791274

research-article2018
CRE0010.1177/0269215518791274Clinical RehabilitationKleffelgaard et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

The effects of vestibular 2019, Vol. 33(1) 74­–84

© The Author(s) 2018
Article reuse guidelines:
rehabilitation on dizziness and sagepub.com/journals-permissions
DOI: 10.1177/0269215518791274
https://doi.org/10.1177/0269215518791274

balance problems in patients journals.sagepub.com/home/cre

after traumatic brain injury: a

randomized controlled trial

Ingerid Kleffelgaard1,2,3 , Helene Lundgaard Soberg1,2,

Anne-Lise Tamber2, Kari Anette Bruusgaard2,
Are Hugo Pripp2,4, Maria Sandhaug5
and Birgitta Langhammer2,6

Abstract
Objective: To investigate the effects of group-based vestibular rehabilitation in patients with traumatic
brain injury.
Design: A single-blind randomized controlled trial.
Setting: University Hospital (recruitment and baseline assessments) and Metropolitan University
(experimental intervention).
Subjects: A total of 65 patients (45 women) with mild-to-moderate traumatic brain injury (mean age
39.4 ± 13.0 years) were randomly assigned to intervention (n = 33) or control group (n = 32).
Intervention: Group-based vestibular rehabilitation for eight weeks. Participants were tested at baseline
(3.5 ± 2.1 months after injury) and at two post-intervention follow-ups (2.7 ± 0.8 and 4.4 ± 1.0 months after
baseline testing).
Main measures: Primary outcome: Dizziness Handicap Inventory. Secondary outcome: High-Level
Mobility Assessment Tool. Other outcomes: Vertigo Symptom Scale; Rivermead Post-concussion
Symptoms Questionnaire; Hospital Anxiety and Depression Scale; and Balance Error Scoring System.
Between-group differences were analyzed with a linear mixed-model analysis for repeated measurements.
Results: At baseline, no group differences were revealed (personal factors, clinical characteristics
and outcome measures). At the first follow-up, statistically significant mean differences in favor of the
intervention were found in the primary (−8.7, 95% confidence interval (CI): −16.6 to −0.9) and secondary
outcomes (3.7 points, 95% CI: 1.4–6.0). At the second follow-up, no significant between-group differences

