Concordance and discordance in patient and provider perceptions of dizziness Gary P. Jacobson Ph.D., Erin G. Piker Ph.D., Kenneth E. Watford DNP, Jill Gruenwald Au.D., George B. Wanna M.D., Alejandro Rivas M.D. PII: DOI: Reference:
S0196-0709(14)00111-2 doi: 10.1016/j.amjoto.2014.05.003 YAJOT 1392
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Revised date: Accepted date:
26 February 2014 1 May 2014 5 May 2014
Please cite this article as: Jacobson Gary P., Piker Erin G., Watford Kenneth E., Gruenwald Jill, Wanna George B., Rivas Alejandro, Concordance and discordance in patient and provider perceptions of dizziness, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.05.003
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Concordance and discordance in patient and provider perceptions of dizziness
Gary P. Jacobson, Ph.D., Vanderbilt University Medical Center, Nashville, TN
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Erin G. Piker, Ph.D., Duke University Medical Center, Durham, NC
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Kenneth E. Watford, DNP, Vanderbilt University Medical Center, Nashville, TN Jill Gruenwald, Au.D. , Vanderbilt University Medical Center, Nashville, TN
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George B. Wanna, M.D., Vanderbilt University Medical Center, Nashville, TN
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Alejandro Rivas, M.D., Vanderbilt University Medical Center, Nashville, TN
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Corresponding author: Gary P. Jacobson, Ph.D., Vanderbilt Bill Wilkerson Center, Medical Center East, South Tower, 1215 21st Avenue South, Suite 9302, Nashville, TN
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37232-8025. Phone: 615-322-4568, FAX: 615-936-1640, email:
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[email protected]
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ABSTRACT
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Purpose: The purpose of the present investigation was to determine whether there are
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significant differences in patient/healthcare provider perceptions of patient’s dizziness
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severity, dizziness disability/handicap, anxiety, and signs of autonomic system activation.
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Materials and Methods: This was a prospective investigation of 30 patient-provider
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dyads drawn as a sample of convenience from an otology clinic in a large, tertiary care, medical center. Patients completed both the Dizziness Handicap Inventory (DHI) and the Vestibular Symptom Scale (VSS) prior to vestibular function testing. Providers were
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instructed to complete the same measures following the patient’s clinic visit from what
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they estimated was the patient’s point of view. The two measures were analyzed for
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concordance and discordance.
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Results: Patient/provider differences in DHI and VSS vertigo subscale scores were not significantly different. However, difference scores on the VSS anxiety/autonomic subscale indicated that providers significantly under-estimated patient anxiety and symptoms of autonomic system activation.
Conclusions: The results suggest that providers may be missing information pertinent to the role anxiety and autonomic system activation may play in patient visits for complaints of dizziness. We suggest that this problem can be mitigated by administrating to patients prior to their clinic visit a standardized measure that quantifies patient self-report
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dizziness, vertigo, anxiety and autonomic system arousal. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders
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that are rooted in clinically significant anxiety either related to, or unrelated to, a history
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of vestibular system impairment.
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INTRODUCTION
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There is an increasing body of evidence in areas such as arthritis, pain, and
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cancer that suggests the patient’s health status, self-report symptom severity, disability,
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and handicap are not always concordant with those of the healthcare provider who must evaluate the patient and manage the condition (1-5). Discordant views between the
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patient and provider on the effect that disease has on a patient may negatively influence
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patient outcomes, while concordant views result in better patient outcomes (6). That is, ultimately, it is the view of the provider that is used to formulate the plan of treatment. To
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date, no studies have been conducted to assess patient-provider concordance and discordance in patients with dizziness and vertigo.
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Two psychometrically sound self-report questionnaires for use with dizzy,
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vertiginous, and unsteady patients are the Dizziness Handicap Inventory (DHI)(7) and Vertigo Symptom Scale (VSS)(8). The DHI is 25-item self-report questionnaire designed
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to evaluate self-perceived handicap in dizzy patients (7). The VSS is a 34-item questionnaire designed to quantify the severity of vertigo and the symptoms of anxiety and autonomic arousal in dizzy patients (8). The purpose of this investigation was to extend the use of the DHI and VSS, to measure the concordance/discordance between the patient’s self-report dizziness disability/handicap and dizziness severity, and, the health care provider’s estimate of the same.
