisation for Health Research and Development (ZonMw) for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Funding: This study was funded by the Netherlands Organisation for Health Research and Development (ZonMw) (programme Quality in health care; grant No 839110015). The sponsors did not participate in the study design; data collection, analysis, and interpretation; or the preparation or submission of this report.

  • Ethical approval: The study protocol was approved by the medical ethics committee of the VU University Medical Center. All participants included in the study provided written informed consent.

  • Data sharing: Deidentified individual participant data and data analysis plan available from the corresponding author on reasonable request.

  • The manuscript’s guarantor (VAvV) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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