5Department of Research, Statped, Oslo, Norway

1Department of Physical Medicine and Rehabilitation, Oslo
6Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
University Hospital, Oslo, Norway
2Faculty of Health Sciences, Oslo Metropolitan University,
Corresponding author:
Oslo, Norway Ingerid Kleffelgaard, Department of Physical Medicine and
3Faculty of Medicine, University of Oslo, Oslo, Norway
Rehabilitation, Oslo University Hospital, Postboks 4950
4Oslo Centre of Biostatistics and Epidemiology, Research
Nydalen, 0424 Oslo, Norway.
Support Services, Oslo University Hospital, Oslo, Norway Email: ingerid.kleffelgard@ous-hf.no
Kleffelgaard et al.
were found. No significant between-group differences in the other outcomes were found at the two
follow-ups.
Conclusion: The intervention appeared to speed up recovery for patients with dizziness and balance
problems after traumatic brain injury. However, the benefits had dissipated two months after the end of
the intervention.
Keywords
Dizziness, neurological rehabilitation, physical therapy, postural balance, traumatic brain injury
Received: 13 November 2017; accepted: 6 July 2018
Introduction
Traumatic brain injury is a common cause of long-
term disability in the areas of physical, cognitive,
behavioral, and emotional functioning in young
adults.1,2 Dizziness and balance problems in
patients after traumatic brain injury are reported to
have a prevalence of 23.8%–81%.2 These problems
can remain disabling for several months after
injury and have the potential to restrict several
aspects of the patients’ personal and social life.2–4
Traumatic brain injury can cause injury to the inner
ear, leading to conditions such as benign paroxys-
mal positional vertigo, labyrinthine concussion,
and unilateral vestibular loss.2,3 Other mechanisms
affecting the central nervous system may also
account for persisting dizziness including micro-
structural injury to the brain and psychological fac-
tors including anxiety and depression.3,5 Injuries to
the visual system and neck injuries can also affect
the vestibular system’s output and thereby cause
dizziness.2,6
Vestibular rehabilitation is an accepted and fre-
quently used treatment for dizziness and balance
problems. Vestibular rehabilitation is a broad con-
cept that includes compensation and balance train-
ing after a vestibular lesion and in other causes of
vertigo dizziness and balance problems. Current
vestibular rehabilitation includes a combination of
exercises mainly addressing the patient’s impair-
ments and activity limitations.7
Primary studies have reported favorable out-
comes related to applying vestibular rehabilitation
in the treatment of patients with traumatic brain
injury.8–10 However, according to systematic
75
reviews,11,12 the evidence is limited at present, and
studies with stronger methodological design and
quality, larger sample sizes, and control groups are
warranted.
Hence, the primary objective of this study was
to investigate the effects of a modified group-based
vestibular rehabilitation intervention on dizziness-
related disability and mobility in patients with
mild-to-moderate traumatic brain injury. The
hypothesis was that a modified group-based ves-
tibular rehabilitation intervention would have sig-
nificantly positive effects on dizziness-related
disability and mobility after traumatic brain injury
in addition to the usual multidisciplinary traumatic
brain injury rehabilitation. The secondary objective
was to explore the changes in dizziness symptoms,
post-concussive symptoms, balance, and psycho-
logical distress between baseline and follow-ups
after the intervention.
Methods
The study was designed as a single-blind randomized
controlled trial. The study has been registered with
the Clinical Trials Registry (#NCT01695577) and
approved by the Regional Committee for Medical
Research Ethics, Norway (#2012/195b 20120306).
Participants were recruited between January
2013 and October 2015. Inclusion criteria were
patients with traumatic brain injury, aged 16–
60 years who reported mild, moderate, or severe
feelings of dizziness on the Rivermead Post-
Concussion Symptoms Questionnaire13 (dizziness
score ⩾ 2) and/or had a positive Romberg’s test.
Exclusion criteria were severe psychological disease
76
or substance abuse reported in their medical record,
insufficient command of Norwegian and/or cogni-
tive dysfunction (unable to follow instructions and/
or fill in forms), fractures, or other comorbidities
affecting mobility and independent gait, and scores
<15 points on the Dizziness Handicap Inventory.14
The cut-off point at 15 points was selected because a
total score of ⩾16 indicates a handicap for patients
with peripheral or central pathology.15
Physiatrists at the outpatient clinic of the
Department of Physical Medicine and
Rehabilitation at Oslo University Hospital referred
eligible patients to the interventionist, who per-
formed clinical assessments of the patients and
provided the patients with oral and written infor-
mation about participation in the study. Written
informed consent was obtained from all partici-
pants. Information regarding personal factors,
cause of injury and severity of injury were recorded
from the patients’ medical records. Personal factors
included age at the time of the injury, married/
cohabiting (yes/no), level of education (cut-off set
at >12 years), preinjury employment/studies (yes/
no), and preinjury comorbidities (yes/no). Severity
of injury included the Glasgow Coma Scale score,
loss of consciousness (yes/no or not reported),
post-traumatic amnesia (yes/no or not reported)
and the presence of intracranial abnormality on
magnetic resonance imaging scans/computer
tomography (yes/no or not reported).
The clinical assessments of the vestibular system
