Relationship between change in balanceand self-reported handicap aftervestibular rehabilitation therapy

KATE MURRAY and SARA CARROLL University of Melbourne, AustraliaKEITH HILL National Ageing Research Institute, Victoria, Australia

ABSTRACT Background and Purpose. Dizziness and balance problems are two com-monly reported symptoms of vestibular system disease, with subsequent alterations inlifestyle and reports of physical, functional and emotional handicap. Vestibular rehabilita-tion therapy (VRT) was developed to improve the functional status of patients withvestibular dysfunction. The aim of the present study was to investigate the relationshipbetween change in balance performance and change in self-rated handicap after a four-week home exercise programme in 16 subjects with chronic vestibular disease. Method.Before and after the treatment intervention, balance was tested by use of a Smart BalanceMaster (SBM) system (Neurocom® International, Clackamas, OR, USA) and self-ratedhandicap was measured by use of the Dizziness Handicap Inventory (DHI). Results. Signif-icant improvement was observed in both the SBM (p<0.001) and DHI (p = 0.003) scoresover the testing period. A moderately strong negative correlation existed between change inSBM and DHI scores (Spearman’s r = –0.6). Further analysis using the DHI subscales indi-cated, however, that the emotional component showed no significant change over time, anda poor correlation with change in balance scores (Spearman’s r = –0.39). Conclusions.These results indicate that a home-based exercise programme can significantly improve bal-ance abilities in people with chronic vestibular dysfunction, but that outcomes may beenhanced by addressing the emotional issues associated with their disability.

Key words: balance, handicap, outcome measures, posturography, vestibular disease,vestibular rehabilitation

INTRODUCTION

The human vestibular system consists of aperipheral sensory apparatus, which lieswithin the inner ear, and a central processor,which consists primarily of the vestibularnuclei and the cerebellum. It is integratedwith the proprioceptive and visual systemsto provide sensory information used in themaintenance of balance. Vestibular disor-

ders may be due to peripheral inner earpathology or central dysfunction. Dizzinessand balance deficits are two particularlydisabling and commonly reported symp-toms of vestibular system disease. Theresultant alteration to lifestyle, loss of con-fidence, increased risk of falls and reportsof physical, functional and emotional hand-icap make this a major health problem forpeople of all ages. At a specialist falls and

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balance clinic, 38% of clients were diag-nosed with a vestibular disorder(Tideiksaar, 1994). Indeed, the fear ofsudden dizziness or having a fall can causepatients to be withdrawn and may lead tosymptoms of panic and agoraphobia (Clarket al., 1994). The situation is often compli-cated as there are a multitude of potentialcauses for symptoms of dizziness, includingthe presence of psychological dysfunctionsuch as anxiety disorders and depression(Eagger et al., 1991). Kroenke et al. (1992)studied 100 patients with chronic dizziness,and identified psychiatric disorders to bethe primary cause in 16% of the population.In some cases, it can be difficult to deter-mine if it is the panic or the vestibulardisorder which is the primary cause of thepatient’s symptoms.

Vestibular rehabilitation therapy (VRT)is an exercise-based form of therapy thatwas developed to improve the functionalstatus of patients with vestibular system dis-ease (Denham and McKinnon Wolf, 1997).It has been advocated as a valid treatmenttechnique since the 1940s, but has onlygained credence over the past 15 years, asknowledge of the physiology and plasticityof the vestibular system has improved(Herdman et al., 1994). Recent controlled,prospective studies have demonstrated thatthis form of rehabilitation can result in bothsubjective and objective reports ofimproved balance in patients with chronicvestibular loss (Horak et al., 1992). In addi-tion, the use of a customized, as opposed toa generic, programme has been found toresult in statistically greater improvementsin terms of motion sensitivity (p = 0.01),post-treatment disability levels (p = 0.001)and static (p = 0.01) and dynamic (p = 0.02)balance (Shepard and Telian, 1995). Areview of the literature indicates a range oftreatment options commonly used whenplanning a vestibular therapy programme,

