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Relationship between health-related quality of life and disability in women with peripheral vertigo
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ORIGINAL ARTICLE
Relationship between health-related quality of life and disability in women with peripheral vertigo Vanessa Vélez León,a Vanessa Lucero Gutiérrez,a Celia Escobar Hurtado,a and Robinson Ramirez-Velezb,* Universidad del Valle, Escuela de Rehabilitación Humana, Cali, Colombia Universidad del Valle, Departamento de Ciencias Fisiológicas, Bioquímica, Cali, Colombia
a
b
Received December 1, 2009; accepted March 16, 2010
KEYWORDS Dizziness; Disabilities; Quality of life
Abstract Objective: To study the relationship between disability and health-related quality of life in women with vertigo of peripheral origin. Methods: Cross-sectional study in 26 women diagnosed with vertigo, classified by type of peripheral vestibular disturbance: benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Ménière’s disease, post-trauma and others. In a self-report interview, a 12-item shortform (SF-12) health survey on quality of life was applied; disability was assessed with the questionnaire “Dizziness Handicap Inventory” (DHI). Measures of central tendency, dispersion for the domains and types of vestibular disturbance were used and internal DHI consistency and inter-scale correlation were calculated. Results: Patients in the vestibular neuritis and Ménière groups displayed a higher level of disability according to the DHI functional (29.5±5.5 vs 27.0±8.8) and physical domains (23.0±4.1 vs 21.5±6.6). Based on the SF-12 domains, greater deterioration in quality of life was perceived in physical (22.9±3.9 vs 22.6±4.6) and emotional performance (15.4±5.0 vs 11.3±6.0), respectively. Acceptable and significant inverse correlations were found between the physical component summary (PCS-12) of the SF-12 and the physical, emotional and functional aspects of the DHI questionnaire (r=−0.51 to −0.78, P<.01). Internal consistency (Cronbach’s alpha index) of the DHI questionnaire was appropriate for the sample. Conclusions: The DHI and the SF-12 are useful, practical and valid instruments for assessing the impact of dizziness on the quality of life of patients with this symptom. © 2009 Elsevier España, S.L. All rights reserved.
*Corresponding author. E-mail address: [email protected] (R. Ramirez-Velez).
0001-6519/$ - see front matter © 2009 Elsevier España, S.L. All rights reserved.
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PALABRAS CLAVE Vértigo; Discapacidad; Calidad de vida
V. Vélez León et al
Relación entre la calidad de vida relacionada con la salud y la discapacidad en mujeres con vértigo de origen periférico Resumen Objetivo: Estudiar la relación entre la discapacidad y la calidad de vida en mujeres con vértigo de origen periférico. Métodos: Estudio transversal, en 26 mujeres con diagnóstico clínico de vértigo clasificado según el tipo de alteración vestibular periférica: vértigo posicional paroxístico benigno (VPPB), neuronitis vestibular, enfermedad de Ménière, postrauma y otros. Se aplicó por entrevista autodiligenciada el cuestionario de calidad de vida 12-item short (SF-12) y la discapacidad se evaluó con el cuestionario «Dizziness Handicap Inventory» (DHI). Se usaron medidas de tendencia central, dispersión para los dominios y tipo de alteración vestibular; cálculo de consistencia interna para el DHI y correlación interescalas. Resultados: Los pacientes del grupo neuronitis vestibular y enfermedad de Ménière acusaron mayor nivel de discapacidad según el DHI en los dominios aspecto funcional (29,5 ± 5,5 vs. 27,0 ± 8,8) y físico (23,0 ± 4,1 vs. 21,5 ± 6,6) y una percepción de mayor deterioro en su calidad de vida según el SF-12 en los dominios desempeño físico (22,9 ± 3,9 vs. 22,6 ± 4,6) y desempeño emocional (15,4 ± 5,0 vs. 11,3 ± 6,0) respectivamente. Correlaciones inversas aceptables y significativas se encontraron entre el constructo físico (PCS-12) del SF-12 y los aspectos físico, funcional y emocional del cuestionario DHI (r = –0,51 a –078, p < 0,01). La consistencia interna (índice a de Cronbach) del cuestionario DHI fue adecuada para la muestra. Conclusiones: El DHI y el SF-12 son herramientas útiles, prácticas y válidas para evaluar el impacto del vértigo en la calidad de vida de los pacientes con este síntoma. © 2009 Elsevier España, S.L. Todos los derechos reservados.
Introduction In recent years, studies evaluating the impact of different vestibular disorders on the perception of an individual about their quality of life, by measuring health-related quality of life (HRQOL) in disorders such as vertigo, dizziness and imbalance, are well documented.1,2 However, precisely establishing the extent to which the condition is affecting the patient from the point of view of functionality and quality of life is a process that is complex and difficult to interpret because there are no precise indicators for its understanding. Consequently, health indicators derived from self-reports have proved useful in a variety of studies evaluating the HRQOL of an individual or a collective. At present, the term “quality of life” is recognised as a subjective, multidimensional concept constructed from the experience of each person, considering the cultural context and value system through the perception of an individual about him- or herself, free of judgments and external values.3 Given that quality of life depends on many other factors apart from the subjective perception of health, in these cases some researchers prefer to use the term Health-Related Quality of Life,4 which is defined as: “The perception of an individual about their position in life, in the context of culture and value system in relation to their objectives, expectations, standards and
concerns” (WHOQOL GROUP, 1995).5 To investigate HRQOL, different instruments measuring health allow subjects to express their perceptions of health status and permit the healthcare professional to determine the degree of limitation and disability. Tools based on the self-report of perceived health results have been developed under the validity and reliability6 of various population groups as a support element to assess health in the most objective manner. The questionnaires “Dizziness Handicap Inventory” (DHI) and “12-Short Form Health Survey” (SF-12) have been applied to groups of patients with acute and chronic vestibular disease, peripheral, central or mixed, to assess their functional limitations, the degree of impairment of quality of life as perceived by patients and their families, the condition prior to medical intervention, the evolution and the response to treatment once started, among other points.7 Due to their reliability, validity and implementation brevity, these questionnaires have become a viable option in quickly ascertaining the HRQOL of the general population, although they have revealed differences in demographic strata, income levels, gender and age groups.8 For example, several studies have suggested that patients with acute peripheral vestibular disorders obtained lower HRQOL scores compared with healthy controls, and the female gender is prevalent in HRQOL deterioration.9,10 It has
Relationship between health-related quality of life and disability in women with peripheral vertigo
also been postulated that these clinical disorders have been associated with a lower patient participation in activities of daily living due to the impact on the emotional, social and work-related aspects.11 A report by Mendel et al12 studying the impact of vertigo on the daily lives of 99 patients with vestibular disease concluded that those who suffered from vertigo typically presented disabilities for their social life and physical activity, along with an impaired quality of life. Bamiou et al13 assessed the disability of patients with partial loss of vestibular function compared with patients with total loss. The authors found that, although vertigo was more severe in the group with partial loss than in the group with total loss, disability was similar in both groups. In another study, Cohen et al14 identified that when the manifestations of vestibular disease are intermittent, as in Ménière’s disease, they can have a major impact on the daily life of a patient. The main purpose of this article is thus to determine the relation between disability and HRQOL in women with vertigo of peripheral origin. This would make it possible to propose and implement a comprehensive care plan for these individuals, by offering a therapeutic and rehabilitation option in the various conditions of their daily life activities.
