Sarah Kirby

How likely are older people to take up different falls prevention activities

OBJECTIVE To determine the extent to which older people are willing to engage in different falls prevention activities, and how this may vary in different sectors of the older population. METHODS A survey sent to patients aged over 54 in ten general practices in the Southampton, Bristol and Manchester areas of the UK in 2006 yielded 5,440 respondents. The survey assessed willingness to attend classes of strength and balance training (SBT), carry out SBT at home, or accept support to reduce home hazards. Participants were asked their gender, age, education, home tenure, ethnic group, and how often they had fallen during the past year. RESULTS Over 60% of the sample would consider doing SBT at home and 36.4% said they would definitely do SBT at home. Only 22.6% would definitely attend group sessions and 41.1% would definitely not attend. Older age, recent falls and lower socioeconomic status were associated with a greater willingness to carry out SBT at home (but not in classes) and accept help with home hazards. CONCLUSIONS Health promotion programmes should give prominence to home-based performance of SBT as a method of encouraging the entire older population to engage in falls prevention, including those most in need.

Evaluation of Booklet-Based Self-Management of Symptoms in Meniere Disease: A Randomized Controlled Trial

Objective: This study examined the effectiveness of booklet-based education in vestibular rehabilitation (VR) and symptom control (SC) techniques to manage vertigo and dizziness in Ménière disease. Methods: Participants (n = 360) were randomized to a waiting list control group or to receive either a VR or an SC self-management booklet. VR involved provoking dizziness in a controlled manner by making repeated head movements in order to promote neurological and psychological habituation. SC involved using applied relaxation, challenging negative beliefs, and lifestyle modification to reduce amplification of dizziness by anxiety. Subjective improvement in health, enablement (ability to understand and cope with symptoms), and adherence were measured at 3 and 6 months. Symptoms, handicap, anxiety and depression, and negative beliefs about symptoms were assessed pretreatment and at 3 and 6 months. Results: At 6-month follow-up, 45 (37.5%) of the VR group and 47 (39.2%) of the SC group reported improvement compared with 19 (15.8%) controls; the relative probability of improvement compared with controls was 2.37 (95% confidence interval [CI], 1.48–3.80) for VR and 2.47 (95% CI, 1.55–3.95) for SC. Both intervention groups reported greater enablement than controls (p < .001, d > 0.70). At 3 months, the VR group had reduced symptoms, anxiety, handicap, and negative beliefs about dizziness; the SC group had reduced handicap; but the control group showed no improvement. Reported adherence levels were low and strongly related to outcome. Conclusions: Self-management booklets offer an inexpensive and easily disseminated means of helping people with Ménière disease to cope with dizziness symptoms. VR = vestibular rehabilitation; SC = symptom control; VSS = Vertigo Symptom Scale; VSS-SF = Vertigo Symptom Scale–Short Form; CI = confidence interval.

Clinical and cost effectiveness of booklet based vestibular rehabilitation for chronic dizziness in primary care: single blind, parallel group, pragmatic, randomised controlled trial

Objective To determine the clinical and cost effectiveness of booklet based vestibular rehabilitation with and without telephone support for chronic dizziness, compared with routine care. Design Single blind, parallel group, pragmatic, randomised controlled trial. Setting 35 general practices across southern England between October 2008 and January 2011. Participants Patients aged 18 years or over with chronic dizziness (mean duration >five years) not attributable to non-vestibular causes (confirmed by general practitioner) and that could be aggravated by head movement (confirmed by patient). Interventions Participants randomly allocated to receive routine medical care, booklet based vestibular rehabilitation only, or booklet based vestibular rehabilitation with telephone support. For the booklet approach, participants received self management booklets providing comprehensive advice on undertaking vestibular rehabilitation exercises at home daily for up to 12 weeks and using cognitive behavioural techniques to promote positive beliefs and treatment adherence. Participants receiving telephone support were offered up to three brief sessions of structured support from a vestibular therapist. Main outcome measures Vertigo symptom scale-short form and total healthcare costs related to dizziness per quality adjusted life year (QALY). Results Of 337 randomised participants, 276 (82%) completed all clinical measures at the primary endpoint, 12 weeks, and 263 (78%) at one year follow-up. We analysed clinical effectiveness by intention to treat, using analysis of covariance to compare groups after intervention, controlling for baseline symptom scores. At 12 weeks, scores on the vertigo symptom scale in the telephone support group did not differ significantly from those in the routine care group (adjusted mean difference −1.79 (95% confidence interval −3.69 tο 0.11), P=0.064). At one year, both intervention groups improved significantly relative to routine care (telephone support −2.52 (−4.52 to −0.51), P=0.014; booklet only −2.43 (−4.27 to −0.60), P=0.010). Analysis of cost effectiveness acceptability curves showed that both interventions were highly cost effective; at very low QALY values, the booklet only approach was most likely to be cost effective, but the approach with additional telephone support was most likely to be cost effective at QALY values more than £1200 (€1488;