with the focus primarily on physical andfunctional rehabilitation. These activitiesmay include habituation, gaze stability, bal-ance, gait and general f itness training(Shepard et al., 1990). In addition, Morris(1991) and Cohen (1994) stressed theimportance of graded functional tasks andthe need for adaptation of the home andwork environments and the provision ofassistive gait devices to ensure safety. It isonly recently, however, that various authorshave stressed the vital role of psychologicalmanagement in this patient group (Robert-son and Ireland, 1995), with reports thatstandard vestibular therapy is ineffectiveunless psychological problems are resolved.

A multitude of measures have been usedto describe the outcome of VRT. One of themore common tools is computerizeddynamic posturography (CDP), which mea-sures postural stability under a variety ofsensory input conditions (Nashner, 1993).Although it is potentially a very usefulcomponent of patient assessment (Di Fabio,1995), CDP is unable to quantify the effectsof dizziness and impaired balance on every-day function (Jacobson and Newman,1990). To address the specif ic physical,functional and emotional factors associatedwith vestibular system disease, Jacobsonand Newman (1990) developed a self-assessment questionnaire known as theDizziness Handicap Inventory (DHI). Thisquestionnaire evaluates an individual’s per-ception of the level of handicap caused byvestibular dysfunction and consists of 25items, which encompass the functional,emotional and physical impacts of their dis-order. Jacobson et al. (1991) studied 367patients referred for balance function test-ing and found a signif icant negativecorrelation between the sensory organiza-tion component of CDP and the DHI. Thisindicated that prior to therapeutic interven-tion, individuals with poor postural stability

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also commonly reported greater levels ofself-perceived balance function handicap.The study, however, only used patients witha peripheral vestibular disorder and gave noindication as to the exclusion criteria used.Conflicting results have been reported byRobertson and Ireland (1995), who foundno clinically useful correlation between thetwo variables and hypothesized that this dis-crepancy could be explained by the conceptthat handicap relates more to psychologicalfunctioning than to physical disability. Incontrast, this study only used patientsreferred for dizziness, with subsequentdiagnoses suggestive of peripheral involve-ment (60%) and non-vestibular causes(40%). The differing results reported in theliterature and the paucity of studies investi-gating the association between change inbalance ability, and change in self-reportedhandicap after vestibular therapy, high-lighted the need for further research.

The primary aim of the present studywas to investigate the degree of correlationbetween change in CDP and change in DHIscores in patients undergoing a formalvestibular rehabilitation programme. A sec-ondary aim was to determine whether thepredominantly physical approach used investibular rehabilitation was adequate ineffectiveness, or whether a broaderapproach may be necessary to address allthe needs (functional, emotional and physi-cal) of this particular patient group.

Written consent was obtained from eachsubject and the study was approved by theHealth Sciences Human Ethics Committeeat The University of Melbourne.

METHOD

Subjects

Sixteen subjects (14 female; 2 male) parti-cipated in the study. Their mean (SD) age

was 61.9 (14.9) years, ranging from 30 to80 years. Subjects were included in thestudy if they had any of the following:

• Uncompensated peripheral or centralvestibular system disease, based on acomprehensive assessment by a neurolo-gist, including clinical evaluation anddiagnostic testing (caloric and rotationalchair tests).

• A history of positional or motion-provoked dizziness.

• A history of impaired balance and gaitdisturbance.