Material and methods A cross-sectional study was conducted in women attending specialist medical consultation due to episodes of vertigo in the previous 12 months as a consequence of a vestibular disorder. The patients were stable and without active symptoms when included in the study. These participants attended medical control (ENT service) at a level III healthcare institution in the city of Santiago de Cali during the period between February 2008 and April 2009. Through intent sampling, 26 women over 20 years of age with peripheral vestibular disorder who were in a position to understand and follow verbal commands were invited to participate and to accept their inclusion in the study through informed consent. We excluded individuals who presented central vestibular alterations, “dizziness” without a diagnosis of vestibular disorder, people with clinical diagnosis of CNS degenerative diseases and/or cerebellar disease. The Institutional Review Committee of Human Ethics of the Health Faculty at the Universidad del Valle (formal declaration 113-08) and of the Hospital Universitario del Valle ensured the safety of the study in accordance to the legal framework (Resolution No. 008430 from 1993) issued by the Ministry of Health. Once patients met the criteria for eligibility and inclusion, stratification was carried out according to the type of vertigo with peripheral origin. This was diagnosed by the department of otolaryngology at the University Hospital, based on canalith-repositioning studies, audiology, electronystagmography and biochemical and caloric tests15,16 as follows: 1) benign paroxysmal positional vertigo (BPPV), 2) vestibular neuronitis, 3) Ménière’s disease, 4) posttraumatic vertigo and 5) other types of vertigo. Through personal interviews in medical records coded to maintain confidentiality data, information was collected on demographic characteristics (origin, educational level) and
257
clinical data (type of peripheral vestibular disorder: BPPV, Ménière, posttraumatic, vestibular neuronitis and other types of vertigo), duration of disease (<1 month, 1 to 12 months and >12 months), use of medication (yes or no), having received prior vestibular rehabilitation (yes or no) or currently receiving vestibular rehabilitation (yes or no). The assessment of disability by vertigo was evaluated through the health questionnaire “Dizziness Handicap Inventory” (DHI), developed by Jacobson et al17 in 1990 and validated by Ceballos LR et al1 in 2004, a tool used to quantify the impact of vertigo in daily life activities and situations. At present, this instrument is widely spread and has been used in numerous investigations; it is considered a standard instrument for people with vertigo, as its level of reliability is 0.97.1,3,9 To verify the reliability of the instrument, we carried out an internal consistency analysis of each of the 3 aspects of the DHI in relation to its total with the statistic (Cronbach a), considering a minimum value of 0.7 as acceptable. The HRQOL was evaluated through the generic health questionnaire “12-item short form of the SF-36® Health Survey” validated in Colombia by Lugo et al,18 who found that the scales exceeded the suggested reliability standard (Cronbach a>0.7). This instrument reflects the measurements of the PCS-12 (physical component) functional status and the MCS-12 (mental component) emotional status (12 items from 8 dimensions or domains).19 The number of response options ranges from 3-6 depending on the item; each question is assigned a value that is then transformed into a 0-100 scale, where 0 corresponds to the worst health status and 100 to the best health status (quality of life or perceived health).18 Additionally, a pilot study was conducted to estimate the average time for self-administration of the instruments, which was 16 min. To analyse the results we used the descriptive statistics criteria, tabulated and analysed with SPSS© version 11.5. We obtained the index (Cronbach’s a) for terms of internal consistency of each of the 3 aspects in the DHI in relation to the total. The Pearson correlation coefficient (r) was used to determine the relationship between the components (aspects and domains) of the SF-12 and the DHI. The differences in scores on the results of the SF-12 and DHI questionnaires between groups according to type of peripheral vestibular disorder was verified by oneway analysis of variance (ANOVA). A value of P<.05 was considered significant.
Results We included 30 patients with vertigo of peripheral origin. Of the total participants, 13.4% (n=4) were males and 86.6% (n=26) were females, who were included in the analysis, thus excluding men. The mean age was 51.3±4.6 years (range 21-73). The age range between 51-60 years was 34.6% (n=9), this being the range with the largest number of participants. Based on origin, 57.7% (n=15) were from urban areas, while 42.3% (n=11) came from rural areas. With regard to education, 50.0% (n=13) had completed studies to elementary level, 38.5% (n=10) had completed secondary education, 7.7% (n=2) higher education, and 3.8 % (n=1) did not have any studies.
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Clinical characteristics were studied through the stratification of the 6 types of peripheral vestibular disorder found in order of frequency as follows: 30.7% BPPV (n=8), other types of vertigo 19.2% (n=5), posttraumatic vertigo 19.2% (n=5), Ménière’s disease 15.3% (n=4) and vestibular neuronitis 15.3% (n=4). With regard to clinical evolution of the disease, 69.2% (n=18) corresponded to the range of 1-12 months, 26.9% (n=7) over 12 months and 3.8% (n=1) under 1 month of evolution. For the analysis and study of HRQOL, we included only women who suffered between 1-12 months of clinical diagnosis and had no active symptoms. Of the participants, 73.1% (n=19) did not use drugs, while 26.9% (n=7) did make use of them. It was found that 69.2% (n=18) had not previously received vestibular rehabilitation, while 30.8% (n=8) had received it at some point. The participants who were currently under vestibular rehabilitation treatment represented 34.6% (n=9) and those who were not in treatment represented 65.4% (n=17) (Table 1). Figure shows the distribution by type of disability (severe disability, moderate disability and without disability) according to the physical, functional and emotional aspects of patients with vertigo of peripheral origin, as assessed by the DHI questionnaire. In the emotional aspect, it was found that 16.6% of total participants reported severe disability, 43.3% reported a moderate degree of disability, followed by 40% who presented no disability. In the functional aspect, half of the participants reported severe disability, 33.3% moderate disability and 16.6% no disability. In the physical aspect, severe disability prevailed in 73.3% of all the participants, while moderate disability was found in 23.3% and 3.3% were in the grade of no disability. Table 2 presents the results of the domains in the SF-12 health questionnaire according to the type of peripheral vestibular alteration. Low scores can be observed in the domains of emotional and physical performance, and significant differences in the groups of vestibular neuronitis, posttraumatic and others. The highest scores in the questionnaire for all types of disorders are found in the domain of vitality. Table 3 shows the average results on the DHI questionnaire and the distribution by type of peripheral vestibular disorder, with severe disability being observed in the physical aspect (20.0±5.5), moderate disability in the functional (24.0±9.6) and no disability on the emotional (16.9±9.7). The total number of patients with BPPV reported, on average, a level of severe disability in the physical aspect (20.6±5.4) and moderate in the functional (23.5±8.5) and emotional (16.7±8.1) aspects. Patients with vestibular neuronitis said that they had severe disability in the physical (23.0±4.1) and functional (29.5±5.5) domains, while in the emotional aspect they were recorded as suffering moderate disability (20.0±11.1.) In all patients diagnosed with Ménière’s disease, an average level of severe disability was found in the physical aspect (21.5±6.6) and also in the functional (27.0±8.8), while a moderate degree of disability was found in the emotional aspect (19.5±11.8). Patients with posttraumatic vertigo reported moderate disability in the physical (14.8±5.4) and functional (15.2±11.5) aspects and no disability in the emotional (11.8±9.7) aspect. Finally, patients with other vertigos reported severe disability on the physical (20.2±4.9) and functional (26.0±9.6) aspects and registered moderate disability on the emotional (17.5±11.1) domain.