Cognitions associated with anxiety in Ménière's disease

1932). Using the booklet approach with telephone support, five (three to 12) patients would need to be treated for one patient to report subjective improvement at one year. Conclusions Booklet based vestibular rehabilitation for chronic dizziness is a simple and cost effective means of improving patient reported outcomes in primary care. Trial registration ClinicalTrials.gov NCT00732797.

Understanding psychological distress in Ménière's disease: A systematic review

OBJECTIVES The purpose of this longitudinal study was to identify cognitions associated with anxiety and maintenance of anxiety in people with Ménières disease. METHOD At baseline, participants completed the Hospital Anxiety and Depression Scale (HADS), the Revised Illness Perception Questionnaire, the Dizziness Beliefs Scale, the Fear-Avoidance Beliefs Questionnaire, the Intolerance of Uncertainty Scale, and measures of demographic and illness characteristics. Participants were then randomized to a no-treatment group or to receive one of two self-help booklets, and completed the HADS again at 3-month follow-up. RESULTS After symptom severity had been controlled for, baseline anxiety was found to be associated with intolerance of uncertainty, fear-avoidance of physical activity, belief that dizziness would develop into a severe attack of vertigo, and several illness perception subscales (emotional representations, consequences, psychological causes, and perceived treatment effectiveness). Anxiety on follow-up was predicted by higher baseline levels of autonomic/somatic symptoms and intolerance of uncertainty, and by reporting less understanding of the illness. These longitudinal relationships were found in those who did and who did not receive self-help booklets. CONCLUSIONS Our findings suggest that intolerance of uncertainty is associated with anxiety in Ménières disease. A controlled trial is needed to see whether anxiety might be reduced in Ménières disease by helping patients tolerate and cope with uncertainty.

Context Effects and Behaviour Change Techniques in Randomised Trials: a Systematic Review Using the Example of Trials to Increase Adherence to Physical Activity in Musculoskeletal Pain

Abstract It has long been suspected that psychological disturbance is common in Ménières disease (MD), but there has been no systematic review of research on this topic since 1977. The aim of this review was to investigate whether components of post-traumatic stress disorder (PTSD) or health anxiety contribute to distress, so that support and psychological therapy can be tailored better to the particular problems of people with MD. We systematically identified all studies of psychological factors associated with MD between 1977 and 2004. We then tabulated the findings from each of the 28 studies to match them to the components of PTSD and health anxiety. Levels of psychosocial impairment and distress were comparable to patients with similar illness. Evidence was found for some of the components of both PTSD and health anxiety. We conclude that more specific research into PTSD-like symptoms and health anxiety in MD is needed. There was a general lack of research into psychological mechanisms contributing to distress in this population, many studies had methodological weaknesses, and only one qualitative and one longitudinal study had been carried out.

Predictors of adherence to home-based physical therapies: a systematic review

Objective: To describe and explore the effects of contextual and behaviour change technique (BCT) content of control and target interventions in clinical trials. Design: Review and meta-analysis of 42 trials from a Cochrane review of physical activity in chronic musculoskeletal pain. Main Outcome Measures: Two researchers coded descriptions of target and control interventions for (a) 93 BCTs and (b) whether target and control interventions shared each of five contextual features (practitioners’ characteristics, patient-practitioner relationship, intervention credibility, superficial treatment characteristics e.g. delivery modality, and environment). Quality of study reporting was assessed. Effect sizes for adherence to physical activity and class attendance were computed (Cohen’s d) and analysed separately. Results: For physical activity outcomes, after controlling for reporting quality, larger effect sizes were associated with target and control interventions using different modalities (β = −.34, p = .030), target and control interventions involving equivalent patient-practitioner relationship (β = .40, p = .002), and target interventions having more unique BCTs (i.e. more BCTs not also in the control) (β = .008, p = .030). There were no significant effect moderators for class attendance outcomes. Conclusion: Contents of control conditions can influence effect sizes and should be considered carefully in trial design and systematic reviews.

The contribution of symptoms of posttraumatic stress disorder, health anxiety and intolerance of uncertainty to distress in Ménière's disease.