METHODS
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Subjects were 30 consecutive patients evaluated at the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences who consented to participate in
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this study. The protocol was approved by the Institutional Review Board (IRB #101126) of the Vanderbilt University School of Medicine. Full informed consent was obtained
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from each patient.
Both the DHI and VSS were mailed to patients prior to their clinic visits. These
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were collected from the patients at the time of their balance function testing. Patients
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then were evaluated by their healthcare providers. At the conclusion of the appointment
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the healthcare provider completed their versions of the DHI and VSS.
Questionnaires
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The DHI is a 25-item self-report questionnaire that provides a method to quantify
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the impact that dizziness, unsteadiness and vertigo have on a patient’s normal daily activities and psychosocial function(7). It is significant to note that in order to extend its
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potential usefulness, the words “dizzy,” “vertigo,” or “unsteady” were not used in the questions. Instead the words, “your problem” were substituted (e.g. “Because of your problem is it difficult for you to concentrate?”). In this manner it was hoped the DHI could be used with all patients who were dizzy, vertiginous or unsteady. Items from the DHI were developed based on case-history reports of patients with dizziness. Each of the 25 questions is answered “yes,” “sometimes,” or “no.” A “yes” response is awarded 4 points, a “sometimes” response is awarded 2 points and a “no” response is awarded 0 points. The maximum score is 100 points representing severe self-report dizziness disability/handicap and the minimum score is zero points representing no self-report
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dizziness disability/ handicap. The DHI as originally conceived consisted of three subscales assessing the functional, emotional and physical effects of dizziness/vertigo on
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everyday life. Subsequent to the publication of the initial report other investigators showed that the subscale structure does not, in fact, exist (9,10). Accordingly, the DHI is
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best reported as a single total score. The DHI is shown in Appendix A. The VSS is a 34-item inventory designed to measure symptoms associated with
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dizziness (8). The VSS consists of 2 subscales. The vertigo severity subscale (VSSVER) consists of 19 items that target the physical symptoms associated with vertigo and
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dizziness (e.g. “unable to stand or walk properly without support”). The anxiety/autonomic symptom scale (VSS-AA) consists of 15 items that assess anxiety and
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somatic symptoms often reported by dizzy patients (e.g. “heart pounding or fluttering”).
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Items comprising the VSS were developed based on patient interviews (8). Patients are asked to respond to each symptom on a 5 point Likert scale about how often they
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experience each symptom. The scale is anchored on one end with “Never” (i.e. 0 points)
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and on the opposite end with “Very often” (i.e. 4 points). Thus, the absolute range of scores for the AA subscale is 0 - 60 points and the range for the VER subscale is 0 - 76 points. Alternatively, the VSS subscales can yield normalized scores, ranging from 0 - 4. High scores suggest over-reporting due to excessive attention to physical status, emotional distress, or general concern about health. The VSS is shown in Appendix B. For each of the patient versions of the DHI and VSS a healthcare provider version was created. For the DHI-p and VSS-p this was accomplished by replacing the word “you” or “your” with the words “my patient.” The healthcare provider versions of the DHI-p and VSS-p are shown in Appendices C and D.
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Statistical Analysis
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Basic demographic information was gathered for the patients including age and sex. Scores on the DHI and VSS for the patient and healthcare provider were collected
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and tabulated for analysis. Descriptive statistics were used to characterize the study population. Paired t-tests were used to determine whether there were statistically
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significant differences between patient and provider ratings. Pearson correlation
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coefficients were calculated to assess the degree of association between patient’s and
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provider’s reports.