V. Vélez León et al
Table 1 Socio-demographic and clinical characteristics of patients with peripheral-origin vertigo attending a level III healthcare institution in the city of Santiago de Cali Variable Age ranges ≤30 years 31-40 years 41-50 years 51-60 years 61-70 years ≥71 years
n
%
2 3 6 9 4 2
7.7 11.5 23.1 34.6 15.4 7.7
Origin Urban Rural
15 11
57.7 42.3
Level of education None Primary Secondary Higher
1 13 10 2
3.8 50.0 38.5 7.7
8 4 5 4 5
30.8 15.4 19.2 15.4 19.2
Time of clinical evolution ≤1 month De 1-12 months ≥12 months
1 18 7
3.8 69.2 26.9
Use of drugs Yes No
7 19
26.9 73.1
Prior vestibular rehabilitation Yes No
8 18
30.8 69.2
Current vestibular rehabilitation Yes No
9 17
34.6 65.4
Type of vestibular peripheral disorder BPPV Ménière Posttraumatic Vestibular neuronitis Other vertigos
BPPV indicates benign paroxysmal positional vertigo.
The internal consistency results (Cronbach a) were the following: physical aspect: 0.81, emotional: 0.87 and functional: 0.82. The Cronbach a for the full questionnaire was found to be 0.88. Table 4 shows the correlation between the domains of the SF-12 health questionnaire and the aspects of the DHI questionnaire. It was found that 73.4% of the correlations showed a significance level of 0.01; that is, they presented a margin of error of 1%, with this being the highest level of demand. A significance level of 0.05 was presented by16.3% of the correlations, while 10% of the data did not
Relationship between health-related quality of life and disability in women with peripheral vertigo
correlate significantly. It is noteworthy that the functional, physical and emotional domains of the DHI presented important and significant correlations with all those of the SF-12 (P<.05), except for the categories of general health and social function.
Discussion The objective of this research was to determine the relationship between disability and HRQOL in women with vertigo of peripheral origin attending a level III healthcare
16.6
Emotional disability
43.3 40 50
Functional disabilityl
Severe Moderate No disability
33.3 16.6
Physical disability
73.3
23.3 3.3 0
5 10 20 30 40 50 60 70 80 90 100 110 Percentage
Figure Distribution of disability in patients with vertigo of peripheral origin attending a level III healthcare institution in the city of Santiago de Cali.
259
institution in the city of Santiago de Cali. As described previously, HRQOL measurement varies among individuals because it is a dynamic construct containing continuous interactions between the patients and their environment, and includes physical, mental and social aspects. Consequently, it is appropriate to examine the interaction between the disease, the changes occurring in the life of the individual, the received and perceived social contributions and the stage of life at which the pathology takes place. The clinical features found in this study showed that the women evaluated ranged between 51-60 years of age, and the type of peripheral vestibular disorder that occurred more frequently was benign paroxysmal positional vertigo (BPPV). These results are consistent with studies by other authors and used as references in this study.1,3,9 Similarly, the HRQOL results obtained from the interpretation of the DHI health questionnaire, which estimates how the disability affects the quality of life, show that the category presenting severe disability with greater frequency was the physical (73.3%), followed by the functional aspect (50%) and, to a lesser extent, the emotional aspect (16.6%). These results show similarities with those reported in the study by Ceballos et al,1 where physical disability was the most frequent aspect, in 82%, followed by functional impairment (55%) and emotional disability (48%). Likewise, this study revealed that in the internal categories of the DHI health questionnaire, 97.7% of patients presented physical disability, 83.4% functional disability, and 60% emotional disability, coinciding with other reports.1,9 This suggests that patients evaluated using the DHI report a significant impact on all aspects and categories of the health questionnaire, and only a minority of the
Table 2 Results of the SF-12 quality of life questionnaire according to the type of peripheral vestibular disorder Domain
Type of peripheral vestibular disorder
Total (n=26)
BPPV (n=8)
Vestibular neuronitis (n=4)
Ménière (n=4)
Posttraumatic Others (n=5) (n=5)
Physical function Physical performance Physical pain General health Vitality Social function Emotional performance Mental health PCS-12 (physical component) MCS-12 (mental component)
35.2±11.8 22.9±3.9 38.7±16.7 36.9±10.7 51.1±11.0 35.3±14.1 15.4±5.0 39.1±13.5 36.5±8.6 34.0±10.1
36.4±10.5 23.3±4.6 42.7±15.3 35.8±9.8 56.6±11.7 34.1±14.9 16.9±5.5 42.1±14.6 37.4±8.8 36.4±11.6
28.5±8.2 20.3±.0 34.5±15.2 33.4±7.5 42.7±5.8* 36.3±8.2 15.5±5.3 31.0±7.8 32.1±4.6 30.8±6.0
30.7±12.1 22.6±4.6 31.9±19.5 39.8±12.6 45.2±5.0 28.8±15.1 11.3±6.0 31.0±3.5 35.5±7.1 26.9±2.8**
46.1±9.4 24.9±4.6 47.2±17.6 40.8±11.1 61.8±9.0* 38.3±18.0 19.1±4.9 48.6±17.5 43.0±9.8 40.0±12.1
32.8±13.5 22.6±3.4 34.5±17.8 35.8±13.5 45.2±7.1* 37.6±14.7 13.4±4.1 37.8±12.5 34.3±9.2 32.8±9.8
Values expressed as mean ± standard deviation. BPPV indicates benign paroxysmal positional vertigo; MCS-12 (mental component), emotional status; PCS-12 (physical component), functional status. 0 corresponds to the worst health status and 100 to the best health status. *Differences between types of peripheral vestibular disorder. **Differences between types of peripheral vestibular disorder and total.
