Virtual Reality and Biofeedback for Adolescents With Chronic Dizziness

Persistent postural-perceptual dizziness (PPPD) is a chronic vestibular disorder characterized by dizziness, unsteadiness, or non-spinning vertigo exacerbated by position changes, active or passive motion, and complex or moving visual stimuli. PPPD was defined in 2017 as an addition to the International Classification of Vestibular Disorders and will be included in the next iteration of the International Classification of Diseases by the World Health Organization (ICD-11). It is a common diagnosis in patients presenting to tertiary centers for evaluation of vestibular symptoms. Although PPPD is most often described in the adult population, it is also common in children and adolescents with dizziness.

Vestibular migraine is the most common cause of episodic dizziness in children and adults. It can sometimes cause chronic, daily dizziness symptoms and can sometimes also trigger concurrent PPPD, which also causes chronic, daily dizziness.

The symptoms of chronic dizziness profoundly affect quality of life, often keeping children out of school. Moreover, most patients are symptomatic for many months or even years before receiving a diagnosis and initiating treatment. As PPPD is not likely to resolve spontaneously or without treatment, effective early treatment is crucial to alleviating symptom burden. Chronic vestibular migraine is typically treated primarily with medications, which can cause side effects and are sometimes inadequate to achieve complete symptom control.

PPPD is typically precipitated by an event that causes dizziness, vertigo, or unsteadiness, such as an acute or episodic peripheral vestibular disorder, concussion, psychological distress, or adverse medication effect. Though an utterly definitive model is still being established, it is widely accepted that PPPD may develop following these inciting events through the development and perpetuation of maladaptive compensatory strategies, such as overreliance on visual inputs to maintain equilibrium and balance, and heightened anxiety or body vigilance during self-motion or motion-rich environments. These responses to dizziness or unsteadiness are typically transient but become persistent and maladaptive in PPPD, leading to a "rewiring" of the brain that alters how cues related to balance and orientation are processed.

A multi-modal approach to chronic dizziness treatment is often taken to recalibrate maladaptive compensatory strategies and return the sensory system to normal function. One component of treatment includes cognitive behavioral therapy (CBT). The overall goals of CBT include reducing behaviors, thoughts, feelings, and symptoms that perpetuate chronic dizziness, particularly avoidance of environments that provoke dizziness, dependence on the visual system, and excessive monitoring of bodily sensations. Patients develop alternative strategies for responding to symptoms of dizziness or unsteadiness, such as relaxation or distraction techniques. With systematic desensitization exposure response prevention (SDERP) treatment, gradual exposure to provocative environments is essential, enabling patients to habituate to, rather than avoid, symptoms.

Biofeedback (BFB) therapy is a noninvasive intervention through which individuals receive information on their physiological responses and learn to modify them actively. For example, Heart rate variability (HRV) BFB has recently been shown to be an effective intervention for a variety of psychophysiological disorders. The goal of BFB is for patients to gain a strong understanding of their physiological responses to environments around them and leverage that knowledge to lessen the severity and frequency of symptoms.

Given the vital role that visual inputs play in developing and perpetuating chronic dizziness, habituation to visual stimuli must be a significant component of treatment. However, visually provoked symptoms, rather than motion or position-provoked symptoms, are often the most resistant to current treatment options. One cause may be that visual stimuli are difficult to replicate in the clinic or office. As a result, using SDERP with a fear of symptom hierarchy in these visually stimulating environments cannot be fully addressed in these controlled treatment settings. One way to address this treatment gap is through virtual reality (VR) technology. VR immerses patients in realistic visual environments, making the exposure (in vivo) in real time a valuable adjunct to treatment.

Although VR has not been explicitly described in the treatment of PPPD, it has been piloted in the rehabilitation of peripheral vestibular dysfunction. These studies often employed large virtual reality theaters with multiple projected screens, and participants performed exercises while immersed in the environment. Preliminary studies have shown these VR interventions to be effective, particularly in reducing the severity of visually induced symptoms. Therefore, the current study hypothesizes that integrating VR into current PPPD treatment techniques - specifically BFB, SDERP, and CBT - may benefit patients and further strengthen the effectiveness of these methodologies. The investigators will use a commercially available VR headset, which will enable the use of VR in the office setting and is a relatively low-cost form of VR technology. This study aims to evaluate the feasibility and effectiveness of VR in conjunction with BFB, SDERP, and CBT to investigate if VR technology will enhance the known effective treatments to reduce dizziness as a treatment approach to PPPD and other forms of chronic dizziness.