Subjects were excluded if they presentedwith a history of visual impairment(defined as the inability to read characterson a screen 60 cm from eye level), poorcognitive status, poor written and spokenlanguage skills (which would prevent reli-able completion of the questionnaire andadequate comprehension of the home exer-cise programme), significant self-reportedpain in the lower extremities or back or anyadditional pathology which may affect bal-ance and mobility. Individuals diagnosedwith a primary psychological disorder, suchas anxiety disorders or depression, whichmight be contributing to their symptoms ofimpaired balance, were excluded from thestudy. After assessment by a neurologist,classification with regard to site of lesionindicated that 56.3% of subjects wereadmitted into the study with a peripheralvestibular disorder and 43.7% with centraldysfunction. Mean (SD) duration of timesince onset of symptoms was 17.1 (18.0)months (Table 1).

Instrumentation

Computerized dynamic posturography

A Smart Balance Master (SBM) system

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(Neurocom® International, Clackamas,OR, USA) was used to measure posturalstability before and after the treatmentintervention. This form of CDP incorpo-rates a motorized force platform and visualsurround, both of which can be sway-refer-enced so as to directly follow subjects’centre of gravity sway angle (Figure 1). Thetesting was carried out according to theguidelines from the manufacturer. Eachsubject was fitted with a harness prior totesting, which was secured to an overheadbar by straps. The harness was fitted so thatit would support the subject if a falloccurred, but would not provide support innormal upright stance or during balanceadjustments. Shoes and socks were removedand the subject was positioned on the force-plate, facing into the machine. Foot positionon the forceplate was standardized to heightand specific instructions were given to eachsubject emphasizing the necessity to stand

with arms by sides and keeping as steady aspossible during testing.

Using the sensory organization compo-nent of posturography, subjects wereexposed to six sensory conditions ofincreasing diff iculty. The conditionsincluded all combinations of eyes open,eyes closed and visual conflict conditionson both fixed support and sway-referencedsupport surfaces. A complete protocol con-sisted of 14 trials, including one trial forconditions one and two, and three consecu-tive trials for conditions three to six. Eachtrial was 20 seconds in duration.

An equilibrium score was the outcomemeasure provided for each trial of the test.This score compares the maximum peak topeak displacement of an individual’s centreof force during testing, to their theoreticallimits of stability (12.5˚). It is presented ona scale from 0% to 100%, where 0% repre-sents a fall and 100%, complete stability. A

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TABLE 1: Distribution of subjects by gender, age, site of lesion, diagnosis, length of time since onset ofsymptoms, home situation and external supports

Subject no. Gender Age Site of Diagnosis Months Social situation(n=16) lesion since onset Lives alone Home help

1 F 53 P Vest n section 18 N N2 F 53 P Neuronitis 12 N N3 M 72 P Unknown 24 N N4 F 70 C Other central 6 N N5 F 48 P Vest n section 24 N N6 M 80 C Other central 24 N N7 F 72 P Neuronitis 4 N N8 F 30 P Acoustic neuroma 6 N N9 F 65 P Neuronitis 3 N N10 F 51 P Vest n section 12 Y N11 F 71 C CVA 78 N N12 F 52 P Ménière’s disease 12 N Y13 F 75 C Other central 3 Y N14 F 76 C Unknown 12 N N15 F 43 P Unknown 24 Y N16 F 80 C Other central 12 Y Y

P = Peripheral; C = Central; Vest n section = Vestibular nerve section; CVA = Cerebrovascular accident.

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composite score of average stability wascalculated by adding the single equilibriumscores for all trials and dividing the sum by14.

Independent studies have demonstratedthe test–retest reliability of SBM measuresin clinically normal adults (Ford-Smith etal., 1995; Hageman et al., 1995). Ford-Smith et al. (1995) evaluated reliability inhealthy, non-institutionalized adults andconcluded that the composite score of aver-age stability was the most useful measure inassessing balance performance and treat-ment effectiveness. In addition, Di Fabio(1995) identified a specificity of 92% forthe sensory organization component ofCDP, indicating that nearly all subjects whoshould have tested negative (that is, with

normal vestibular function), did test nega-tive. The same author investigated thesensitivity of posturography by pooling theresults of f ive studies and indicated thatabnormalities in CDP were found in only40% of patients with a diagnosed vestibulardisorder. In this way, CDP may provide sup-plemental information about vestibulardysfunction, but does not have specif icdiagnostic significance (Norre et al., 1989).