260
V. Vélez León et al
Table 3 Results of the disability survey by type of peripheral vestibular disorder Domain
Type vestibular peripheral disorder
Total (n=26)
BPPV (n=8)
Vestibular neuronitis (n=4)
Ménière (n=4)
Posttraumatic (n=5)
Others (n=5)
Physical aspect
20.0±5.5
20.6±5.4
23.0±4.1
21.5±6.6
14.8±5.4
20.2±4.9
Functional aspect
24.0±9.6
23.5±8.5
29.5±5.5
27.0±8.8
15.2±11.5
26.0±9.6
Emotional aspect
16.9±9.7
16.7±8.1
20.0±11.1
19.5±11.8
11.8±9.7
17.5±11.1
Total DHI
60.9±8.2
60.8±7.3
72.5±7.0*
68±9.0
41.8±8.8**,*
63.7±8.5
Values expressed as mean ± standard deviation. BPPV indicates benign paroxysmal positional vertigo; DHI, “Dizziness Handicap Inventory”. Functional and emotional aspect. Without disabilities 0-14 points. Moderate disability 15-24 points. Severe disability 25 points onwards. Physical aspect. Without disabilities 0-9 points. Moderate disability 10-16 points. Severe disability 17 points onwards. *Differences between types of peripheral vestibular disorder. **Differences between types of peripheral vestibular disorder and total.
Table 4 Correlations between the domains in the SF-12 questionnaire and the type of disability according to the DHI in patients with peripheral vestibular disorder (n=26) Domains in SF-12
Type of disability according to DHI
Physical aspect
Functional aspect
Emotional aspect
Physical function Physical performance Physical pain General health Vitality Social function Emotional performance Mental health PCS-12 (physical component) MCS-12 (mental component)
–0.53* –0.63* –0.44** –0.15 –0.51* –0.35 –0.43** –0.54* –0.51* –0.46*
–0.66* –0.74* –0.61* –0.37** –0.49* –0.55* –0.54* –0.46* –0.78* –0.43**
–0.53* –0.67* –0.47* –0.35 –0.46** –0.54* –0.52* –0.52* –0.59* –0.51*
DHI indicates “Dizziness Handicap Inventory”. PCS Functional status (physical component). MCS Emotional status (mental component). *Correlation is significant at level 0.01 (bilateral). **Correlation is significant at level 0.05 level (bilateral).
participants indicated no disability. This finding indicates that patients with peripheral vestibular disorder in the study presented a limitation in performing daily activities and restriction in participation which affected their quality of life, in addition to a structural and/or functional deficiency, although in their own individual perception they did not refer suffering some kind of disability status. It is also noteworthy that the perception of disability by posttraumatic patients is strikingly low, given their behaviour in other series. This finding may be explained by the clinical characteristics defining posttraumatic patients not suffering from BPPV, who perceive their clinical condition as a highly disabling and chronic situation, one that is not life threatening but interferes significantly in their personal functioning.
This would imply that a more profound assessment should be considered in the case of women with posttraumatic vertigo in whom a psychiatric cause is suspected or in whom psychiatric symptoms are manifested. The results of the domains in the SF-12 questionnaire showed that emotional status presented a lower score, which translates into further deterioration of the quality of life, followed by the physical domain. The category that showed the highest scores, interpreted as better HRQOL, was vitality, with significant differences between the conditions: vestibular neuronitis, posttraumatic vertigo and other vertigos, P<.05. In general, patients with a diagnosis of posttraumatic vertigo presented the highest scores with respect to the other types of peripheral vestibular
Relationship between health-related quality of life and disability in women with peripheral vertigo
disorders in the SF-12 questionnaire, indicating that these patients perceive a better quality of life. However, the results found in this study should be regarded with caution when compared with other research, due to the presence of average values below 50 points, as these results do not match those found by other authors.1,4,9 Patients with posttraumatic vertigo generally reported lesser degrees of disability in the emotional aspect and they were the only ones to present moderate disability in the physical aspect. This contrasted with patients suffering from other types of vestibular disorders, who accused severe disability. When comparing studies that used these questionnaires in the measurement of results to assess HRQOL perception in the international literature with a population similar to ours, we found that the lowest scores were in the domains of emotional performance, physical performance, mental health and social functioning, which were much lower and not consistent with the results found in this study.1,4,9,12-17 Similarly, participants in this study showed further deterioration in their quality of life in the categories of PCS (physical component) and MCS (mental component) of the SF-12 health questionnaire.1,4,9 Finally, in the correlations between internal categories of both questionnaires used, we found that most of them presented a high level of significance (P<.01) and “r” values considered as acceptable. This shows that, besides the correlation obtained in the majority of the responses provided by participants, the variables of both questionnaires showed an inverse behaviour; that is, the greater the deterioration in the quality of life expressed by low scores, the greater the degree of disability expressed by high scores, and vice versa. This coincides with reports by other authors.1,3,5,9,20 Although some studies have shown that health status is significantly affected by the presence and severity of vertigo, there are insufficient data to estimate the disability and incapacity for work associated to patients with each type of vertigo.1,4 Limitations to this study, such as the characteristics of the specific population in terms of working design, resource constraints, sample size and sampling rate may introduce a number of biases and the results can only be extrapolated as a reference value to the target population, since the group of individuals intervened is not representative.
Financing The authors declare that the investigation did not receive any institutional and/or private financial resources for its completion.
Conflict of interests The authors of the study declare no conflict of interests.