at baseline consisted of tests of the oculomotor sys-
tem (smooth pursuit, saccadic eye movements) and
the vestibulo-ocular reflex (head-thrust test, clinical
test for dynamic visual acuity). Benign paroxysmal
positional vertigo was tested with the Dix-Hallpike
and Roll test. All of these tests were performed and
evaluated according to descriptions in Herdman
and Clendaniel.7 In addition, the neck was screened
for painful active range of movement.
The interventionist assessed all included partici-
pants prior to randomization. Participants were
randomly assigned (1:1 allocation) to receive a
group-based vestibular rehabilitation intervention
in addition to the usual multidisciplinary traumatic
brain injury rehabilitation. Allocation followed a
computer-generated list of random numbers in
Clinical Rehabilitation 33(1)
blocks of four, prepared by a statistician not
involved in the trial. The allocation sequence was
concealed from the interventionist. An uninvolved
research assistant stored the list and prepared
sequentially numbered, opaque, sealed envelopes.
The envelopes were kept in a locked drawer and
drawn consecutively after consented inclusion in
the study. The envelopes were given to the partici-
pants by the interventionist after the baseline
assessments. The participants opened the sealed
envelopes and were subsequently enrolled in the
intervention or control group.
A blinded outcome assessor (physical educator)
carried out the follow-up assessments. The partici-
pants and the interventionist were not blinded for
the group allocation. An uninvolved research assis-
tant entered the data into the statistical database,
and the interventionist was blinded for group allo-
cation during the statistical analyses.
Intervention
Both groups were offered the usual multidiscipli-
nary outpatient rehabilitation comprising clinical
examinations by a physiatrist and assessments and
follow-ups by a multidisciplinary team if needed.
The main focus of the multidisciplinary rehabilita-
tion was to help the patient return to daily life
activities and return to work. The multidisciplinary
outpatient rehabilitation is described in a publica-
tion by Vikane et al.16
Patients in the intervention group received a
group-based vestibular rehabilitation intervention
twice weekly for eight weeks. Attending all 16 ses-
sions was considered 100% adherence to the inter-
vention. The intervention is described in detail in
another publication17 and consisted of guidance,
individually tailored exercises, a home exercise
program, and an exercise diary. Two Physical
Therapists experienced in vestibular and traumatic
brain injury rehabilitation were responsible for the
intervention. The intervention was mainly based on
principles from motor control theory for improving
balance18 and theory of positive psychology for
coping with symptom pressure and disease bur-
den.19 Elements from established vestibular reha-
bilitation interventions were included and followed
Kleffelgaard et al.
the principles of habituation, adaptation/gaze stabil-
ity, substitution exercises, and balance relearning.7
The individual tailoring of exercises was based
on symptoms, signs, and functional challenges at
each patient’s baseline assessments. The exercises
typically comprised Brandt–Daroff exercises for
benign paroxysmal positional vertigo, habituation
exercises for motion sensitivity and central post-
traumatic vertigo, gaze-stabilization exercises
(adaptation and substitution) for symptoms exhib-
ited during eye–head coordination and reduced
vestibulo–ocular reflex, and exercises for reduced
balance focusing on improving sensory integra-
tion. The home exercise program included two to
five individually modified exercises and general
physical activity like walking, biking, and skiing.
The exercise diary was used to enhance awareness
and motivation and to register the performed exer-
cises, activities, and the patients’ responses to
them. Guidance facilitated increased self-efficacy
through social modeling and a focus on positive
experiences, gaining control by interpretation of
physical and emotional symptoms, and strengthen-
ing the patients’ beliefs in their own ability to reach
their goals.19
The control group did not receive any rehabili-
tation intervention in place of the group-based ves-
tibular rehabilitation intervention, thus the
intervention group had a greater total amount of
time involved in therapy. However, patients with a
positive positioning test (Dix-Hallpike and Roll
test) were treated with repositioning maneuvers
after the baseline assessments (Epley and Bar-B-
Que Roll maneuvers) by the interventionist.20 Not
to treat benign paroxysmal positional vertigo was
considered to be in conflict with research ethics,
because of the strong existing evidence on the
effect of maneuver treatments.20 Furthermore, after
the eight-week intervention period, participants in
both groups could participate in psychoeducative
group sessions addressing strategies to lessen their
post-concussion symptoms and facilitating self-
efficacy and return to work. The multidisciplinary
team at Oslo University Hospital was responsible
for these two-hour group sessions held weekly over
four consecutive weeks, as described in the publi-
cation by Vikane et al.16
77
Outcome measures
The primary outcome of the intervention was dizzi-
ness-related disability measured with the Dizziness
Handicap Inventory.14 The Norwegian version has
demonstrated satisfactory measurement properties
with a minimal clinical important change of ⩾11
points and smallest detectable difference of ⩾20
points.21
The secondary outcome of the intervention was
mobility measured with the High-Level Mobility
Assessment Tool for traumatic brain injury.22 The