RESULTS
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The study sample consisted of 30 patient-provider dyads (i.e. patient sample mean
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age 56.5 years, ± 16.3 years, 8 male). There were three providers who participated in this investigation (i.e. mean age 42.3 years, ± 4.8 years, all providers were male). The
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distribution of diagnoses for these patients is shown in Table 1. The most common diagnoses in this cohort were migrainous vertigo, Meniere’s Disease, benign paroxysmal positional vertigo (BPPV), and vestibular neuritis.
DHI The mean patient DHI total score was 43.80 points (± 21.9) and mean DHI-p total score was 48.27 points (± 22.2; see Figure 1A). Healthcare providers tended to slightly overestimate self-report dizziness disability handicap, but there was no significant difference between the two groups (t = -1.077, df = 29, p = .290). There was a significant
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moderate positive predictive relationship (r = .472, p = .008) between the total DHI
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scores volunteered by patients and estimated by their healthcare providers (see Figure 2).
VSS
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The mean VSS-VER subscale score (i.e. physical symptoms) for patients was
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23.23 points (± 15.9) and for providers was 24.73 points (± 16.83; see Figure 1B). There were no significant group differences (t = -.452, df = 29, p = .655). There was a
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significant moderate positive predictive relationship (r = .469, p = .016) between the VSS-VER scores volunteered by patients and estimated by their providers (see Figure 3).
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The mean VSS-AA subscale scores (i.e. anxiety and autonomic symptoms) for patients was 21.27 points (± 12.7) and the mean score on the healthcare provider version
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was 7.23 points (± 5.2) resulting in a significant difference in mean scores between
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groups (t = 7.174, df = 29, p < .001; see Figure 1C). Health care providers significantly rated the patients as having fewer anxiety and autonomic symptoms associated with their
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dizziness and/or vertigo, though patients reported just as many anxiety/autonomic symptoms as they did physical vertigo/dizziness symptoms. There was a significant moderate positive predictive relationship (r = .673, p < .001) between the VSS-AA scores volunteered by patients and their healthcare providers (see Figure 4).
DISCUSSION
The present investigation has shown that, whereas healthcare providers may be concordant with the patient in appreciating the physical manifestations of dizziness and
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vertigo they may have discordant perceptions of the impact of dizziness and vertigo on autonomic system arousal and anxiety. We suggest this has occurred because much of
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vertigo case history-taking is concentrated on eliciting from the patient a description of the characteristics of vertigo symptoms (e.g. duration, precipitating factors, associated
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symptoms). There is some overlap in the items comprising the VER subscale of the VSS and those comprising the “physical” and “functional” subscales of the DHI. Therefore it
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is possible that the provider recalled this information in the process of generating the
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report of their examination.
In contrast, it is likely that signs of anxiety or autonomic system activation could be missed entirely were the items not to be grouped together as a subscale. Recall that
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the items comprising the AA subscale of the VSS include items such as: “pains in the
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heart or chest region”, ” hot or cold spells”, “tension/soreness in your muscles”, “trembling shivering”, “heavy feeling in the arms or legs”, “headache or feeling of
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pressure in the head”, “difficulty breathing”, “short of breath”, “loss of concentration or
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memory”, “feeling faint, about to black out.” While a dizziness case history might include questions regarding whether the patient is short of breath, or has had migraine headaches, it is only by completing a scale like the VSS that it is possible to identify patterns of response suggestive of dizziness occurring as a physiological manifestation of a primary anxiety disorder (e.g. psychogenic chronic subjective dizziness)(11). In this regard, it has been estimated that 16% of dizziness encountered in a specialty clinic has a psychiatric cause (12). The completion by the patient of the VSS prior to the appointment visit is an efficient method of enabling the provider to have access to this information prior to the structured interview. In a similar manner, it would be valuable
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for the clinical neurophysiologist to have access to this information to generate hypotheses during the quantitative assessment as to the possible origins of the patient’s
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complaints.