References 1. Ceballos LR, Vargas AAM. Aplicación y utilidad del Dizziness Handicap Inventory en pacientes con vértigo del Servicio de Otorrinolaringología del Hospital de Especialidades del Centro
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Médico Nacional Siglo xxi. An Med Asoc Med Hosp ABC. 2004;49:176-83. 2. Duracinsky M, Mosnier I, Bouccara D, Sterkers O, Chassany O; Working Group of the Société Française d’Oto-RhinoLaryngologie (ORL). Literature review of questionnaires assessing vertigo and dizziness, and their impact on patients’ quality of life. Value Health. 2007;10:273-84. 3. Rucci P, Rossi A, Mauri M, Maina G, Pieraccini F, Pallanti S, et al; Gruppo Equip. Validity and reliability of Quality of Life, Enjoyment and Satisfaction Questionnaire, Short Form. Epidemiol Psichiatr Soc. 2007;16:79-89. 4. Ramírez-Vélez R. Calidad de vida y enfermedad pulmonar obstructiva crónica. Rev Cienc Salud. Bogotá (Colombia). 2007;5:90-100. 5. WHOQOL GROUP. The world Health Organization Quality of Life Assessment (WHOQOL): position paper from the World Health Organization. Special issue “Quality of life”. Soc Sci Med. 1995;41:1403-9. 6. Khanna D, Tsevat J. Health-related quality of life: an introduction. Am J Manag Care. 2007;13:S218-23. 7. González del Pino B, Pérez Fernández N. Disability in patients with benign paroxysmal positional vertigo with posterior semicircular canal involvement. Acta Otorrinolaringol Esp. 2003;54:401-8. 8. Skevington SM, Lotfy M, O’Connell KA, for the WHOQOL Group. The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res. 2004;13:299-310. 9. Vilagut G, Ferrer M, Rajmil L, Rebollo P, Pemayer-Miralda G, Quintana JM, et al. El cuestionario de salud SF-36 español: una década de experiencias y nuevos desarrollos. Gac Sanit. 2005; 19:135-50. 10. Kurre A, Van Gool CJ, Bastiaenen CH, Gloor-Juzi T, Straumann D, De Bruin ED. Translation, cross-cultural adaptation and reliability of the German version of the dizziness handicap inventory. Otol Neurotol. 2009;30:359-67. 11. Gutiérrez-Márquez A, Jáuregui-Renaud K, Viveros-Renteria L, Villanueva-Padrón LA. Discapacidad por enfermedad auditiva y vestibular en un centro de atención especializada. Gac Méd Méx. 2005;114:105-10. 12. Mendel B, Bergenius J, Langius A. Dizziness symptom severity and impact on daily living as perceived by patients suffering from peripheral vestibular disorder. Clin Otolaryngol Allied Sci. 1999;24:286-93. 13. Bamiou DE, Davies RA, Mckee M, Luxón L. The effect of severity of unilateral vestibular dysfunction on symptoms, disabilities and handicap in vertiginous patients. Clin Otolaryngol & Allied Sci. 1999;24:31-8. 14. Cohen H, Ewell LR, Jenkins HA. Disability in Meniére’s disease. Arch Otolaryngol Head Neck Surg. 1995;121:29-33. 15. Baloh RW, Yue Q, Jacobson KM, Honrubia V. Persistent directionchanging positional nystagmus: Another variant of benign positional nystagmus? Neurology. 1995;45:1297-301. 16. Lempert T, Tiel-Wilck K. A positional maneuver for treatment of horizontal canal benign positional vertigo. Laryngoscope. 1996;106:476-8. 17. Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116:424-7. 18. Lugo LE, García HI, Gómez CR. Confiabilidad del cuestionario de calidad de vida en salud SF-36 en Medellín, Colombia. Rev Fac Nac Salud Pública. 2006;24:37-50. 19. Porter GA. Assessing the outcomes of rehabilitation in patients with end-stage renal disease. Am J Kidney Dis. 1994;24(1 Suppl 1):S22-27. 20. Fielder H, Denholm SW, Lyons RA, Fielder CP. Measurement of health status in patients with vertigo. Clin Otolaryngol Allied Sci. 1996;21:124-6.
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ORIGINAL ARTICLE
Relationship between health-related quality of life and disability in women with peripheral vertigo Vanessa Vélez León,a Vanessa Lucero Gutiérrez,a Celia Escobar Hurtado,a and Robinson Ramirez-Velezb,* Universidad del Valle, Escuela de Rehabilitación Humana, Cali, Colombia Universidad del Valle, Departamento de Ciencias Fisiológicas, Bioquímica, Cali, Colombia
a
b
Received December 1, 2009; accepted March 16, 2010
KEYWORDS Dizziness; Disabilities; Quality of life
Abstract Objective: To study the relationship between disability and health-related quality of life in women with vertigo of peripheral origin. Methods: Cross-sectional study in 26 women diagnosed with vertigo, classified by type of peripheral vestibular disturbance: benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Ménière’s disease, post-trauma and others. In a self-report interview, a 12-item shortform (SF-12) health survey on quality of life was applied; disability was assessed with the questionnaire “Dizziness Handicap Inventory” (DHI). Measures of central tendency, dispersion for the domains and types of vestibular disturbance were used and internal DHI consistency and inter-scale correlation were calculated. Results: Patients in the vestibular neuritis and Ménière groups displayed a higher level of disability according to the DHI functional (29.5±5.5 vs 27.0±8.8) and physical domains (23.0±4.1 vs 21.5±6.6). Based on the SF-12 domains, greater deterioration in quality of life was perceived in physical (22.9±3.9 vs 22.6±4.6) and emotional performance (15.4±5.0 vs 11.3±6.0), respectively. Acceptable and significant inverse correlations were found between the physical component summary (PCS-12) of the SF-12 and the physical, emotional and functional aspects of the DHI questionnaire (r=−0.51 to −0.78, P<.01). Internal consistency (Cronbach’s alpha index) of the DHI questionnaire was appropriate for the sample. Conclusions: The DHI and the SF-12 are useful, practical and valid instruments for assessing the impact of dizziness on the quality of life of patients with this symptom. © 2009 Elsevier España, S.L. All rights reserved.
*Corresponding author. E-mail address: [email protected] (R. Ramirez-Velez).
0001-6519/$ - see front matter © 2009 Elsevier España, S.L. All rights reserved.
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PALABRAS CLAVE Vértigo; Discapacidad; Calidad de vida
V. Vélez León et al
Relación entre la calidad de vida relacionada con la salud y la discapacidad en mujeres con vértigo de origen periférico Resumen Objetivo: Estudiar la relación entre la discapacidad y la calidad de vida en mujeres con vértigo de origen periférico. Métodos: Estudio transversal, en 26 mujeres con diagnóstico clínico de vértigo clasificado según el tipo de alteración vestibular periférica: vértigo posicional paroxístico benigno (VPPB), neuronitis vestibular, enfermedad de Ménière, postrauma y otros. Se aplicó por entrevista autodiligenciada el cuestionario de calidad de vida 12-item short (SF-12) y la discapacidad se evaluó con el cuestionario «Dizziness Handicap Inventory» (DHI). Se usaron medidas de tendencia central, dispersión para los dominios y tipo de alteración vestibular; cálculo de consistencia interna para el DHI y correlación interescalas. Resultados: Los pacientes del grupo neuronitis vestibular y enfermedad de Ménière acusaron mayor nivel de discapacidad según el DHI en los dominios aspecto funcional (29,5 ± 5,5 vs. 27,0 ± 8,8) y físico (23,0 ± 4,1 vs. 21,5 ± 6,6) y una percepción de mayor deterioro en su calidad de vida según el SF-12 en los dominios desempeño físico (22,9 ± 3,9 vs. 22,6 ± 4,6) y desempeño emocional (15,4 ± 5,0 vs. 11,3 ± 6,0) respectivamente. Correlaciones inversas aceptables y significativas se encontraron entre el constructo físico (PCS-12) del SF-12 y los aspectos físico, funcional y emocional del cuestionario DHI (r = –0,51 a –078, p < 0,01). La consistencia interna (índice a de Cronbach) del cuestionario DHI fue adecuada para la muestra. Conclusiones: El DHI y el SF-12 son herramientas útiles, prácticas y válidas para evaluar el impacto del vértigo en la calidad de vida de los pacientes con este síntoma. © 2009 Elsevier España, S.L. Todos los derechos reservados.