Dizziness Handicap Inventory

The Dizziness Handicap Inventory (see theAppendix), developed by Jacobson andNewman (1990), was designed to evaluatethe self-perceived handicap caused by bal-ance system disease. It consists of 25

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FIGURE 1: The Smart Balance Master (SBM) system.

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self-assessment items, with nine functional,nine emotional and seven physical ques-tions. Each question is marked with a ‘Yes’,‘No’ or ‘Sometimes’. ‘Yes’ answers toitems scored four points, ‘Sometimes’scored two points and ‘No’ scored zeropoints. Scores were obtained for each of thethree subsections (functional, emotional andphysical) and a total score was then calcu-lated to encompass the overall impact ofvestibular disease. The maximum possiblescore was 100 points, indicating a severelevel of perceived handicap. Jacobson andNewman (1990) administered the question-naire to 106 consecutive patients referred totheir facility for vestibular testing anddemonstrated good face validity, high inter-nal consistency for the total score(Chronbach’s alpha coefficient = 0.89) andhigh test–retest reliability (total score, Pear-son’s r = 0.97; p<0.0001).

Procedure

Subjects underwent a full physiotherapyassessment. The DHI was completed and atrial test on the SBM system was performedin order to familiarize each individual withthe equipment. A single physiotherapist(KM) was involved in the data collectionprocess. An individualized home exerciseprogramme was developed at this pointbased on recommendations by Shepard etal. (1990), including components of habitu-ation, gaze stability, balance, mobility andfitness training. Habituation training aimsto decrease or eliminate the positional ormotion-provoked symptoms of dizzinessand vertigo, through the repetition of spe-cific positions or movements that provokethe symptoms. There is little information onthe specific exercises to be prescribed or theoptimal frequencies of repetition, althoughthese factors appear to be dependent on

individual complaints and the severity ofthe symptoms (Shepard and Telian, 1995).Gaze stability training incorporates exer-cises to improve eye–head co-ordination,with progressively wider frequencies andfull f ield stimuli used as improvementsoccur (Herdman et al., 1994). Balance andmobility training is used to facilitate therecovery of balance and may include exer-cises to correct weight-bearingasymmetries, limited mobility around thecentre of gravity and sensory input selec-tion problems (Shepard and Telian, 1995).Examples include stepping tasks, standingon a compliant support surface with eyesopen or closed and balancing with a pro-gressively smaller base of support. Finally,f itness activities are thought to promoterecovery and are tailored to suit the age,health and interests of the individual.Examples include a graduated walking pro-gramme, jogging, aerobic exercises,bicycling and sports such as golf and bowl-ing (Shepard and Telian, 1995). On average,each home exercise program consisted offour items and was estimated to take a max-imum of 10 minutes to complete (plus timeto participate in some form of fitness exer-cise). Individuals were asked to perform theexercise programme three times every day.The exercise programmes were reviewedweekly and updated to reflect individualimprovements or difficulties. Changes tothe programme might include increasedspeed or duration of an exercise, the addi-tion of other components (for example, eyesclosed/head movement/compliant supportsurface), and the introduction of environ-mental challenges (for example, walking ina busy street rather than in the driveway athome).

Each subject was required to fill out adiary indicating completion of the pre-scribed exercises, and this was reviewed at

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each visit to determine adherence with theprogramme. Failure to complete the diaryand to indicate adequate compliance withthe exercise programme resulted in exclu-sion from the study. Subjects were alsoasked to discontinue any other forms ofphysiotherapy and did not receive occupa-tional therapy or psychology input duringthe course of the study.

