INTRODUCTION

Dizziness is considered by many authors as one of the most common symptoms among adults, especially in the elderly 1-3.

Dizziness is the illusion of movement of the subject or the environment around him or her. This symptom can be caused by a dysfunction in any of the segments of the system related to body balance. When dizziness has a rotation character it is named vertigo. Damage to the vestibular system is the most common organic cause of vertigo 4, 5.

In addition to vertigo, other types of dizziness or instability, together with secondary autonomic symptoms, such as excessive sweating, nausea, and vomiting can result from vestibular system disorders 6.

The patient who has dizziness normally reports difficulty to concentrate, memory loss and fatigue. Physical uncertainty caused by dizziness and imbalance can lead to psychic insecurity, irritability, loss of self-confidence, anxiety, depression and panic 7.

Many patients with dizziness deliberately restrict their physical activities, trips and social gatherings in order to reduce the risk of having these unpleasant and scaring symptoms and to avoid social embarrassment and the stigma they may be associated with 8.

A series of details reported by patients based on their experience with dizziness can provide preliminary indications of the attitudes and beliefs they adopt when facing a vestibular disorder, which can limit the subject both physically and socially.

The somatic-psychological consequences of recurrent vertigo caused by vestibular disorders can included anxiety and panic episodes 9, fear of going out alone 10, interference in daily activities 11, and feelings of being away from reality and depersonalized 12.

The negative aspects described by the patient with dizziness, associated with the limitation and discomfort cause conflict and social embarrassment 11 and also fear of physical inability or severe disease 6.

People with normal psychiatric history can develop signs of anxiety, panic and agoraphobia after a vestibular episode 9, 10.

It may be difficult to differentiate the contribution of physical and psychological disorders to dizziness complaints owing to the considerable overlapping of vertigo, panic and anxiety symptoms 6.

It is evident that psychological symptoms are significant to maintain and value the limitation and stress caused by vertigo.

Vestibular system tests are not particularly sensitive or specific to demonstrate the psychological interference in the clinical picture and in suffering of the patients with dizziness 13.

According to Hallam et al. (1988)14, Hallam, Hinchcliffe (1991)15, there is rare synchronicity between malaise caused by vertigo and the results of tests that are part of the otoneurological assessment.

The otoneurological test is conducted to functionally check the vestibular system, allowing the exclusion of other vestibular disorders associated with the central nervous system, in addition to confirming the history reported by the patient. The physician essentially wants to know about ear conditions, hearing status, skills to respond to the balance test, presence or absence of nystagmus, and to make sure that the central nervous system (CNS) functioning is normal. However, sometimes, the diagnosis of patients that suffer from vertigo is made only based on the history reported by the patient 16.

The possibility of providing an instrument capable of defining a detailed profile of a patient with vertigo and to what extent quality of life is affected has med many researchers to think about questionnaires and to test them, trying to create assessment parameters for quality of life. In addition, defining the most affected aspects in these subjects can help the determination of the most appropriate therapy.

To assess quality of life in patients who have an abnormal routine owing to the presence of vestibular symptoms can contribute to defining the most appropriate management. Currently, the concern about the impact that the disease and intervention of the health care professionals has on quality of life of subjects is very high 17.

Since quality of life is a qualitative element, there have been innumerous attempts to try to measure it and many instruments were designed, translated and validated with this purpose in mind. The term quality of life (QoL) has been described at MEDLINE since 1977 and a database survey retrieved 1,000 QoL instruments, comprising over 11,000 citations in the past 20 years. The World Health Organization (WHO) has a group especially dedicated to this purpose - the World Health Organization - Quality of Life Group (WHOQoL).18

The concept of health currently includes many functional, spiritual, cognitive, emotional and social aspects. The WHO defines QoL as "the perception the subjects has of its status in life, within the context of his/her culture and the value system in which he/she is inserted and relative to his/her objectives, expectations, standards and concerns" 18.

There are two types of questionnaire that can be used to assess QoL: specific questionnaires designed to specific body parts, which are preferred by clinicians, and the generic ones, that assess general health of subjects 17.

In 1990, Jacobson and Newman19 designed and validated a questionnaire specific to dizziness - the Dizziness Handicap Inventory (DHI), in order to assess self-perception of the disabling effects of dizziness. The authors stated that DHI required little time to be applied and the results collected from it were easy to analyze and interpret, bringing useful information to planning and conduction of dizziness management.

Jacobson, Newman (1990)19 considered that the quantification of the medical, surgical and rehabilitation effects were too difficult to be analyzed. They stated that conventional tests for diagnosis are inappropriate to assess the disabling effects caused by vestibular system diseases.