Introduction In recent years, studies evaluating the impact of different vestibular disorders on the perception of an individual about their quality of life, by measuring health-related quality of life (HRQOL) in disorders such as vertigo, dizziness and imbalance, are well documented.1,2 However, precisely establishing the extent to which the condition is affecting the patient from the point of view of functionality and quality of life is a process that is complex and difficult to interpret because there are no precise indicators for its understanding. Consequently, health indicators derived from self-reports have proved useful in a variety of studies evaluating the HRQOL of an individual or a collective. At present, the term “quality of life” is recognised as a subjective, multidimensional concept constructed from the experience of each person, considering the cultural context and value system through the perception of an individual about him- or herself, free of judgments and external values.3 Given that quality of life depends on many other factors apart from the subjective perception of health, in these cases some researchers prefer to use the term Health-Related Quality of Life,4 which is defined as: “The perception of an individual about their position in life, in the context of culture and value system in relation to their objectives, expectations, standards and
concerns” (WHOQOL GROUP, 1995).5 To investigate HRQOL, different instruments measuring health allow subjects to express their perceptions of health status and permit the healthcare professional to determine the degree of limitation and disability. Tools based on the self-report of perceived health results have been developed under the validity and reliability6 of various population groups as a support element to assess health in the most objective manner. The questionnaires “Dizziness Handicap Inventory” (DHI) and “12-Short Form Health Survey” (SF-12) have been applied to groups of patients with acute and chronic vestibular disease, peripheral, central or mixed, to assess their functional limitations, the degree of impairment of quality of life as perceived by patients and their families, the condition prior to medical intervention, the evolution and the response to treatment once started, among other points.7 Due to their reliability, validity and implementation brevity, these questionnaires have become a viable option in quickly ascertaining the HRQOL of the general population, although they have revealed differences in demographic strata, income levels, gender and age groups.8 For example, several studies have suggested that patients with acute peripheral vestibular disorders obtained lower HRQOL scores compared with healthy controls, and the female gender is prevalent in HRQOL deterioration.9,10 It has
Relationship between health-related quality of life and disability in women with peripheral vertigo
also been postulated that these clinical disorders have been associated with a lower patient participation in activities of daily living due to the impact on the emotional, social and work-related aspects.11 A report by Mendel et al12 studying the impact of vertigo on the daily lives of 99 patients with vestibular disease concluded that those who suffered from vertigo typically presented disabilities for their social life and physical activity, along with an impaired quality of life. Bamiou et al13 assessed the disability of patients with partial loss of vestibular function compared with patients with total loss. The authors found that, although vertigo was more severe in the group with partial loss than in the group with total loss, disability was similar in both groups. In another study, Cohen et al14 identified that when the manifestations of vestibular disease are intermittent, as in Ménière’s disease, they can have a major impact on the daily life of a patient. The main purpose of this article is thus to determine the relation between disability and HRQOL in women with vertigo of peripheral origin. This would make it possible to propose and implement a comprehensive care plan for these individuals, by offering a therapeutic and rehabilitation option in the various conditions of their daily life activities.
Material and methods A cross-sectional study was conducted in women attending specialist medical consultation due to episodes of vertigo in the previous 12 months as a consequence of a vestibular disorder. The patients were stable and without active symptoms when included in the study. These participants attended medical control (ENT service) at a level III healthcare institution in the city of Santiago de Cali during the period between February 2008 and April 2009. Through intent sampling, 26 women over 20 years of age with peripheral vestibular disorder who were in a position to understand and follow verbal commands were invited to participate and to accept their inclusion in the study through informed consent. We excluded individuals who presented central vestibular alterations, “dizziness” without a diagnosis of vestibular disorder, people with clinical diagnosis of CNS degenerative diseases and/or cerebellar disease. The Institutional Review Committee of Human Ethics of the Health Faculty at the Universidad del Valle (formal declaration 113-08) and of the Hospital Universitario del Valle ensured the safety of the study in accordance to the legal framework (Resolution No. 008430 from 1993) issued by the Ministry of Health. Once patients met the criteria for eligibility and inclusion, stratification was carried out according to the type of vertigo with peripheral origin. This was diagnosed by the department of otolaryngology at the University Hospital, based on canalith-repositioning studies, audiology, electronystagmography and biochemical and caloric tests15,16 as follows: 1) benign paroxysmal positional vertigo (BPPV), 2) vestibular neuronitis, 3) Ménière’s disease, 4) posttraumatic vertigo and 5) other types of vertigo. Through personal interviews in medical records coded to maintain confidentiality data, information was collected on demographic characteristics (origin, educational level) and
257
clinical data (type of peripheral vestibular disorder: BPPV, Ménière, posttraumatic, vestibular neuronitis and other types of vertigo), duration of disease (<1 month, 1 to 12 months and >12 months), use of medication (yes or no), having received prior vestibular rehabilitation (yes or no) or currently receiving vestibular rehabilitation (yes or no). The assessment of disability by vertigo was evaluated through the health questionnaire “Dizziness Handicap Inventory” (DHI), developed by Jacobson et al17 in 1990 and validated by Ceballos LR et al1 in 2004, a tool used to quantify the impact of vertigo in daily life activities and situations. At present, this instrument is widely spread and has been used in numerous investigations; it is considered a standard instrument for people with vertigo, as its level of reliability is 0.97.1,3,9 To verify the reliability of the instrument, we carried out an internal consistency analysis of each of the 3 aspects of the DHI in relation to its total with the statistic (Cronbach a), considering a minimum value of 0.7 as acceptable. The HRQOL was evaluated through the generic health questionnaire “12-item short form of the SF-36® Health Survey” validated in Colombia by Lugo et al,18 who found that the scales exceeded the suggested reliability standard (Cronbach a>0.7). This instrument reflects the measurements of the PCS-12 (physical component) functional status and the MCS-12 (mental component) emotional status (12 items from 8 dimensions or domains).19 The number of response options ranges from 3-6 depending on the item; each question is assigned a value that is then transformed into a 0-100 scale, where 0 corresponds to the worst health status and 100 to the best health status (quality of life or perceived health).18 Additionally, a pilot study was conducted to estimate the average time for self-administration of the instruments, which was 16 min. To analyse the results we used the descriptive statistics criteria, tabulated and analysed with SPSS© version 11.5. We obtained the index (Cronbach’s a) for terms of internal consistency of each of the 3 aspects in the DHI in relation to the total. The Pearson correlation coefficient (r) was used to determine the relationship between the components (aspects and domains) of the SF-12 and the DHI. The differences in scores on the results of the SF-12 and DHI questionnaires between groups according to type of peripheral vestibular disorder was verified by oneway analysis of variance (ANOVA). A value of P<.05 was considered significant.
Results We included 30 patients with vertigo of peripheral origin. Of the total participants, 13.4% (n=4) were males and 86.6% (n=26) were females, who were included in the analysis, thus excluding men. The mean age was 51.3±4.6 years (range 21-73). The age range between 51-60 years was 34.6% (n=9), this being the range with the largest number of participants. Based on origin, 57.7% (n=15) were from urban areas, while 42.3% (n=11) came from rural areas. With regard to education, 50.0% (n=13) had completed studies to elementary level, 38.5% (n=10) had completed secondary education, 7.7% (n=2) higher education, and 3.8 % (n=1) did not have any studies.