Subjects returned the next day to beretested on the SBM system, with this scorebeing recorded and used for subsequentanalyses. They were required to attendphysiotherapy on a weekly basis for areview and update of their home exerciseprogramme. After a period of four weeks,subjects were asked to complete the DHIagain and were re-tested on the SBMsystem.

Statistical analysis

Descriptive analyses were performed on theSBM measures, including analysis of skew.Repeated-measures Student’s t-tests wereused to examine the effect of therapy onpostural stability (SBM measures). Non-parametric tests (Wilcoxon signed rankstests) were used to examine the effect oftherapy on the DHI scores, due to the ordi-nal nature of data collected using this tool.Each of the three subcomponents of theDHI (functional, emotional and physical)was analysed individually to determinechange in specific aspects of the subject’sperceived handicap.

A Spearman’s r correlation coefficientwas used to determine the extent to whichchange in scores of postural stability werecorrelated with change in scores of handi-cap. Additional analyses involvedinvestigating the correlation betweenchange in stability scores and change ineach subscale of the DHI. As two depen-

dent variables were being studied, alpha wasset at 0.016 for all statistical analyses inorder to maintain the familywise error rateat 0.05.

RESULTS

Baseline and post-therapy measures

Descriptive analysis of average stabilityscores at baseline and post-therapy timepoints identified a skew of less than 2.0,therefore parametric analyses were used. Oninitial testing, SBM average stability scoresranged from 7% to 68%, with a mean (SD)of 53.4% (15.8%). Initial DHI scoresranged from 34 to 90 (median 55.9), indi-cating a level of handicap in the higherrange before participation in the study.

Compliance with the home exerciseprogramme

With one exception, the diary was com-pleted satisfactorily by all subjects,demonstrating adequate compliance withthe home exercise programme (completionof the exercises three times every day). Theindividual who failed to comply with theexercise programme was excluded from thestudy at this point.

Change in outcome measures

Following the four-week period of vestibulartherapy, there was a mean (SD) improve-ment (increase) in average stability scores of10.4% (9.2%) (Figure 2) and an improve-ment (decrease) in the median DHI scores of14 points. This change was significant bothin measurements of balance (Student’s t test= –4.51; df = 15; p<0.001) and reports ofhandicap (Z = –3.016; p = 0.003). Break-down of the total DHI score for each subject

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into its three subcomponents indicated amedian improvement in the functional sub-scale of six points, in the emotional subscaleof four points, and the physical subscale ofthree points (Figure 3). This change wasfound only to be significant for the func-tional (Z = –3.058; p = 0.002) and thephysical (Z = –2.441; p = 0.015) subscales.The emotional subscale showed no signifi-cant change (Z = –1.992; p = 0.046).

Correlates between change scores

Change in balance performance on theSBM and change in DHI scores were signif-icantly correlated (Spearman’s r = –0.60;p = 0.015; Figure 4). Additional analysesdetermined that there was no significantcorrelation between change in scores ofaverage stability and change in functional(Spearman’s r = –0.19; p = 0.47) and emo-tional (Spearman’s r = –0.23; p = 0.39)

levels of perceived handicap. There was,however, a significant correlation betweenchange in the physical subscale and changein the average stability score (Spearman’sr = –0.77; p = 0.001).

DISCUSSION

The primary aim of the present study was toinvestigate the degree of correlation thatexists between change in scores of posturalstability and change in levels of self-reported handicap, in patients with chronicvestibular dysfunction undergoing rehabili-tation. A significant negative correlationwas found to exist between the variables.This indicates that improvement in anobjective measure of balance is related to acorresponding improvement in subjectivereports of handicap, that is, as subjects withimpaired balance become steadier, theirsense of handicap lessens.

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FIGURE 2: Mean average stability scores measured by use of the Smart Balance Master (SBM) system pre-and post-therapy.

