Cognition Behavioural Therapy-Informed Tele- Vestibular Rehabilitation for Persistent Postural- Perceptual Dizziness: A Clinical Case Study

Abstract

Background and Aim: Persistent Postural-Perceptual Dizziness (PPPD) is a chronic functional vestibular disorder characterized by persistent non-spinning dizziness aggravated by motion and visually complex environments. Multimodal management including Vestibular Rehabilitation Therapy (VRT) and Cognitive Behavioral Therapy (CBT) is recommended; however, evidence supporting cognition-integrated tele-vestibular rehabilitation remains limited. This case aimed to examine the clinical utility of a CBT- informed tele-vestibular rehabilitation model in PPPD secondary to peripheral vestibular dysfunction.

The Case: A 31-year-old female presented with a history of persistent dizziness, episodic vertigo, motion sensitivity, and visual dependence, along with anxiety and depressive symptoms. Audiological findings were normal. Vestibular evaluation revealed spontaneous left-beating nystagmus, right-sided utricular involvement on ocular vestibular evoked myogenic potentials (oVEMP) (prolonged latencies, reduced amplitudes), and corrective saccades in the right lateral canal on video Head Impulse Test (vHIT); MRI findings were unremarkable. Baseline scores indicated severe handicap (Dizziness Handicap Index (DHI): 76/100) and high functional limitation (Vestibular Disorders Activities of Daily Living Scale (VADL); Niigata PPPD questionnaire: 83/114). The patient underwent a structured program comprising four months of tele-VRT followed by six months of cognition-integrated tele- rehabilitation incorporating psychoeducation, self-monitoring, and cognitive restructuring. Post-intervention outcomes demonstrated reduced symptom severity (Nigata PPPD Questionnaire (NPQ) 45/114), improved VADL scores, decreased DHI (53/100), increased right oVEMP amplitudes, and resolution of corrective saccades on vHIT.

Conclusion: Cognition-integrated tele-vestibular rehabilitation was associated with meaningful functional, psychological, and partial objective vestibular improvements. This case highlights the feasibility and potential benefit of remotely delivered, multidimensional rehabilitation in PPPD and underscores the need for larger controlled studies.