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Clinical characteristics were studied through the stratification of the 6 types of peripheral vestibular disorder found in order of frequency as follows: 30.7% BPPV (n=8), other types of vertigo 19.2% (n=5), posttraumatic vertigo 19.2% (n=5), Ménière’s disease 15.3% (n=4) and vestibular neuronitis 15.3% (n=4). With regard to clinical evolution of the disease, 69.2% (n=18) corresponded to the range of 1-12 months, 26.9% (n=7) over 12 months and 3.8% (n=1) under 1 month of evolution. For the analysis and study of HRQOL, we included only women who suffered between 1-12 months of clinical diagnosis and had no active symptoms. Of the participants, 73.1% (n=19) did not use drugs, while 26.9% (n=7) did make use of them. It was found that 69.2% (n=18) had not previously received vestibular rehabilitation, while 30.8% (n=8) had received it at some point. The participants who were currently under vestibular rehabilitation treatment represented 34.6% (n=9) and those who were not in treatment represented 65.4% (n=17) (Table 1). Figure shows the distribution by type of disability (severe disability, moderate disability and without disability) according to the physical, functional and emotional aspects of patients with vertigo of peripheral origin, as assessed by the DHI questionnaire. In the emotional aspect, it was found that 16.6% of total participants reported severe disability, 43.3% reported a moderate degree of disability, followed by 40% who presented no disability. In the functional aspect, half of the participants reported severe disability, 33.3% moderate disability and 16.6% no disability. In the physical aspect, severe disability prevailed in 73.3% of all the participants, while moderate disability was found in 23.3% and 3.3% were in the grade of no disability. Table 2 presents the results of the domains in the SF-12 health questionnaire according to the type of peripheral vestibular alteration. Low scores can be observed in the domains of emotional and physical performance, and significant differences in the groups of vestibular neuronitis, posttraumatic and others. The highest scores in the questionnaire for all types of disorders are found in the domain of vitality. Table 3 shows the average results on the DHI questionnaire and the distribution by type of peripheral vestibular disorder, with severe disability being observed in the physical aspect (20.0±5.5), moderate disability in the functional (24.0±9.6) and no disability on the emotional (16.9±9.7). The total number of patients with BPPV reported, on average, a level of severe disability in the physical aspect (20.6±5.4) and moderate in the functional (23.5±8.5) and emotional (16.7±8.1) aspects. Patients with vestibular neuronitis said that they had severe disability in the physical (23.0±4.1) and functional (29.5±5.5) domains, while in the emotional aspect they were recorded as suffering moderate disability (20.0±11.1.) In all patients diagnosed with Ménière’s disease, an average level of severe disability was found in the physical aspect (21.5±6.6) and also in the functional (27.0±8.8), while a moderate degree of disability was found in the emotional aspect (19.5±11.8). Patients with posttraumatic vertigo reported moderate disability in the physical (14.8±5.4) and functional (15.2±11.5) aspects and no disability in the emotional (11.8±9.7) aspect. Finally, patients with other vertigos reported severe disability on the physical (20.2±4.9) and functional (26.0±9.6) aspects and registered moderate disability on the emotional (17.5±11.1) domain.
V. Vélez León et al
Table 1 Socio-demographic and clinical characteristics of patients with peripheral-origin vertigo attending a level III healthcare institution in the city of Santiago de Cali Variable Age ranges ≤30 years 31-40 years 41-50 years 51-60 years 61-70 years ≥71 years
n
%
2 3 6 9 4 2
7.7 11.5 23.1 34.6 15.4 7.7
Origin Urban Rural
15 11
57.7 42.3
Level of education None Primary Secondary Higher
1 13 10 2
3.8 50.0 38.5 7.7
8 4 5 4 5
30.8 15.4 19.2 15.4 19.2
Time of clinical evolution ≤1 month De 1-12 months ≥12 months
1 18 7
3.8 69.2 26.9
Use of drugs Yes No
7 19
26.9 73.1
Prior vestibular rehabilitation Yes No
8 18
30.8 69.2
Current vestibular rehabilitation Yes No
9 17
34.6 65.4
Type of vestibular peripheral disorder BPPV Ménière Posttraumatic Vestibular neuronitis Other vertigos
BPPV indicates benign paroxysmal positional vertigo.
The internal consistency results (Cronbach a) were the following: physical aspect: 0.81, emotional: 0.87 and functional: 0.82. The Cronbach a for the full questionnaire was found to be 0.88. Table 4 shows the correlation between the domains of the SF-12 health questionnaire and the aspects of the DHI questionnaire. It was found that 73.4% of the correlations showed a significance level of 0.01; that is, they presented a margin of error of 1%, with this being the highest level of demand. A significance level of 0.05 was presented by16.3% of the correlations, while 10% of the data did not
Relationship between health-related quality of life and disability in women with peripheral vertigo
correlate significantly. It is noteworthy that the functional, physical and emotional domains of the DHI presented important and significant correlations with all those of the SF-12 (P<.05), except for the categories of general health and social function.
Discussion The objective of this research was to determine the relationship between disability and HRQOL in women with vertigo of peripheral origin attending a level III healthcare
16.6
Emotional disability
43.3 40 50
Functional disabilityl
Severe Moderate No disability
33.3 16.6
Physical disability
73.3
23.3 3.3 0
5 10 20 30 40 50 60 70 80 90 100 110 Percentage
Figure Distribution of disability in patients with vertigo of peripheral origin attending a level III healthcare institution in the city of Santiago de Cali.
259
institution in the city of Santiago de Cali. As described previously, HRQOL measurement varies among individuals because it is a dynamic construct containing continuous interactions between the patients and their environment, and includes physical, mental and social aspects. Consequently, it is appropriate to examine the interaction between the disease, the changes occurring in the life of the individual, the received and perceived social contributions and the stage of life at which the pathology takes place. The clinical features found in this study showed that the women evaluated ranged between 51-60 years of age, and the type of peripheral vestibular disorder that occurred more frequently was benign paroxysmal positional vertigo (BPPV). These results are consistent with studies by other authors and used as references in this study.1,3,9 Similarly, the HRQOL results obtained from the interpretation of the DHI health questionnaire, which estimates how the disability affects the quality of life, show that the category presenting severe disability with greater frequency was the physical (73.3%), followed by the functional aspect (50%) and, to a lesser extent, the emotional aspect (16.6%). These results show similarities with those reported in the study by Ceballos et al,1 where physical disability was the most frequent aspect, in 82%, followed by functional impairment (55%) and emotional disability (48%). Likewise, this study revealed that in the internal categories of the DHI health questionnaire, 97.7% of patients presented physical disability, 83.4% functional disability, and 60% emotional disability, coinciding with other reports.1,9 This suggests that patients evaluated using the DHI report a significant impact on all aspects and categories of the health questionnaire, and only a minority of the
Table 2 Results of the SF-12 quality of life questionnaire according to the type of peripheral vestibular disorder Domain
Type of peripheral vestibular disorder
Total (n=26)
BPPV (n=8)
Vestibular neuronitis (n=4)
Ménière (n=4)
Posttraumatic Others (n=5) (n=5)
Physical function Physical performance Physical pain General health Vitality Social function Emotional performance Mental health PCS-12 (physical component) MCS-12 (mental component)
35.2±11.8 22.9±3.9 38.7±16.7 36.9±10.7 51.1±11.0 35.3±14.1 15.4±5.0 39.1±13.5 36.5±8.6 34.0±10.1
36.4±10.5 23.3±4.6 42.7±15.3 35.8±9.8 56.6±11.7 34.1±14.9 16.9±5.5 42.1±14.6 37.4±8.8 36.4±11.6
28.5±8.2 20.3±.0 34.5±15.2 33.4±7.5 42.7±5.8* 36.3±8.2 15.5±5.3 31.0±7.8 32.1±4.6 30.8±6.0
30.7±12.1 22.6±4.6 31.9±19.5 39.8±12.6 45.2±5.0 28.8±15.1 11.3±6.0 31.0±3.5 35.5±7.1 26.9±2.8**
46.1±9.4 24.9±4.6 47.2±17.6 40.8±11.1 61.8±9.0* 38.3±18.0 19.1±4.9 48.6±17.5 43.0±9.8 40.0±12.1
32.8±13.5 22.6±3.4 34.5±17.8 35.8±13.5 45.2±7.1* 37.6±14.7 13.4±4.1 37.8±12.5 34.3±9.2 32.8±9.8
Values expressed as mean ± standard deviation. BPPV indicates benign paroxysmal positional vertigo; MCS-12 (mental component), emotional status; PCS-12 (physical component), functional status. 0 corresponds to the worst health status and 100 to the best health status. *Differences between types of peripheral vestibular disorder. **Differences between types of peripheral vestibular disorder and total.