Abstract Purpose: Self-managed, home-based physical therapy (HBPT) is an increasingly common element of physical therapy rehabilitation programmes but non-adherence can reach 70%. Understanding factors that influence patients’ adherence to HBPTs could help practitioners support better adherence. Research to date has focussed largely on clinic-based physiotherapy. The objective of this review, therefore, was to identify specific factors, which influence adherence to home-based, self-managed physical therapies. Method: A systematic review was conducted, in which eight online databases were searched using combinations of key terms relating to physical therapies, adherence and predictors. Matching records were screened against eligibility criteria and 30 quantitative articles were quality assessed and included in the final review. Relevant data were extracted and a narrative synthesis approach was taken to aggregating findings across studies. Results: There was relatively strong evidence that the following factors predicted adherence to HBPTs: intention to engage in the HBPT, self-motivation, self-efficacy, previous adherence to exercise-related behaviours and social support. Conclusions: This review has identified a range of factors that appear to be related to patients’ adherence to their self-managed physical rehabilitation therapies. Awareness of these factors may inform design of interventions to improve adherence. Implications for Rehabilitation Non-adherence to physical rehabilitation therapies is often high – particularly in self-managed, home-based programmes, despite good adherence being important in achieving positive outcomes. The findings of this systematic review indicate that greater self-efficacy, self-motivation, social support, intentions and previous adherence to physical therapies predict higher adherence to HBPTs. Assessment of these domains before providing individuals with their HBPT regimes may allow identification of ‘risk factors’ for poor adherence. These can then potentially be addressed or managed prior to, or alongside, the therapy. Interventions to support patients’ self-managed physical rehabilitation should include elements designed to enhance patients’ self-efficacy, self-motivation and social support given the evidence that these factors are good predictors of adherence.

Internet-based vestibular rehabilitation for adults aged 50 years and over: a protocol for a randomised controlled trial

This study assessed whether symptoms of posttraumatic stress disorder (PTSD), health anxiety, and intolerance of uncertainty were associated with distress in members of the Ménières Society (n = 800), and compared the extent of anxiety, depression, intolerance of uncertainty, and health anxiety with a healthy control group (n = 484). PTSD symptoms were associated with anxiety, depression, and handicap. Health anxiety was associated with anxiety and depression. Intolerance of uncertainty was directly associated with anxiety; its association with depression and handicap was mediated by PTSD symptoms. The Ménières group reported more anxiety, depression, and health anxiety than the control group, but were not more intolerant of uncertainty. More than half of the Ménières group reported experiencing partial or full PTSD symptoms. As PTSD, health anxiety and intolerance of uncertainty are modifiable with psychological treatment, we advise that clinicians should screen patients with Ménières disease who are particularly distressed.

Change and processes of change within interventions to promote adjustment to multiple sclerosis: Learning from patient experiences

Introduction Dizziness is highly prevalent in older adults and can lead to falls, fear of falling, loss of confidence, anxiety and depression. Vestibular rehabilitation (VR) exercises are effective in reducing dizziness due to vestibular dysfunction, but access to trained therapists is limited. Providing dizzy patients with booklets teaching them how to carry out VR exercises has been shown to be a cost-effective way of managing dizziness in primary care. Internet-based intervention delivery has many advantages over paper-based methods, including the provision of video instructions, automated tailoring and symptom-related feedback. This trial will examine whether an internet-based VR intervention is (1) effective in reducing dizziness and (2) a cost-effective primary care treatment option. Methods/analysis This will be a single blind, randomised controlled trial carried out in UK primary care. A stand-alone internet-based VR intervention will be compared with routine care in 262 dizzy patients aged 50 years and over. Measures will be taken at baseline, 3 and 6 months. Our primary outcome measure will be the effectiveness of the intervention in reducing dizziness symptoms compared with routine care at 6 months. Cost-effectiveness will be examined along with the effect of the intervention on dizziness-related disability and symptoms of depression and anxiety. Psychological process variables including expectancy, self-efficacy and acceptance will be explored in relation to adherence and symptom reduction. Ethics/dissemination This trial has undergone ethical scrutiny and been approved by an NHS Research Ethics Committee, Southampton A REC Reference: 13/SC/0119. The findings of this trial will be disseminated to the scientific community through presentations at national and international conferences, and by publishing in peer review journals. Findings will be disseminated to the public through targeted press releases. This trial will provide valuable information on the role of internet interventions in facilitating self-management in older adults. Trial registration number ISRCTN: 86912968.