To investigate QoL in a systematized fashion using a translated and adapted questionnaire to the language used in each country is extremely important. Cultural adaptation of the instrument is essential for its application with the given population of any country, which has its own language and habits 20.

DHI is a single translated questionnaire to be applied to the Brazilian population aiming at assessing the QoL deficit caused by dizziness in patients, named Brazilian version of DHI. Castro (2003)21; Ganança et al. (2003a)22 conducted the cultural adaptation of the questionnaire that comprised translation from English to Portuguese and linguistic adaptation, review of grammar and idiomatic equivalence, cultural adaptation and intra and inter-researcher reproducibility. The effects of treatment in vestibular system affections, be it medication, surgical or rehabilitation, can also be followed and measured using this QoL questionnaire.

Many studies showed the importance of assessing the QoL handicap in vertigo patients in order to quantify the effects caused by vertigo in the daily living functions of patients, in addition to helping in the selection of management options and their follow-up 6, 8, 17, 19, 23-29.

The purpose of the present study was to describe the results obtained in the application of the Brazilian version of DHI and to compare it to the conclusion of patients' vestibular exams.

METHOD

There were 25 consecutive patients that participated in the study and came to the Ambulatory of the Discipline of Otoneurology, Department of Otorhinolaryngology and Human Communication Disorders, Federal University of Sao Paulo - Escola Paulista de Medicina, complaining of chronic dizziness (for over three months) and diagnostic hypothesis of peripheral vestibular syndrome. The research study was approved by the ethics committee of UNIBAN.

The patients were male and female adults, ages ranging from 44 to 88 years. They all agreed to participate in the study by signing the informed consent.

This group of patients answered the Brazilian version of DHI 21, 22 culturally adapted to the Portuguese language used in Brazil.

The questionnaire assesses the interference of dizziness in quality of life of the patients and it comprises 25 questions (Figure 1). Questions 01, 04, 08, 11, 13, 17 and 25 assess physical aspect, questions 02, 09, 10, 15, 18, 20, 21, 22 and 23 assess emotional aspects and questions 03, 05, 06, 07, 12, 14, 16, 19 and 24 assess functional aspects.

The results obtained were compiled and the most affected aspects for each patient were collected, involving physical, emotional and functional aspects.

The answers given by patients were scored as follows: answers "yes" were scored four points, answers "no" were not scored (score zero) and answers "sometimes" were scored two points.

The total score, as well as specific scores of each aspect (physical, functional and emotional) were computed. Therefore, the main total score corresponded to one hundred points, a situation in which we detected maximum damage caused by dizziness, and the smallest score of zero point in which dizziness had no effect on the subject's life. Therefore, we assessed each aspect individually, since the higher the score, the worse the damage caused by dizziness.

The results obtained with the application of the Brazilian version of DHI were compared to the results of the vestibular test for each of the 25 studied patients. All patients had already been submitted to vestibular exam according to the procedures adopted by the Ambulatory of the Discipline of Otoneurology UNIFESP-EPM.

The vestibular exam was conducted by the Division of Vestibular Test using a vectonystagmographer brand BERGER, model VN 36, manufactured in Brazil, according to the criteria proposed by Mangabeira Albernaz et al. (1986)30, both in the sequence of the tasks and in the interpretation parameters.
The test consisted of the following stages: biological calibration of ocular movement, search for spontaneous nystagmus, semi-spontaneous nystagmus, pendulum test, optokinetic nystagmus, peri-rotation nystagmus and post-caloric nystagmus.

The possible results we found were normal, peripheral vestibular hypofunction syndrome (SVPD), peripheral vestibular hyperfunction syndrome (SVPI), central vestibular syndrome (SVC) or mixed vestibular syndrome (SVM). In the test, it is also possible to identify the affected side, right (R) or left (L) or both.

Statistical treatment used to assess the possible associations between peripheral hypofunction or hyperfunction syndrome and the total score results, as well as the score of physical, emotional and functional aspects, was conducted by Chi-square test (x2) for association tables, complying with the restriction of Cochnan and, if present, we used Fisher's exact test.

In this association, we defined the division of scores for median value, since using chi-square test or Fisher's exact test, which are non-parametric tests, it would not be valid to use arithmetic mean.
The rejection level for the null hypothesis was fixed at a level below 0.05 (5.00%).

When the calculated statistics presented significance, we used an asterisk (*) to characterize it. Otherwise, we considered it not significant.

RESULTS

The group consisted of 25 subjects that answered the Brazilian version of DHI who presented ages ranging from 44 to 88 years and mean age of 66.88 years. Nineteen subjects were female and six were male.

