Experiences of patients and physiotherapists with blended internet-based vestibular rehabilitation: a qualitative interview study

Perceived value of physiotherapist visits

Many patients appreciated the opportunity to discuss their vestibular symptoms with the physiotherapist and ask specific dizziness-related questions. Both patients and physiotherapists described this personal attention as an important added value of the visits:

‘Well, it was just talking about how things were going. Just the interest in me so to speak. It is, well you know, you can talk about it with family but they have no clue what it is if you don’t experience it yourself. To speak with someone who knows how it goes in other people, than that’s nice, just to have a chat about it. Even though it doesn’t directly achieve anything. It is just nice.’ (PA05)

‘You are always of added value, because just the fact that you give people attention, that they are heard, that they notice that someone takes them seriously, I definitely think that those are important factors. Not just practising the exercises.’ (PH19)

Another important aspect of the physiotherapist visits was help in executing the VR exercises properly. The majority of patients mentioned having received helpful tips, often related to the pace of the exercises:

‘Because that is what the physiotherapist can do, I mean, I can do a video, I can imitate it, but that does not mean that I am doing it in the same way.’ (PA12)

Almost all physiotherapists also thought they improved the execution of exercises. Sometimes adjustments were minor, but some physiotherapists described patients who had created ineffective variations of the exercises that were very different from the prescribed exercises. Physiotherapists generally found that patients were open to their suggestions, and applied their tips for executing the exercises well. Some patients reported that the physiotherapist paid extra attention to safety, especially when performing exercises with eyes closed or when walking around. Some physiotherapists also mentioned that their support increased the safety of the patients and reduced fear, especially for exercises that had to be performed while walking around. Half of all patients mentioned that they appreciated that the physiotherapist confirmed they performed exercises adequately, and several physiotherapists also said that confirmation was important to patients. Some patients found that the physiotherapist visits added weight to the intervention and made it feel more like a serious treatment:

‘Otherwise it would just become an internet titbit, like “Oh well, let’s give it a go”.’ (PA10)

More than half of the patients said the physiotherapist visits did not affect their daily adherence to the exercises. They practised every day because they felt a commitment to the treatment. However, some patients said the physiotherapist did help them adhere to treatment. Because they knew the physiotherapist would come to visit them again later, they felt an extra incentive to keep practising daily. On the other hand, all physiotherapists thought they had a positive influence on adherence to therapy. According to many physiotherapists, patients felt held accountable because they knew the physiotherapist would visit them again. One physiotherapist described that the effect on adherence to therapy was caused by a combination of factors:

‘You could say the overall effect is that compliance to therapy is improved. You take away part of the fear, which makes patients practice better, or you provide patients with a better understanding of the exercises, what actually makes patients perform the exercises more often.’ (PH16)

A few physiotherapists mentioned providing computer assistance as an important aspect of their visits. However, most physiotherapists did not access the computer during the visits and advised patients to simply contact the research team. None of the patients mentioned computer assistance as an added value of the physiotherapist visits.

The majority of patients said they had no negative remarks on any aspect of the physiotherapist visits. Some patients felt the physiotherapist visits provided little additional value over the vertigo training website. According to several patients, the exercises were clear enough and quite easy to do by following the instructions on the website. On the other hand, all physiotherapists said they thought their visits had beneficial effects on top of an internet-based treatment. Most physiotherapists did mention that the level of physiotherapy support that patients required was not the same for everyone:

‘Well, at my first visit I just asked, how are you, did you already perform the exercises? Well, then they showed me. In one case, this woman, that is really the best example, she actually knew the exercises by heart and I only had to observe, and think, well what am I even doing here? [Laughs] And looking at the last woman I saw, yeah she really had no clue what to do. […] she even had trouble starting the computer, and where to look in the computer, and she didn’t know if she would get new exercises or not. So it was all not very clear to her.’ (PH19)

Most physiotherapists described clear differences between patients in the way they handled the computer, executed the exercises, needed confirmation, and appreciated the physiotherapist visits. Older age, severe comorbidity, a high intensity of vestibular symptoms, cognitive problems, and trouble with the Dutch language were all mentioned as reasons that increased the need for physiotherapy support.

Content and logistics of physiotherapy visits

The content of the first and second visit was described in the same manner by both patients and physiotherapists. In the first visit the physiotherapist talked with patients about their vestibular symptoms, provided information about vestibular symptoms and the exercises, answered questions, asked patients to show them how they performed the exercises, and corrected them if needed. In the second visit, the physiotherapist asked patients to demonstrate the exercises again to check if they had implemented the improvements suggested in the first visit. Because exercises were often more difficult at this stage (for example, performed while walking around), the physiotherapist sometimes offered support and gave tips to practise safely. The physiotherapist also asked about the adherence to therapy in the second visit. All physiotherapists said they followed the trial protocol for all patients. Several physiotherapists were sometimes tempted to deviate from protocol in patients with specific vestibular conditions, such as benign paroxysmal positional vertigo, or invalidating comorbidity, such as Parkinson’s disease that, according to them, required a more personalised treatment.