Pre-therapy Post-therapy

70

60

50

40

30

20

10

0

Mea

n av

erag

e st

abil

ity

scor

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FIGURE 3: Median total and subscale scores measured by use of the Dizziness Handicap Inventory (DHI) pre-and post-therapy

FIGURE 4: Scattergram showing the correlation between change in SBM and DHI (total) scores. With outlier,Pearson’s r = –0.42; p = 0.101; without outlier, Pearson’s r = –0.6; p = 0.018. *Four-week follow-up scoresminus initial score.

Total Functional Emotional Physical

60

50

40

30

20

10

0

Med

ian

DH

I sc

ores

■ Pre-therapy■ Post-therapy

–10 0 10 20 30

Change in Smart Balance Master Scores*

10

0

–10

–20

–30

–40

–50

–60

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These findings are important since theyindicate that a programme which demandsactive patient participation and requiresminimal hospital-based intervention can besuccessful both in terms of physical andquality of life measures, in a group ofpatients with long-standing vestibular dis-ease. In the present climate of limitedhealth resources, this makes vestibular ther-apy a cost-effective and justif iabletreatment approach for this specific patientgroup. Further data collection and extend-ing the length of the study would assist inmaking these results more understandableacross a wider range of diagnoses.

Further analysis revealed, however, thatthe three components of the DHI con-tributed differentially to the overallassociation with postural stability. As maybe expected from a conceptual point of view,the strongest association was with the physi-cal component of the DHI. No significantcorrelation was found for the functional sub-scale, but it was the emotional component ofthe questionnaire which showed neither sig-nificant improvement over time, nor a strongcorrelation with change in postural stabilityscores. This raises important questionsregarding the provision and efficacy of VRT.It seems that the structure of the vestibularprogramme provided in the present studywas unable to address the wide-rangingneeds of some patients with vestibular dis-ease. Indeed, a review of the literatureindicates that most vestibular rehabilitationprogrammes described tend to focus primar-ily on the rehabilitation of physical(habituation, balance and fitness retraining)and functional factors (Cohen, 1994; Shep-ard and Telian, 1995). Some authors havesuggested that this form of vestibular reha-bilitation is able simultaneously to addressthe physical and the psychological causes ofdizziness, since it encourages the gradualresumption of normal activity and empha-

sizes that control over recovery resides withthe individual (Yardley and Luxon, 1994).More recently, however, other authors havestressed the importance of simultaneouslymanaging the symptoms of anxiety andpanic with other complaints related to dizzi-ness and impaired balance (Robertson andIreland, 1995) and have commented thatstandard vestibular therapy is ineffectiveunless psychological problems are resolved.Counselling services to deal with the traumaof becoming functionally disabled may beindicated (Cohen et al., 1992) and earlyreferral for appropriate cognitive and behav-ioural therapy, relaxation, and stressmanagement may be effective. Antidepres-sant medication has also been suggested as auseful adjunct in the treatment of thesepatients (Tusa and Herdman, 1995).

The main focus of the rehabilitation pro-gramme used in the present study was toreduce sensations of dizziness and imbal-ance through physical exercises includinghabituation, balance and general f itnesstraining. Education about vestibular systemdisease and general support was provided bythe treating physiotherapist, but there was noformal psychology input to address the psy-chological factors associated with vestibulardysfunction. The results indicate that, over-all, the degree of emotional supportprovided in this programme, in conjunctionwith the physical and functional improve-ments achieved, was able to reduce levels ofpatient handicap in the majority of cases.However, the absence of more formal psy-chological input, may explain the lack ofsignificant change in the emotional subscaleof the DHI and its poor correlation withchange in balance scores. The importance ofaddressing psychological issues cannot beunderestimated and a better understandingof these aspects may assist clinicians indeveloping a programme which more thor-oughly addresses all the needs of individuals

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with vestibular system disease. Furtherinvestigation is required, however, to iden-tify whether the DHI is the best screeningtool to determine the relative effects ofvestibular dysfunction, and to assist clini-cians in identifying areas which requirespecific intervention. The DHI uses a three-point ordinal scale and this may be unable toadequately measure emotional handicap andsubsequently record change after a course ofvestibular rehabilitation. More research isneeded to investigate these ideas.