Norwegian version has demonstrated satisfactory
measurement properties with a minimal detectable
change of −3 to +4 points.23
Other outcomes are as follows:
•• The frequency and severity of dizziness symp-
toms was measured with the Vertigo Symptom
Scale–Short Form.24 The two subscales relating
to vertigo-balance symptoms and to autonomic-
anxiety symptoms were analyzed.
•• Self-reported post-concussion symptoms were
measured with the Rivermead Post-concussion
Symptoms Questionnaire.13 The physical and
psychological subscales were analyzed.25
•• Psychological distress was assessed with the
Hospital Anxiety and Depression Scale. The anx-
iety and depression subscales were analyzed.26
•• Balance was assessed with the Balance Error
Scoring System.27
Statistical analyses
Continuous variables were described with mean
and standard deviation (SD) or median and inter-
quartile range (IQR) and categorical variables were
described with number of observations and per-
centage. Intention-to-treat analyses were per-
formed when comparing the intervention group
with the control group on the primary and second-
ary outcomes for all participants enrolled and fol-
lowed-up in the study regardless of adherence to
the vestibular rehabilitation intervention.
To evaluate the treatment effect, a linear mixed-
model analysis for repeated measurements with a ran-
dom intercept was used to assess the between-group
78
differences at the two follow-ups. As fixed effects, the
statistical model included the baseline value of the
outcome as a covariate, the main effects of treatment
and follow-up, the interaction term between treatment
and follow-up, and the interaction term between the
baseline value of the outcome and follow-up.
Assumptions for all statistical tests were assessed
with adequate descriptive statistics. Results are pre-
sented as mean differences with 95% confidence
intervals (CIs) and P values at each follow-up time
point. IBM SPSS Statistics for Windows (v. 23;
IBM Corp., Armonk, NY, USA) was used for the
statistical analysis. All statistical tests were two-
sided and assumed a 5% significance level.
Sample size and power calculations were based
on the primary outcome measure from a methodo-
logical study performed in Norway.21 Estimations
were based on 80% power (β = 0.8), an alpha (α) of
0.05, an SD (δ) of 15 and a clinically relevant
between-group difference of approximately 11
points and a 10% loss to follow-up. The trial thus
needed to include 35 patients in each group, a total
of 70 patients.
Results
A total of 65 patients were included in the study. One
patient withdrew after randomization and did not
consent to the use of baseline data, leaving 64
included patients. One participant (2%) was lost at
the first follow-up. A total of nine (14%) were lost at
the second follow-up (Figure 1). There were no sig-
nificant differences between the groups in frequency
or causes of drop-outs. Characteristics of both
groups are presented in Table 1. There were no
major differences in baseline characteristics between
the groups in terms of personal factors, clinical char-
acteristics, and outcome measures or in participation
in the multidisciplinary rehabilitation and/or the
psychoeducational groups (Table 1). There were no
major differences between the groups in any of the
outcome measures at baseline (Table 2).
Baseline assessments were conducted 3.5 ± 2.1
(mean ± SD) months after injury. The first follow-
up assessments were conducted at a mean of
2.7 ± 0.8 months after the baseline testing. The sec-
ond follow-up assessments were conducted
Clinical Rehabilitation 33(1)
approximately two months after the end of the
intervention at a mean of 4.4 ± 1.0 months after
baseline testing. At baseline, the participants pre-
sented with a mix of vestibular, visual, and muscu-
loskeletal clinical findings/characteristics (Table 1).
The self-reported outcome measures indicated
that the included participants had moderate dizzi-
ness-related disability and severe symptoms of
dizziness.14,24 The participants also reported a con-
siderable burden of post-concussion symptoms and
psychological distress.13,26 The performance-based
scores for balance and mobility were below popula-
tion norms, indicating reduced balance when stand-
ing with eyes closed and reduced functioning and
tempo in usual mobility tasks (Table 2).29,30
No adverse events of the intervention were reg-
istered. One patient had a fall during the mobility
testing (High-level Mobility Assesment Tool for
traumatic brain injury). No injuries were registered
after the fall, but he was offered an assessment by a
physiatrist. For the 33 patients in the intervention
group, 22 patients (67%) had ⩾50% adherence and
12 of these had ⩾80% adherence. Two patients
(6%) did not attend at all, and the remaining 9
(27%) patients attended between one and seven
sessions.
At the first post-intervention follow-up, a statis-
tically significant between-group mean difference
was found in the respective primary and secondary
outcome measures in favor of the intervention
group. At the second post-intervention follow-up,
the between-group differences were no longer sta-
tistically significant (Table 3). The intervention
group maintained their level of improvement,
while the control group improved over time in diz-
ziness-related disability and mobility problems
(Table 2). No significant differences between the
groups were found in any of the other outcomes at
the two post-intervention follow-ups (Table 3).
Discussion
The results from this randomized controlled trial
showed that an eight-week modified group-based
vestibular rehabilitation intervention, in addition to
the usual multidisciplinary traumatic brain injury
rehabilitation, improved dizziness-related disability
Kleffelgaard et al. 79