Both patients and physiotherapists mentioned that the second visit was often much shorter than the first visit. The first physiotherapist visit mostly took place in the first week, and the second visit in the third week of the 6-week treatment period. Both patients and therapists appreciated the timing of the first visit, including the fact that patients had already started practising the exercises. Opinions about the optimal timing of the second visit were more varied, most patients found it hard to remember when the second visit exactly took place. None of the patients would have appreciated the visit to occur sooner than the third week, but several physiotherapists would have liked a visit in the second week for certain patients to be sure the exercises were executed properly. Some patients and physiotherapists said the second visit could have been planned a little later. That way more patients would have reached the more difficult walking exercises, and would benefit more from the physiotherapist’s guidance. Most patients and physiotherapists were satisfied with two physiotherapeutic visits. For several patients one visit would have been enough, and some physiotherapists also said that this would suffice for patients who performed well. None of the patients thought they needed a third visit. However, many physiotherapists thought that certain patients might have benefited from more than two visits:

‘I think for one-third of the patients, I would be able to deal with them in one visit. Certainly. Yes. [Interviewer: And the other two-thirds?] Those were the older patients. [Interviewer: And you would rather visit them three times?] Yes, yes, exactly.’ (PH22)

Patients generally found the home visits convenient and pleasant. Physiotherapists also mentioned several advantages of home visits. The home situation felt familiar to patients and physiotherapists could observe patients in their natural habitat to assess if they had created a safe environment to perform their exercises:

‘Advising someone “Place a chair in front of you, and practise close to the sofa, so if you go backwards, right, then nothing can go wrong”. And that gave them the confidence, and they could just do it. “Oh yeah, well, I’ll do it like this then.” Yeah, yeah, and you might not have figured that out here in the centre. That, at home, it is like this.’ (PH18)

A disadvantage of home visits according to physiotherapists was that it was more time-intensive than treatment in the clinic and, therefore, more costly. Although patients enjoyed the home visits, some said they could have just as easily visited the physiotherapy clinic. Several physiotherapists said that home visits were most valuable in older patients with intense vestibular symptoms, while most other patients could just as well have been seen at the physiotherapy clinic.

Experiences with vertigo training website and exercises

Patients generally appreciated the information provided, the exercise videos and the possibility to print out instructions for the exercises on the vertigo training website. One patient found the website difficult to navigate and not user-friendly.

All patients found the exercises easy to perform and implement in their daily life. Patients mentioned that the exercises worked best when they did them each day. Physiotherapists also noticed that most patients performed their exercises twice daily. Most patients were not anxious to perform any of the exercises, but a few patients were slightly anxious to perform the walking exercises. None of the patients or physiotherapists described any serious side effects, most only mentioned a temporary increase in dizziness. One patient even welcomed the dizziness and nausea she experienced after performing the exercises, because it made her feel she was doing something that works. The exercises consisted of neck movements, and both patients and physiotherapists talked about the effects it had on their neck. At first, practising often led to pain in the neck, but after a couple of weeks patients felt their neck was more flexible than before. Owing to the simple nature of the exercises, many patients doubted at the start of the trial if the exercises would work. Nevertheless, most patients expressed that the exercises had helped reduce their vestibular symptoms:

‘I think it is surprising that something so simple, can have such an impact! Yeah, it totally surprised me. Because I thought it was all connected to complicated organs, that don’t, I don’t know, function properly. And that it is beyond your influence, it is part of getting older, or having bad luck, but it actually isn’t all that bad.’ (PA01)

The majority of patients said the Vertigo Training website had impacted their life in a positive way. Many patients said it increased their self-confidence. Patients developed more awareness of their vestibular symptoms, which helped give them a sense of control. They learnt what factors exacerbated their symptoms and acknowledged they had subconsciously started avoiding certain activities, such as turning their head in the car or walking in the dark. Several patients mentioned that the exercises gave them control over their symptoms, which they had not previously experienced:

‘A couple of weeks ago, it came back for a little while, and then I thought, well let’s just do them again. And it wasn’t like I immediately started practising daily, but it was a moment of, just getting back into it, checking how it’s going. So that provides me with a bit of grip. … But I think, well … I can do something about it myself. And of course you never had that before.’ (PA09)

Many patients mentioned that they had continued to do the exercises long after the trial period. Although they were only asked to practise daily for the 6-week intervention period, the majority of patients still used the exercises in some way more than 7 months later. Most patients said they would start the exercises again when experiencing a return or increase of their vestibular symptoms. One patient, who was aged 91 years, said that she continued with the exercises after the intervention period because it took her longer to reach her treatment goals:

‘Well, so then I had to repeat those exercises until they did not make me dizzy anymore. So before I finally got it right, because that took a long time, certainly a couple of months, before I got the hang of it. Before I could say, “Well, I can stand in the bathroom, without falling” and stuff like that. So that, that takes a very long time! Because look, you are of course old and things don’t go as fast as you would like. [Laughs]’ (PA14)

Almost half of the physiotherapists started using the exercises with other patients in their own practice after the trial. Several patients advised the research team to implement the vertigo training website and exercises in daily general practice as soon as possible:

‘Well, I think it would be nice, because for me it really, really, yeah improved the situation, if it would be more accessible to other people because it is not a, really, heavy treatment. And I, I personally much prefer it over pills against dizziness or whatever.’ (PA10)