CONCLUSION

In order to provide a service of optimalquality and success, it is vital that VRT beroutinely reviewed to ensure that it meetsthe wide-ranging needs of patients withvestibular disease. The results of the presentstudy indicated that as subjects’ balanceimproves, there is a corresponding improve-ment in their perceived levels of handicap.The current structure of VRT, with anemphasis on the more physical and func-tional components of rehabilitation, iswell-placed to achieve this change. For indi-viduals with a greater emotional componentto their disability, additional psychologicalassessment and treatment may be a neces-sary adjunct to the programme. Furtherresearch is necessary to investigate theseissues using a larger and more diversegroup of subjects with symptoms ofvestibular dysfunction.

APPENDIX

Dizziness Handicap Inventory (DHI)

P1 Does looking up increase your problem?Yes No Sometimes

E2 Because of your problem, do you feelfrustrated?Yes No Sometimes

F3 Because of your problem, do yourestrict your travel for business orrecreation?Yes No Sometimes

P4 Does walking down the aisle of asupermarket increase your problem?Yes No Sometimes

F5 Because of your problem, do you havedifficulty getting into or out of bed?Yes No Sometimes

F6 Does your problem signif icantlyrestrict your participation in socialactivities such as going out to dinner,the movies, dancing, or to parties?Yes No Sometimes

F7 Because of your problem, do you havedifficulty reading?Yes No Sometimes

P8 Does performing more ambitiousactivities like sports or dancing orhousehold chores such as sweeping orputting dishes away increase yourproblem?Yes No Sometimes

E9 Because of your problem, are youafraid to leave your home withouthaving someone accompany you?Yes No Sometimes

E10 Because of your problem, are youembarrassed in front of others?Yes No Sometimes

P11 Do quick movements of your headincrease your problem?Yes No Sometimes

F12 Because of your problem, do youavoid heights?Yes No Sometimes

P13 Does turning over in bed increase yourproblem?Yes No Sometimes

F14 Because of your problem, is it difficult

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for you to do strenuous housework oryardwork?

Yes No Sometimes

E15 Because of your problem, are youafraid people may think you are intoxi-cated?

Yes No Sometimes

F16 Because of your problem, is it difficultfor you to walk by yourself?

Yes No Sometimes

P17 Does walking down a sidewalkincrease your problem?

Yes No Sometimes

E18 Because of your problem, is it difficultfor you to concentrate?

Yes No Sometimes

F19 Because of your problem, is it difficultfor you to walk around your house inthe dark?

Yes No Sometimes

E20 Because of your problem, are youafraid to stay home alone?

Yes No Sometimes

E21 Because of your problem, do you feelhandicapped?

Yes No Sometimes

E22 Has your problem placed stress onyour relationship with members ofyour family or friends?

Yes No Sometimes

E23 Because of your problem, are youdepressed?

Yes No Sometimes

F24 Does your problem interfere with yourjob or household responsibilities?

Yes No Sometimes

P25 Does bending over increase your prob-lem?

Yes No Sometimes

Total

Total : F = E = P =

F = Functional; E = Emotional; P = Physical.

REFERENCES

Clark DB, Hirsch BE, Smith MG, Furman JMR,Jacob RG. Panic in otolaryngology patients pre-senting with dizziness or hearing loss. AmericanJournal of Psychiatry 1994; 151: 1223–1225.

Cohen H. Vestibular rehabilitation improves daily lifefunction. American Journal of OccupationalTherapy 1994; 48: 919–925.

Cohen H, Rubin A, Gombash L. The team approachto the treatment of the dizzy patient. Archives ofPhysical Medicine and Rehabilitation 1992; 73:703–708.