It is noteworthy that similar findings have been reported across modalities. For
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example, in the area of pain management (i.e. patients suffering from rheumatoid arthritis, osteoarthritis, and fibromyalgia) and cancer, investigators have reported that
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patients and providers often differ on the assessment of the patient’s mental function,
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quality of life, anxiety, and depression (1,3,5,13-15). The magnitude of disagreement has varied with some providers rating the patient as more disabled, and others as less
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disabled, than the patient’s own self-ratings (3). Additionally, providers have been shown to underestimate symptoms of pain in cancer and in post-surgery where providers
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have been shown to underestimate patient pain (16-18). Pain is a symptom that is difficult
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for clinicians to quantify during a physical exam and is most accurately measured by directly asking the patient to perform a subjective rating (e.g. by using a 1-10 scale).
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Similarly, patient anxiety and autonomic symptoms, that occur often in dizzy patients (19), may be overlooked or under-appreciated by healthcare providers since anxiety may not be easily observed during the physical examination. Another possible reason for the discordant views between patients and providers is that the two may focus on different characteristics of health. For example, patients with multiple sclerosis and their providers significantly differ in their opinions regarding what areas of health are most important. That is, healthcare providers rate physical function as the highest priority and patients have been shown to rate mental and emotional health as most important (20). Thus it was shown that patients evaluate the
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personal impact of a disease while providers focus on the resolution of physical symptoms. Yet, we know that the resolution of symptoms does not mean necessarily that
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the patient has been “cured” (21).
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LIMITATIONS
The study was conducted with a relatively small sample of patient/healthcare
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provider dyads. However, the results of this investigation showed highly significant
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discordance between patients and their healthcare providers on detection of symptoms associated with anxiety and autonomic system arousal. This suggests that the same
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discordance may occur for provider and patient samples located elsewhere. Another limitation is inherent to all studies that aim to measure patient and
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provider concordance. There is no standard definition and no standard method to
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measure discordance, but product-moment correlations have traditionally been used and, accordingly, were used in the current investigation. Correlation values measure the
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strength of a linear association between two variables; however correlations can be misleading if there is systematic bias and they do not offer information for individual patients. In the current investigation, patients consistently scored higher than their providers on the AA subscale of the VSS. There was a systematic patient-provider difference of ~15-20 points (with some individual dyads showing a difference as great as 40 points), but the correlation was still moderately high and statistically significant.
CONCLUSION
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This investigation has illustrated that there can exist both concordance and discordance between the patient and healthcare provider in estimations of the patient’s
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dizziness perceptions. We have reported that patients and providers were congruent in perceptions of dizziness symptoms (i.e. VER subscale of the VSS) and the psychosocial
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impact of dizziness on the patient (i.e. DHI total score). However, in the current sample, we have observed that providers underestimated the magnitude of patient symptoms that
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commonly are manifested by patients who have either, or both, anxiety disorders and
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autonomic system arousal (i.e. AA subscale of the VSS). Awareness of these symptoms can be facilitated by asking patients to complete standardized scales such as the VSS
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prior to their visit with their healthcare provider. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders that are
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rooted in clinically significant anxiety either related to, or unrelated to, a history of
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vestibular system impairment.
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Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Archives of otolaryngology--head & neck surgery 1990;116:424-7.
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between Dizziness Handicap Inventory and Dizziness Characteristics and Impact on Quality of Life scales. Acta oto-laryngologica. Supplementum 2001;545:145-
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Hidding A, van Santen M, De Klerk Eet al. Comparison between self-report measures and clinical observations of functional disability in ankylosing spondylitis, rheumatoid arthritis and fibromyalgia. The Journal of rheumatology 1994;21:818-23.
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Suarez-Almazor ME, Conner-Spady B. Rating of arthritis health states by patients, physicians, and the general public. Implications for cost-utility analyses. The Journal of rheumatology 2001;28:648-56.
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Brunelli C, Costantini M, Di Giulio Pet al. Quality-of-life evaluation: when do terminal cancer patients and health-care providers agree? Journal of pain and
Peteet J, Tay V, Cohen Get al. Pain characteristics and treatment in an outpatient
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cancer population. Cancer 1986;57:1259-65. 18.
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symptom management 1998;15:151-8.