Figure 1. CONSORT flowchart of the study.

OUH: Oslo University Hospital; DHI: Dizziness Handicap Inventory.
*Administrative error: one patient was offered the psychoeducative group sessions prior to the modified group-based vestibular
rehabilitation rehabilitation and was not randomized.
**One patient withdrew after randomization and did not give consent for us to use data from the baseline assessment.

and mobility in favor of the intervention group at
the first post-intervention follow-up. The effect of
the intervention was maintained. However, after the
end of the intervention, the control group continued
to improve and at the second post-intervention fol-
low-up, they were at the same level as the
intervention group. No differences between the
groups were found on the severity of vertigo symp-
toms, post-concussion symptoms, psychological
distress, and balance at the two follow-ups.
The results from this study support findings from
other studies that indicate benefits of vestibular
80 Clinical Rehabilitation 33(1)

Table 1. Baseline characteristics of participants in personal factors, clinical characteristics, and attendance in
multidisciplinary rehabilitation per treatment group.

Variables Intervention (n = 33) Control (n = 31)

Age in years at inclusion (mean ± SD) 37.6 ± 12.3 41.2 ± 13.6
Gender: women, n (%) 23 (70) 22 (71)
Married/cohabiting, n (%) 28 (85) 19 (61)
Education level >12 years, n (%) 28 (85) 22 (71)
Employed/studying preinjury, n (%) 31 (94) 28 (90)
Preinjury comorbidity, n (%) 13 (39) 15 (48)
Complete sick-leave post injury, n (%) 19 (58) 15 (48)
Time since injury in months, mean ± SD 3.9 ± 2.2 3.4 ± 1.9
GCS median (IQR) 15 (15–15) 15 (14–15); n = 30
PTA, n (%) 21 (64) 20 (65)
LOC, n (%) 24 (73) 21 (68)
Positive MRI/CT, n (%) 11 (33) 15 (48)
Cause of injury, n (%)
Traffic accidents 6 (18) 4 (13)
Fall 19 (58) 22 (71)
Violence 2 (6) 4 (13)
Sport and other 6 (18) 1 (3)
BPPV, n (%) 8 (24) 9 (29)
Positive DVAT, n (%) 13 (41), n = 32 6 (19)
Positive HIT, n (%) 2 (6) 1 (3)
Oculomotor tests/symptoms, n (%) 19 (58) 20 (65)
Neck pain, n (%) 9 (27) 15 (48)
Multidisciplinary rehabilitation, n (%) 29 (89) 25 (81)
Psychoeducative group sessions, n (%) 19 (58) 14 (45)

