AUTHOR=Suica Zorica , Behrendt Frank , Ziller Carina , Gäumann Szabina , Schädler Stefan , Hilfiker Roger , Parmar Katrin , Gerth Hans Ulrich , Bonati Leo H. , Schuster-Amft Corina 

TITLE=Comparative effectiveness of non- pharmacological treatments in patients with persistent postural-perceptual dizziness: a systematic review and effect sizes analyses

JOURNAL=Frontiers in Neurology

VOLUME=Volume 15 - 2024

YEAR=2024

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1426566

DOI=10.3389/fneur.2024.1426566

ISSN=1664-2295

ABSTRACT=The patho-psychological mechanisms of persistent postural-perceptual dizziness (PPPD) appear to be very complex, and a multimodal, multidisciplinary approach is suggested for treating patients with PPPD. The aim of this review was to provide a comprehensive overview of nonpharmacological treatments and their comparative effectiveness in patients with PPPD.Methods: Scopus, Web of Science, PsycINFO, Medline, Embase, CINAHL, Cochrane Library and ClinicalTrials.gov were searched in April 2022 with a search update in August 2023. Only randomised controlled trials (RCTs) were included. Two reviewers independently identified eligible trials, extracted data, double-checked all extracted information from the included articles and assessed the risk of bias using the Cochrane risk of bias tool.A qualitative synthesis was performed, considering methodological heterogeneity between trials.Finally, an effect size analysis was performed for each treatment comparison. The standardised mean differences (SMD) and their corresponding 95% confidence intervals (95%CI) were calculated for each trial using Review Manager 5.4.: Thirteen RCTs (618 patients with moderate or mild dizziness) out of 1362 references describing seven different non-pharmacological comparisons were selected. Nine trials included patients with PPPD, and four trials included patients with functional dizziness. The trials used different interventions that were classified as: 1) psychotherapeutic interventions (cognitive behavioural therapy, patient education), 2) physiotherapeutic interventions/training (vestibular rehabilitation, optokinetic stimulation), 3) stimulation procedures (vagus nerve stimulation, transcranial direct current stimulation) and 4) device application (visual desensitisation using personalised glasses). However, most of the trials investigated the effects of single interventions, rather than multimodal interdisciplinary treatment of patients with PPPD. The SMD for dizziness handicap and severity was between 0.04 and 0.52 in most trials. In one trial using visual desensitisation, the SMD was 1.09 (strong effect on the severity of dizziness) and 1.05 (strong effect on dizziness handicap). Discussion: Several individual interventions have shown benefits in the treatment of patients with PPPD with small to moderate effects. However, the multimodal treatment or a combination of vestibular rehabilitation with visual desensitisation, cognitive behavioural therapy including patient education, and medication support should be further investigated. Future trials should include a large sample size with severe dizziness, and provide a longer follow-up period.