All patients presented impaired quality of life owing to dizziness in at least two aspects assessed by the Brazilian version. Total scores and scores for physical, emotional and functional aspects are described in Chart 2.

The results of the vestibular test of the patients are described in Chart 3. The vestibular test was affected in 19 out of 25 cases (76.0%), being that 2 subjects presented SVPI on the right, four had SVPI on the left, 1 had bilateral SVPI, 8 had SVPD on the right, 2 had SVPD on the left, and 2 had bilateral SVPD.

The affected results of the vestibular test in patients, regardless of the affected side and uni or bilateral vestibular impairment, were analyzed concerning the total score median and the scores of physical, emotional and functional aspects, collected from the application of Brazilian DHI.

There was no statistically significant difference concerning total score, physical and emotional scores comparing the patients with SVPD and SVPI. The score of functional aspects was higher among patients with SVPD (p= 0.0399*) (Table 1).

Patients with SVPD and SVPI with unilateral affection at the vestibular test were compared in relation to the total score and the score of physical, functional and emotional aspects collected from the application of the Brazilian version of DHI.

There was no statistically significant difference concerning total score and score of physical and emotional aspects comparing patients with SVPD and SVPI and unilateral affection at the vestibular test. The score of the functional aspect was higher among patients with SVPD and unilateral affection at the vestibular exam (p = 0.0262*) (Table 2).

Patients with SVPD and SVPI with bilateral affection in the vestibular test were compared concerning the total score and scores for physical, functional and emotional aspects obtained in the application of the Brazilian version of DHI.

There was no statistically significant difference concerning total score and the scores of physical, emotional and functional aspects obtained with the application of the Brazilian version of SVPD and SVPI and bilateral affection in the exam.

DISCUSSION

Conventional tests used for the diagnosis of vestibular system affections are not efficient to assess all the limiting and/or disabling effects caused by dizziness.

Therefore, it is important to have a tool to assess quality of life of the subjects who suffer from vertigo and/or other types of dizziness to support healthcare professionals involved in the treatment of patients.

DHI was developed in a specific cultural environment, the United States, which is economically, socially and culturally different from other countries, reason why the use of the tool with the Brazilian population required cultural adaptation. It does not suffice to simply translate it; it requires cultural adaptation and the application of the questionnaire so as to determine the same metric characteristics between the original version and the translated version.

The questionnaire was translated and adapted culturally to the Brazilian population and used with 25 patients who had chronic dizziness and diagnostic hypothesis of peripheral vestibular syndrome to assess to what extent dizziness affected the quality of life of subjects.

The age of studied patients ranged from 44 to 88 years. The mean age was 66.88 years, which is very high. It is known that dizziness is more prevalent in elderly subjects, who tend to have a body balance that is more affected than in younger people. The affections that are expected in aging of the body balance-related system, the higher likelihood of chronic-degenerative diseases and chronic and sometimes multiple use of drugs, among other factors, can favor the onset of dizziness or aggravate the intensity of the symptom, causing physical, functional and emotional limitations that are more marked in this age range. The prevalence of advanced age patients in the studied population may have influenced the higher scores when we applied the questionnaire. The patients were included randomly and were part of the population of patients that came to the Ambulatory of Otoneurology, Hospital Sao Paulo (UNIFESP/EPM).

Many of the patients in this study reported limitations in the social activities according to the Brazilian version of DHI. They showed impairment in the questions concerning functional aspects. The results were in accordance with those by Yardley, Putman (1992)8, which described that many patients with dizziness deliberately restrict their physical activities, trips and social gatherings in order to reduce the risk of having unpleasant symptoms.

Functional aspects checked by the Brazilian version of DHI investigated the interference of dizziness in some eye, head and body movement, but focusing on the capacity to perform professional, domestic, social and leisure activities and independence to perform some acts such as walking without help or walking at home in the dark.

Emotional aspects assessed by the questionnaire have also been affected by dizziness in our subjects, indicating affection of the mental structure of patients that presented vestibular system abnormalities. This fact is in accordance with Pratt, Mackenzie (1958)9; Leavy, O'Leary (1947)10; Nobbs (1988)11 and Grisby, Johnston (1989)12, who detected that patients with vestibular system affections many times have anxiety associated with panic episodes, fear of going out alone and feelings of depersonalization, highlighting the correlation between vestibular affections and emotional aspects.

Emotional aspects of the Brazilian version of DHI investigated the likelihood that dizziness had impaired quality of life in patients, which leads to frustration, fear of going out or staying home alone, embarrassment about clinical manifestations, concerns related to self-image, concentration disorder, feeling of inability, affections to the family or social relationship and depression.