BPPV, benign paroxysmal positional vertigo; CT, computed tomography; DVAT, dynamic visual acuity test; GCS, Glasgow Coma
Scale; HIT, head impulse test; IQR, interquartile range; LOC, loss of consciousness; MRI, magnetic resonance imaging; PTA, post-
traumatic amnesia; SD, standard deviation.
Values are shown as numbers (percentages within group), medians (IQR), or mean ± SD.

rehabilitation after traumatic brain injury.8,9 The
result on the main outcome measure favoring the
intervention group at the first post-intervention fol-
low-up indicated that the intervention speeded up
the recovery and as such had a positive effect on
dizziness-related disability. The findings reflect dif-
ferent factors of functioning covered in the Dizziness
Handicap Inventory like “emotional functioning and
participation in social life,” “specific activities/
movements that provoke dizziness and/or unsteadi-
ness,” and “self-perceived walking ability and the
feeling of postural stability in relation to contextual
factors.”31 The reported findings in favor of the
intervention group regarding aspects of “self-per-
ceived walking ability and the feeling of postural
stability in relation to contextual factors” were sup-
ported by the secondary outcome measure. In con-
trast to the multidimensionality of the Dizziness
Handicap Inventory, the High Mobility Assessment
Tool is a unidimensional performance-based meas-
ure of mobility and dynamic balance that captures
the physical dimension of motor performance rather
than cognitive or behavioral dimension that may
limit motor performance.22 Thus, the intervention
seemed to have a positive effect on both motor per-
formance and the patients’ self-perception of their
disability.
The beneficial effects of the vestibular rehabili-
tation intervention were maintained in this study
although no between-group differences were found
Kleffelgaard et al. 81

Table 2. Scores on all outcome measures at baseline, first, and second follow-up per treatment group.

Variables Intervention group Control group

Baseline First follow-up Second follow-up Baseline First follow-up Second follow-up
n = 33 n = 32 n = 27 n = 31 n = 31 n = 28
DHI (0–100 47.9 ± 16.6 32.9 ± 21.3 32.1 ± 20.7 41.4 ± 19.2 36.4 ± 22.7 30.0 ± 24.3
best–worst)
HiMAT (0–54 40.9 ± 9.3 47.6 ± 7.0, n = 29 47.3 ± 8.2, n = 25 39.1 ± 11.9 41.2 ± 12.3, n = 23 44.3 ± 9.6, n = 26
worst–best)
VSSv (0–32 10.9 ± 6.0 6.7 ± 6.0 6.9 ± 4.6 10.2 ± 6.6 8.4 ± 6.6 6.1 ± 5.5
best–worst)
VSSa (0–28 8.3 ± 5.3 7.4 ± 5.7 6.6 ± 5.0 7.7 ± 5.7 6.6 ± 5.1 5.5 ± 5.2
best–worst)
RPQ3 (0–12 6.6 ± 2.8 4.9 ± 3.3 5.3 ± 3.3 5.5 ± 2.4 4.7 ± 2.7 3.6 ± 2.9
best–worst)
RPQ13 (0–52 25.6 ± 8.4 21.1 ± 11.3 20.4 ± 12.0 25.4 ± 10.2 19.6 ± 11.7 17.0 ± 10.9
best–worst)
HADSa (0–21 9.1 ± 4.7 7.9 ± 5.8 7.6 ± 5.0 8.4 ± 3.8 7.9 ± 4.6 6.9 ± 3.9
best–worst)
HADSd (0–21 7.1 ± 4.4 6.1 ± 4.3 6.7 ± 5.2 6.5 ± 5.1 6.2 ± 5.4 5.1 ± 4.8
best–worst)
BESS (0–60 29.7 ± 11.6 19.1 ± 10.6, n = 31 17.5 ± 10.4, n = 26 29.0 ± 9.6 23 ± 9.1, n = 26 20.8 ± 9.0, n = 28
best–worst)

BESS, Balance Error Scoring System; DHI, Dizziness Handicap Inventory; HiMAT, High-level Mobility Assessment Tool for trau-
matic brain injury; HADSa, Hospital Anxiety and Depression Scale, anxiety subscale; HADSd, HADS depression subscale; RPQ,
Rivermead Post-Concussion Symptoms Questionnaire; RPQ3, RPQ Physiological subscale; RPQ13, RPQ Psychological subscale;
SD, standard deviation; VSSv, Vertigo Symptom Scale, vertigo subscale; VSSa, VSS anxiety subscale.
Values are in mean ± SD.

