SUMMARY IN SWEDISH - A comprehensive nurse-led intervention for patients with peripheral vestib

Yrsel är ett symtom som kan uppstå i alla åldrar och kan vara akut eller kronisk, oftast försvinner yrseln spontant men om den blir kronisk utgår den från det vestibulära eller

centrala nervsystemet eller definieras med psykiatriska bakomliggande faktorer relaterade till psykosociala problem. Förekomsten av yrsel och balansbesvär i befolkningen är cirka 21 %. Perifer yrsel orsakas av en störning i strukturer som omfattar innerörat eller balansnerven. Symtom som ofta förekommer vid perifer yrsel är svimningskänsla, svindel och ostadighet. Vissa studier rapporterar att perifer yrsel står för cirka 40-65% av dem som söker vård för yrsel. I tidigare studier beskriver patienter med perifer yrsel en utsatthet och sårbarhet, känslor av att alltid vara trött både psykiskt och fysiskt och en känsla av ständig osäkerhet över hur mycket yrseln kan komma att inkräkta på det dagliga livet. Patienterna utrycker även behov av information och kontinuitet i vården. Flera studier visar att perifer yrsel kan leda till funktionsinskränkningar av såväl fysisk, psykisk som social karaktär. Interventionsstudier som syftar till att stödja patienter att hantera symtom och konsekvenser efter perifer yrsel är få och evidensbaserad kunskap är begränsad. Eftersom det finns en heterogenitet i hur

interventioner har utformats, studiepopulationer, uppföljningstid och utfallsmått saknas kunskap om hur man bäst designar en intervention för att uppnå bästa möjliga resultat för patienten.

Det primära syftet med denna studie var att undersöka effekter och genomförbarhet av en intervention för patienter med perifer yrsel som omfattar gruppundervisning i kombination med individuellt stöd. Ett ytterligare syfte var att undersöka hur väl ett frågeformulär

utvecklat för att mäta specifika yrsel symtom (Vertigo Symptom Scale, appendix 1) stämmer med patienternas upplevelser nedskrivet i dagböcker i samband med en yrselattack.

Basen för de två studierna är en randomiserad kontrollerad studie (RCT). Deltagarna randomiserades till två grupper, en interventionsgrupp (I-grupp) och en kontrollgrupp (K- grupp). Patienterna i I-gruppen fick gruppundervisning och individuellt stöd under en

sexmånadersperiod tillsammans med rutinmässig vård och patienterna i K-gruppen fick enbart rutinmässig vård. Ett flertal frågeformulär utgjorde utfallsmått: The Vertigo Symptom Scale (VSS) inklusive två extra påståenden som formulerats utifrån tidigare studier och klinisk erfarenhet, Hälso-index (HI), Känsla av sammanhang (KASAM), Self-Care Questionnaire (SCQ) och The Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW). Data insamlades före randomiseringen (T1), sex (T2) och nio (T3) månader senare.

Vid T1 uppgav patienterna i I-gruppen att de oftare kände att omvärlden lutar, och uppgav mer somatiska ångest än patienterna i K-gruppen. Det fanns inga statistiska signifikanta skillnader mellan grupperna vid T2. Vid T3 uppgav patienterna i I-gruppen signifikant mindre yrselsymtom med medellång duration (p=0,023), mindre känsla av att omvärlden lutar

(p=0,035) och att underlaget de går på känns gungigt (p=0,017) samt mindre somatisk ångest (p=0,008) än patienterna i K-gruppen. Över tid i I-gruppen uppgav patienterna signifikant färre yrselsymtom med kort duration vid T3 (p=0,049), bättre välbefinnande (p <0,001), bättre hälso-relaterad livskvalitet (p=0,008) och högre grad av Känsla av sammanhang (p=0,023).

Övertid i K-gruppen uppgav patienterna signifikant (p <0,001) bättre välbefinnande vid T3. Patienterna i I-gruppen var i stort sett nöjda med gruppundervisningen. Det enda önskemålet var ytterligare ett tillfälle med läkaren.

Många av de symtom som ingår i Vertigo Symptom Scale (VSS) även beskrevs av patienterna i dagböckerna. De mest rapporterade symtomen var en känsla av att vara vimmelkantig, svimfärdig eller få svindel, känsla av ostadighet och illamående. De symtom som beskrevs av patienterna i dagböcker men som inte ingår i VSS sorterades i fem kategorier; Emotionellt, Trötthet, Öron-relaterade symtom, Kroppsliga symtom och Stress.

Sammanfattningsvis visar resultaten att en intervention som kombinerar gruppundervisning och individuellt stöd är genomförbar för patienter med perifer yrsel. Interventionen kan ha varit ett stöd till att patienterna kunde hantera sina yrselsymtom bättre samt upplevde mindre somatisk ångest. Det finns behov av fler och större studier. Framtida interventionsstudier bör överväga införandet av vestibulär rehabilitering (VR) i kombination med individuellt stöd som fokuserar på att stärka patienternas förmåga att hantera sjukdomsspecifika symtom. I den kliniska vardagen kan det vara värdefullt att låta patienterna systematiskt och rutinmässigt rapportera sina yrselsymtom som underlag för planering av vården i dialog med patienten.

ACKNOWLEDGEMENTS

First and foremost I want to express my sincere gratitude to all patients who kindly

participated in the study, answering questionnaires, contributing their time and were willing to share their experiences with me. I also wish to sincerely thank the following persons:

Ann Langius-Eklöf, my main supervisor for all your encouragement, for inspiring and directing me to the field of research work. For your great commitment and knowledge. Without your guidance and persistent help this has not been possible.

Christina Forsberg, my co-supervisor for your knowledge and encouragement.

Johan Bergenius, my co-supervisor for sharing your excellent knowledge in dizziness and your support.

Tessan Laurinen and Mariana Eriksson at the Department of Audiology, Karolinska University Hospital for help when needed.

Medical Science with a specialization in Healthcare Sciences at Örebro University. Special

thanks to Margareta Gustafsson and Maria Hälleberg-Nyman.

All my colleagues at the Red Cross University College. Special thanks to Barbro Mendel. All my friends no one named, no one forgotten for your company and laughs.

My brothers and sister Anders, Magnus and Ingela, for being there for me, and giving me support.

Last, but by certainly no means least, a very special thank to my dearest ones: Ulf and our daughter Vernina, for showing patience, and for just being there. I love you.

This study was supported by grants from Stockholm County Council, The Swedish Foundation for Health Care Sciences and Allergy Research, Karolinska Institutet, Örebro University and Red Cross University College.

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