The physical aspects that were analyzed in the Brazilian version of DHI, even though they were assessed using fewer questions (7) compared to the other aspects of the questionnaire, produced higher scores.

Fielder et al. (1996)17 also noticed that both for men and women the performance of physical functions were significantly affected by the effects of vertigo, when compared to the other aspects assessed by DHI. Jacobson, Calder (2000)25 confirmed that patients with unilateral SVPD and bilateral SVPD also presented higher scores (statistically significant difference) for physical aspects compared to the group of patients with normal ENG.

The physical aspects in the questionnaire assessed the correlation between onset and/or worsening of the symptom of dizziness and eye, head and body movement of the patients. The onset of dizziness in some specific positions or head movement is very common and can occur, for example, in patients with benign paroxysmal vertigo, which is the most common vestibulopathy. Other postural vertigo types can manifest with dizziness after body tilting. Visual stimuli (supermarket aisles, sidewalk obstacles, people walking) can cause or aggravate dizziness and they are also investigated by the Brazilian version of DHI.

The scores found were compared to the abnormal results of the vestibular exam in order to check the correlation between quality of life impairment caused by dizziness with possible results obtained during vestibulometry.

In this study, when the patients were analyzed considering the vestibular exam affection, we observed that there was statistically significant association between SVPD, regardless of the affected side and uni or bilateral vestibular impairment, and also unilateral SVPD with high scores in functional aspects of the tool.

The reduced number of patients with the diagnosis of bilateral dysfunction of vestibular function in the studied population was not enough to demonstrate any significant association with the results obtained in the application of the Brazilian version of DHI.

We can state, however, that the significant association between SVPD, regardless of the affected side and uni or bilateral vestibular impairment, and the high scores of functional aspects in the Brazilian version of DHI was a result of the prevalent number of cases with unilateral SVPD that presented this behavior.

Jacobson, Calder (2000)25 also detected worse quality of life in patients with unilateral SVPD, related, however, to total score of the assessed aspects in the DHI. They also found worse quality of life in patients with bilateral SVPD concerning total scores and scores of the physical aspects studied in the questionnaire.

SVPD are clinically correlated with vestibular affections in which there is total or partial reduction of vestibular function, normally presenting worse diagnosis concerning SVPI. Vestibular disorders such as vestibular Schwannoma, vestibular neuritis, infections and inner ear traumas, at the same time as destruction of the membranous labyrinth sensorineural epithelium and/or fibers of the vestibular nerves, are characteristically manifested as SVPD and can present marked clinical picture and/or progressive affection of dizziness. Therefore, it can be related to greater damage of quality of life, as observed in patients of this study.
Jacobson Calder (2000)25 detected correlation between higher posture instability presented in sensorial organization subtests in the platform of computer dynamic posture analysis with higher scores in the DHI. They also observed that in patients with spontaneous nystagmus they presented more damage owing to dizziness.

The Brazilian version of DHI can be applied in the Brazilian population as an instrument to allow assessment of the damage caused by dizziness on quality of life of patients with vestibular dysfunction and also as a follow-up method of the clinical evolution to assess therapeutic effects, be it by rehabilitation, drug or surgical treatment.

New studies should be conducted with the Brazilian version of DHI in bilateral vestibular disorder to check the possible correlation with self-perception of quality of life in these patients.

CONCLUSIONS

The patients with chronic dizziness and diagnostic hypothesis of peripheral vestibular syndrome present quality of life impairment concerning physical, functional and emotional aspects, assessed with the application of the Brazilian version of DHI. The patients with SVPD presented greater damage in functional aspects of quality of life assessed by the questionnaire compared to patients with SVPI.





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1 Affiliated Professor, Discipline of Otoneurology, UNIFESP/EPM. Professor of the Post-Graduation Program on Neuromotor Rehabilitation Sciences, UNIBAN.
2 Speech and hearing therapist, Master in Sciences, Post-Graduation Program on Neuromotor Rehabilitation Sciences, UNIBAN.
3 Speech and hearing therapist, Ph.D. studies under course, Course of Post-Graduation in Neurosciences and Behavior, Institute of Psychology - University of Sao Paulo. Professor, Course on Speech and Hearing Therapy, UNIBAN.
4 Affiliated Professor, Discipline of Rheumatology, UNIFESP/EPM.
Affiliation: Federal University of Sao Paulo / Escola Paulista de Medicina and Universidade Bandeirante de Sao Paulo.
Address correspondence to: Dr. Fernando Ganança - Avenida Iraí, 438 cj. 113 Moema Sao Paulo SP 04082-001
Tel/fax (55 11) 5044-6110/ 5532-1679