at the second post-intervention follow-up. Further times to recover.6,10 Furthermore, post-concussion

research is needed to explore whether the improve-
ment in the intervention group would have contin-
ued if the intervention exceeded eight weeks,
compared with the control group. Gottshall10
pointed out that many patients with traumatic brain
injury respond to vestibular rehabilitation over a
period of eight weeks, but some patients need
longer time and continue to improve over an addi-
tional four to eight weeks. The complexity of dizzi-
ness and balance problems after traumatic brain
injury requires individually modified interventions,
and many patients need to progress slowly. The dif-
ferent etiologies of post-traumatic dizziness respond
differently to vestibular rehabilitation interventions.
Benign paroxysmal positional vertigo alone usually
needs a shorter recovery time.10 Complex etiologies
involving a mix between central vestibular disorder
and peripheral vestibular hypofunction need longer
symptoms and concurrent physical, cognitive, and
emotional conditions might impede the recovery of
the dizziness-related disability after traumatic brain
injury.32
We found no difference between the groups in
the other outcomes. The somewhat larger improve-
ments in the intervention group in the vertigo-bal-
ance subscale of the vertigo symptom scale and the
Balance Error Scoring System were expected since
vertigo and standing balance was specifically
addressed in the intervention. These outcomes
assess components of vertigo and standing balance
typically affected by benign paroxysmal positional
vertigo which was treated in both groups. This may
partly explain why the difference between the
groups was not significant.
All patients received assessment and information
from a physiatrist and were offered multidisciplinary
82 Clinical Rehabilitation 33(1)

Table 3. Mean difference for each outcome between the groups (intervention compared with control) at the first
and second post-intervention follow-ups controlled for baseline values using a linear mixed model for repeated
measurements.

Outcome Mean difference P-value Mean difference (95% CI) P-value

(95% CI) between between groups, second
groups, first follow-up follow-up
DHI −8.7 (−16.6 to −0.9) 0.03 −7.0 (−15.2 to −1.2) 0.09
HiMAT 3.7 (1.4 to 6.0) 0.002 2.0 (−0.3 to −4.3) 0.09
VSSv −2.1 (−4.5 to −0.2) 0.08 −0.7 (−3.2 to −1.9) 0.61
VSSa 0.4 (−1.4 to −2.1) 0.69 0.3 (−1.6 to −2.1) 0.77
RPQ3 −0.5 (−1.8 to −0.7) 0.41 0.6 (−0.7 to −1.9) 0.36
RPQ13 1.4 (−2.1 to −4.9) 0.43 2.9 (−0.8 to −6.5) 0.12
HADSa −0.7 (−2.3 to −1.0) 0.43 0.07 (−1.7 to −0.4) 0.93
HADSd −0.6 (−2.4 to −1.1) 0.46 1.1 (−0.8 to −2.9) 0.25
BESS −3.7 (−7.8 to −0.5) 0.09 −3.1 (−7.3 to −1.1) 0.15

BESS, Balance Error Scoring System; CI, confidence interval; DHI, Dizziness Handicap Inventory; HADSa, Hospital Anxiety and
Depression Scale, anxiety subscale; HADSd, HADS depression subscale; HiMAT, High-level Mobility Assessment Tool for trau-
matic brain injury; RPQ, Rivermead Post-Concussion Symptoms Questionnaire; RPQ3, RPQ Physiological subscale; RPQ13, RPQ
Psychological subscale; VSSa, VSS anxiety subscale; VSSv, Vertigo Symptom Scale, vertigo subscale.