Drayer RA, Henderson J, Reidenberg M. Barriers to better pain control in
Piker EG, Jacobson GP, McCaslin DLet al. Psychological comorbidities and their
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hospitalized patients. Journal of pain and symptom management 1999;17:434-40.
relationship to self-reported handicap in samples of dizzy patients. Journal of the
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American Academy of Audiology 2008;19:337-47. Rothwell PM, McDowell Z, Wong CKet al. Doctors and patients don't agree:
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cross sectional study of patients' and doctors' perceptions and assessments of
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disability in multiple sclerosis. BMJ 1997;314:1580-3.
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FIGURE LEGENDS
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Figure 1: Patient and healthcare provider discordance for A) the DHI total score, B) VER subscale of the VSS, and C) AA subscale of the VSS. Standard deviation bars are shown.
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There was little observed discordance for the DHI scores and VSS-VER subscale scores, but there was significant difference between patient and healthcare provider scores on the
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VSS-AA subscale scores.
Figure 2: Scatterplot of individual patient/healthcare provider dyad scores for the DHI
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total score. Linear regression line best fit to the data is shown (r2 = 0.22).
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Figure 3: Scatterplot of individual patient/healthcare provider dyad scores for the VER
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subscale of the VSS. Linear regression line best fit to the data is shown (r2 = 0.22).
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Figure 4: Scatterplot of individual patient/healthcare provider dyad scores for the AA subscale of the VSS. Linear regression line best fit to the data is shown (r2 = 0.45).
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APPENDIX A Dizziness Handicap Inventory (Jacobson & Newman, 1990)
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Yes (4) P1. Does looking up increase your problem? E2. Because of your problem do you feel frustrated? F3. Because of your problem do you restrict your travel for business or recreation? P4. Does walking down the aisle of a supermarket increase your problem? F5. Because of your problem do you have difficulty getting into or out of bed? F6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing, or to parties? F7. Because of your problem do you have difficulty reading? P8. Does performing more ambitious activities like sports, dancing, and household chores, such as sweeping or putting dishes away, increase your problem? E9. Because of your problem are you afraid to leave your home without having someone accompany you? E10. Because of your problem have you been embarrassed in front of others? P11. Do quick movements of your head increase your problem? F12. Because of your problem do you avoid heights? P13. Does turning over in bed increase your problem? F14. Because of your problem is it difficult for you to do strenuous housework or yardwork? E15. Because of your problem are you afraid people may think that you are intoxicated? P16. Because of your problem is it difficult for you to go for a walk by yourself? P17. Does walking down a sidewalk increase your problem? E18. Because of your problem is it difficult for you to concentrate? F19. Because of your problem is it difficult for you to walk around your house in the dark? E20. Because of your problem are you afraid to stay home alone? E21. Because of your problem do you feel handicapped? E22. Has your problem placed stress on your relationships with members of your family and friends? E23. Because of your problem are you depressed? F24. Does your problem interfere with your job or household responsibilities? P25. Does bending over increase your problem?
