As GPs, we frequently encounter patients with vestibular symptoms such as dizziness and vertigo. Most patients do not require referral, diagnosis is primarily based on medical history and physical examination, and effective treatment can be provided by the GP. To our surprise many of our GP colleagues do not share our interest in vestibular symptoms and often ignore two highly effective tools for treating vestibular symptoms—vestibular rehabilitation and the Epley-manoeuvre.
Previous research shows that vestibular rehabilitation is, despite its proven effectiveness, used by fewer than 10% of GPs. The Epley-manoeuvre, another vestibular treatment with well-established effectiveness, is never used by 40% of GPs. While educating GPs about these treatments may be sufficient to increase the uptake of the Epley-manoeuvre, vestibular rehabilitation also requires more accessible way to deliver the treatment. Therefore, the University of Southampton developed a stand-alone internet-based vestibular rehabilitation intervention. Since an unsupported online intervention may not suit all patients, we investigated online vestibular rehabilitation both with and without physiotherapeutic support in Dutch general practice.
The enthusiasm of patients to participate in our trial was heartening. Physiotherapists also told us how diligently most participants performed their daily exercises. This reinforced our impression that these patients require more attention in general practice. Our trial showed that online vestibular rehabilitation, both with and without physiotherapeutic support, can reduce vestibular symptoms in general practice. Several participants told us how surprised they were that, after experiencing vestibular symptoms for so many years, such simple exercises could help them. Intuitively, a difficult problem requires a difficult solution. Perhaps the apparent simplicity of vestibular rehabilitation (and the Epley-manoeuvre) contributes to its low uptake, despite the scientific evidence. In contrast, anti-vertigo medications such as betahistine are excessively prescribed off-label in general practice. In 2017 we already attempted to convince general practitioners to stop prescribing medications and start applying vestibular rehabilitation. Hopefully, our easily accessible online vestibular rehabilitation intervention will contribute to the necessary shift from drugs to exercise.
Dizziness and vertigo can be challenging, but providing proper treatment can be extremely rewarding. Vestibular rehabilitation can ameliorate vestibular symptoms that have been present for many years and a successful Epley-manoeuvre can almost instantly “cure” a patient with benign paroxysmal positional vertigo. As the tools to treat vestibular symptoms are readily available, it is time for GPs to start falling in love with vestibular medicine.
An English version of the online vestibular rehabilitation tested in our article is freely available to all GPs online at https://balance.lifeguidehealth.org/. The Epley-manoeuvre is described and shown in a video in a recent BMJ Practice article.
Vincent van Vugt is a general practice registrar and PhD candidate at the Department of general practice and elderly care medicine, Amsterdam University Medical Centers, location VUMC.
Competing interests: See research paper
Otto Maarsingh is a general practitioner and senior researcher at the Department of general practice and elderly care medicine, Amsterdam University Medical Centers, location VUMC.
Competing interests: See research paper