rehabilitation, which may be beneficial after mild–
moderate traumatic brain injury.16 How to cope with
post-concussion symptoms and psychological dis-
tress was specifically addressed by the multidiscipli-
nary rehabilitation team, and this may explain that
there were no difference between the groups in the
Post-Concussion Symptoms Questionnaire and the
Hospital Anxiety and Depression Scale. Furthermore,
attendance in the psychoeducative group sessions
supplying information on coping strategies and the
importance of physical activity may have had a posi-
tive impact on the burden of symptoms and psycho-
logical distress.16 The attendance in the usual
multidisciplinary traumatic brain injury rehabilita-
tion and psychoeducative group sessions and the
occurrence and treatment of benign paroxysmal
positional vertigo was similar in both groups and did
not compromise the internal validity of the study.
Adherence is important in clinical trials. In this
study, 11 of 33 (33%) attended fewer than eight
sessions. This relatively low adherence may have
contributed to a smaller difference between the
intervention and control groups. Several factors
may affect adherence after traumatic brain injury.
Personal health, fatigue, and a lack of motivation
have been reported as important barriers to physi-
cal activity, and cognitive problems with memory
and pain might be additional barriers.33
Furthermore, post-concussion symptoms, psycho-
logical distress, and neck pain, which were reported
by the included participants, might have affected
the adherence to the intervention.
Limitations
Some limitations warrant caution when interpret-
ing the result of this study. Due to a slower than
expected recruitment rate, and limited time and
economic resources, the study stopped at 65
included patients. Thus, the study included a rela-
tively small number of patients with mild-to-mod-
erate traumatic brain injury from a single hospital.
Studies with an exercise intervention might appeal
to healthier and more motivated individuals.
Furthermore, the study recruited more women than
men. This differs from epidemiological studies
where the incidence of traumatic brain injury is
highest among male patients.1 Hence, the results
must be generalized with caution.
Another limitation is that vestibular diagnoses
were not determined by vestibular and computer-
ized assessments by ear–nose–throat specialists,
but based on symptoms and clinical assessments
made by a physiotherapist. Thus, the intervention
Kleffelgaard et al.
targeted deficits in function rather than specific
diagnoses.
Ascertainment bias was a potential threat to the
internal validity in this study because all partici-
pants and the investigator were aware of the group
allocation. Ideally, the investigator should not be
involved in the implementation of the intervention.
This could have affected the treatment and the fol-
low-ups in favor of the intervention group and thus
have led to exaggerated effect estimates. However,
the outcome assessor was blinded to the group
allocation.
The intervention group received additional
rehabilitation and attention from the researchers
that was not equivalent to the control group. Thus,
the improvements might also be attributed to the
increased rehabilitation time or increased attention
from the researchers and not just from the modified
group-based vestibular rehabilitation intervention.
Nevertheless, the results from this study suggest
that vestibular rehabilitation is a safe and beneficial
intervention, speeding up recovery for patients
with dizziness and balance problems after trau-
matic brain injury. The findings imply that vestibu-
lar rehabilitation safely can be included as a part of
multidisciplinary rehabilitation. Further studies are
needed to secure outcomes that are more robust, to
examine the impact of dose and progression of
exercises and duration of the intervention period on
rehabilitation outcomes.
Clinical message
•• An eight-week modified, group-based
vestibular rehabilitation intervention, in
addition to the usual multidisciplinary
traumatic brain injury rehabilitation, can
speed up recovery in dizziness-related
disability and mobility after a mild-to-
moderate traumatic brain injury
Acknowledgements
We would like to thank all the participants who took part
in the study. We thank the physiatrists Nada Andelic,
Torgeir Hellstrøm and Fredrik Walter Smith who took
part in the recruitment of participants to this study.
Furthermore, we are grateful to the multidisciplinary
83
traumatic brain injury rehabilitation team at Oslo
University Hospital and the colleagues at Oslo
Metropolitan University for collaboration and support
during the study. We would also like to thank Oslo
Metropolitan University for the funding of the study and
for providing necessary equipment and facilities for the
intervention.
Trial registration: Clinical Trials No. NCT01695577.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iDs
Ingerid Kleffelgaard https://orcid.org/0000-0002-
4994-7292
Birgitta Langhammer https://orcid.org/0000-0002-
9639-0570
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