260
V. Vélez León et al
Table 3 Results of the disability survey by type of peripheral vestibular disorder Domain
Type vestibular peripheral disorder
Total (n=26)
BPPV (n=8)
Vestibular neuronitis (n=4)
Ménière (n=4)
Posttraumatic (n=5)
Others (n=5)
Physical aspect
20.0±5.5
20.6±5.4
23.0±4.1
21.5±6.6
14.8±5.4
20.2±4.9
Functional aspect
24.0±9.6
23.5±8.5
29.5±5.5
27.0±8.8
15.2±11.5
26.0±9.6
Emotional aspect
16.9±9.7
16.7±8.1
20.0±11.1
19.5±11.8
11.8±9.7
17.5±11.1
Total DHI
60.9±8.2
60.8±7.3
72.5±7.0*
68±9.0
41.8±8.8**,*
63.7±8.5
Values expressed as mean ± standard deviation. BPPV indicates benign paroxysmal positional vertigo; DHI, “Dizziness Handicap Inventory”. Functional and emotional aspect. Without disabilities 0-14 points. Moderate disability 15-24 points. Severe disability 25 points onwards. Physical aspect. Without disabilities 0-9 points. Moderate disability 10-16 points. Severe disability 17 points onwards. *Differences between types of peripheral vestibular disorder. **Differences between types of peripheral vestibular disorder and total.
Table 4 Correlations between the domains in the SF-12 questionnaire and the type of disability according to the DHI in patients with peripheral vestibular disorder (n=26) Domains in SF-12
Type of disability according to DHI
Physical aspect
Functional aspect
Emotional aspect
Physical function Physical performance Physical pain General health Vitality Social function Emotional performance Mental health PCS-12 (physical component) MCS-12 (mental component)
–0.53* –0.63* –0.44** –0.15 –0.51* –0.35 –0.43** –0.54* –0.51* –0.46*
–0.66* –0.74* –0.61* –0.37** –0.49* –0.55* –0.54* –0.46* –0.78* –0.43**
–0.53* –0.67* –0.47* –0.35 –0.46** –0.54* –0.52* –0.52* –0.59* –0.51*
DHI indicates “Dizziness Handicap Inventory”. PCS Functional status (physical component). MCS Emotional status (mental component). *Correlation is significant at level 0.01 (bilateral). **Correlation is significant at level 0.05 level (bilateral).
participants indicated no disability. This finding indicates that patients with peripheral vestibular disorder in the study presented a limitation in performing daily activities and restriction in participation which affected their quality of life, in addition to a structural and/or functional deficiency, although in their own individual perception they did not refer suffering some kind of disability status. It is also noteworthy that the perception of disability by posttraumatic patients is strikingly low, given their behaviour in other series. This finding may be explained by the clinical characteristics defining posttraumatic patients not suffering from BPPV, who perceive their clinical condition as a highly disabling and chronic situation, one that is not life threatening but interferes significantly in their personal functioning.
This would imply that a more profound assessment should be considered in the case of women with posttraumatic vertigo in whom a psychiatric cause is suspected or in whom psychiatric symptoms are manifested. The results of the domains in the SF-12 questionnaire showed that emotional status presented a lower score, which translates into further deterioration of the quality of life, followed by the physical domain. The category that showed the highest scores, interpreted as better HRQOL, was vitality, with significant differences between the conditions: vestibular neuronitis, posttraumatic vertigo and other vertigos, P<.05. In general, patients with a diagnosis of posttraumatic vertigo presented the highest scores with respect to the other types of peripheral vestibular
Relationship between health-related quality of life and disability in women with peripheral vertigo
disorders in the SF-12 questionnaire, indicating that these patients perceive a better quality of life. However, the results found in this study should be regarded with caution when compared with other research, due to the presence of average values below 50 points, as these results do not match those found by other authors.1,4,9 Patients with posttraumatic vertigo generally reported lesser degrees of disability in the emotional aspect and they were the only ones to present moderate disability in the physical aspect. This contrasted with patients suffering from other types of vestibular disorders, who accused severe disability. When comparing studies that used these questionnaires in the measurement of results to assess HRQOL perception in the international literature with a population similar to ours, we found that the lowest scores were in the domains of emotional performance, physical performance, mental health and social functioning, which were much lower and not consistent with the results found in this study.1,4,9,12-17 Similarly, participants in this study showed further deterioration in their quality of life in the categories of PCS (physical component) and MCS (mental component) of the SF-12 health questionnaire.1,4,9 Finally, in the correlations between internal categories of both questionnaires used, we found that most of them presented a high level of significance (P<.01) and “r” values considered as acceptable. This shows that, besides the correlation obtained in the majority of the responses provided by participants, the variables of both questionnaires showed an inverse behaviour; that is, the greater the deterioration in the quality of life expressed by low scores, the greater the degree of disability expressed by high scores, and vice versa. This coincides with reports by other authors.1,3,5,9,20 Although some studies have shown that health status is significantly affected by the presence and severity of vertigo, there are insufficient data to estimate the disability and incapacity for work associated to patients with each type of vertigo.1,4 Limitations to this study, such as the characteristics of the specific population in terms of working design, resource constraints, sample size and sampling rate may introduce a number of biases and the results can only be extrapolated as a reference value to the target population, since the group of individuals intervened is not representative.
Financing The authors declare that the investigation did not receive any institutional and/or private financial resources for its completion.
Conflict of interests The authors of the study declare no conflict of interests.
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