Denham T, McKinnon Wolf A. Vestibular rehabilita-tion. Rehab Management 1997; April/May:93–95.

Di Fabio R. Sensitivity and specificity of platformposturography for identifying patients withvestibular dysfunction. Physical Therapy 1995;75: 290–305.

Eagger S, Luxon L, Davies R, Coelho A, Ron M.Psychiatric morbidity in patients with peripheralvestibular disorder. Journal of Neurological Neu-rosurgical Psychiatry 1991; 55: 383–387.

Ford-Smith C, Wyman J, Elswick R, Fernandez T,Newton R. Test–retest reliability of the SensoryOrganisation Test in non-institutionalised olderadults. Archives of Physical Medicine and Reha-bilitation 1995; 76: 77–81.

Hageman P, Leibowitz JM, Blanke D. Age andgender effects on postural control measures.Archives of Physical Medicine and Rehabilitation1995; 76: 961–965.

Herdman S, Borello-France D, Whitney S. Treatmentof vestibular hypofunction. In: Herdman S (Ed.).Vestibular Rehabilitation. Philadelphia: FADavis, 1994; 287–315.

Horak F, Jones-Rycewicz C, Black O, Shumway-Cook A. Effects of vestibular rehabilitation ondizziness and imbalance. Otolaryngology Headand Neck Surgery 1992; 106: 175–180.

Murray et al.

PRI 6(4) crc 29/11/02 11:52 AM Page 262

Jacobson G, Newman C. The development of theDizziness Handicap Inventory. Archives of Oto-laryngology and Head and Neck Surgery 1990;116: 424–427.

Jacobson G, Newman C, Hunter L, Balzer G. Balancefunction test correlates of the Dizziness HandicapInventory. Journal of American Academy ofAudiology 1991; 2: 253–260.

Kroenke K, Lucas CA, Rosenberg ML, ScherokmanB, Herbers JE, Wehrle PA et al. Causes of persis-tent dizziness: a prospective study of 100 patientsin ambulatory care. Annals of Internal Medicine1992; 117: 899–904.

Morris P. A habituation approach to treating vertigoin occupational therapy. American Journal ofOccupational Therapy 1991; 45: 556–558.

Nashner L. Computerised dynamic posturography. In:Jacobson G, Newman C, Kartush J (eds). Hand-book of Balance Function Testing. St Louis:Mosby–Year Book, Inc., 1993; 280–307.

Norre M, Forrez G, Beckers A. Clinical applicationof vestibulospinal reflex tests in peripheralvestibular disorders. Acta Otolaryngology 1989;468 (Suppl.): 337–339.

Robertson D, Ireland D. Dizziness Handicap Inven-tory correlates of computerised dynamic

posturography. Journal of Otolaryngolgy 1995;24: 118–124.

Shepard N, Telian S. Programmatic vestibular reha-bilitation. Otolaryngology Head and NeckSurgery 1995; 112: 173–182.

Shepard N, Telian S, Smith-Wheelock M. Habitua-tion and balance retraining therapy. DiagnosticNeurotology 1990; 8: 459–475.

Tideiksaar R. Reducing the risk of falls and injury inolder persons: contributions of a falls and immo-bility clinic. In: Tideiksaar R (Ed.). Falls, Gaitand Balance in the Elderly: From SuccessfulAgeing to Frailty. New York: Springer, 1994.

Tusa R, Herdman S. Vertigo and dysequilibrium. In:Griffin JA (Ed.). Current Topics on Neurology.Basel: Marcel Dekker, 1995; 8–14.

Yardley L, Luxon L. Treating dizziness with vestibu-lar rehabilitation. British Medical Journal 1994;308: 1252–1253.

Address for correspondence: Kate Murray, PublicHealth Division, National Ageing Research Institute,PO Box 31, Parkville, Victoria 3052, Australia (E-mail: k.murray@nari.unimelb.edu.au).

Submitted August 2000; accepted July 2001

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