Sometimes (2)
No (0)
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APPENDIX B
1 A few times
2 Several times
3 Quite often
4 Very often
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
2. Pains in the heart or chest region 0 3. Hot or cold spells 0 4. Unsteadiness so severe that you actually fall 0 5. Nausea (feeling sick), stomach churning 0 6. Tension/soreness in your muscles 0 7. A feeling of being light-headed, "swimmy", or giddy lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
8. Trembling, shivering 9. Feeling of pressure in the ear(s) 10. Heart pounding or fluttering 11. Vomiting 12. Heavy feeling in arms or legs 13. Visual disturbances (e.g. blurring, flickering, spots)
0 0 0 0 0 0
1 1 1 1 1 1
2 2 2 2 2 2
3 3 3 3 3 3
4 4 4 4 4 4
0 Never
1 A few
2 Several
3 Quite
4 Very
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Vertigo Symptom Scale (Yardley, Masson, et al., 1992)
Never
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How often in the past 12 months have you had the following symptoms:
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1. A feeling that things are spinning or moving around, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
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often
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
0 0 0 0 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
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often
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19. Tingling, prickling or numbness in parts of the body 20. Pains in the lower part of your back 21. Excessive sweating 22. Feeling faint, about to black out
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0 0 0 0
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14. Headache or feeling of pressure in the head 15. Unable to stand or walk properly without support 16. Difficulty breathing, short of breath 17. Loss of concentration or memory 18. Feeling unsteady, about to lose balance, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes b. Up to 20 minutes c. 20 minutes to 1 hour d. Several hours e. More than 12 hours
times
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APPENDIX C
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Dizziness Handicap Inventory – Physician (adapted from Jacobson & Newman, 1990)
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P1. Does looking up increase your patient’s problem? E2. Because of your patient’s problem, does he/she feel frustrated? F3. Because of your patient’s problem, does he/she restrict travel for business or recreation? P4. Does walking down the aisle of a supermarket increase your patient’s problem? F5. Because of your patient’s problem, does he/she have difficulty getting into or out of bed? F6. Does your patient’s problem significantly restrict his/her participation in social activities, such as going out to dinner, going to the movies, dancing, or to parties? F7. Because of your patient’s problem does he/she have difficulty reading? P8. Does performing more ambitious activities like sports, dancing, household chores, such as sweeping or putting dishes away, increase your patient’s problem? E9. Because of your patient’s problem is he/she afraid to leave home without having someone accompany him/her? E10. Because of your patient’s problem has he/she been embarrassed in front of others? P11. Do quick movements of your patient’s head increase his/her problem? F12. Because of your patient’s problem does he/she avoid heights? P13. Does turning over in bed increase your patient’s problem? F14. Because of your patient’s problem is it difficult for him/her to do strenuous housework or yardwork? E15. Because of your patient’s problem is he/she afraid people may think that he/she is intoxicated? P16. Because of your patient’s problem is it difficult for him/her to go for a walk by himself/herself? P17. Does walking down a sidewalk increase your patient’s problem? E18. Because of your patient’s problem is it difficult for him/her to concentrate? F19. Because of your patient’s problem is it difficult for him/her to walk around the house in the dark? E20. Because of your patient’s problem is he/she afraid to stay home alone? E21. Because of your patient’s problem does he/she feel handicapped? E22. Has your patient’s problem placed stress on his/her relationships with members of his/her family and friends? E23. Because of your patient’s problem is he/she depressed? F24. Does your patient’s problem interfere with his/her job or household responsibilities? P25. Does bending over increase your patient’s problem?
Yes (4)
Sometimes (2)
No (0)
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APPENDIX D
1 A few times
2 Several times
3 Quite often
4 Very often
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
2. Pains in the heart or chest region 0 3. Hot or cold spells 0 4. Unsteadiness so severe that you actually fall 0 5. Nausea (feeling sick), stomach churning 0 6. Tension/soreness in your muscles 0 7. A feeling of being light-headed, "swimmy", or giddy lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
1 1 1 1 1
2 2 2 2 2
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2 2 2 2 2
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8. Trembling, shivering 9. Feeling of pressure in the ear(s) 10. Heart pounding or fluttering 11. Vomiting 12. Heavy feeling in arms or legs 13. Visual disturbances (e.g. blurring, flickering, spots)
1 1 1 1 1 1
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3 3 3 3 3 3
4 4 4 4 4 4
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1. A feeling that things are spinning or moving around, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
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14. Headache or feeling of pressure in the head 15. Unable to stand or walk properly without support 16. Difficulty breathing, short of breath 17. Loss of concentration or memory 18. Feeling unsteady, about to lose balance, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes b. Up to 20 minutes c. 20 minutes to 1 hour d. Several hours e. More than 12 hours
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Table 1. The distribution of diagnoses in the study sample. Diagnoses Number Percent of total Migrainous vertigo 9 30 Meniere's Disease 4 13 Benign Paroxysmal Positional Vertigo 4 13 Vestibular neuritis 4 13 Chronic Subjective Dizziness 1 3 Post-concussion dizziness 1 3 Orthostatic hypotension 1 3 Multisensory system impairment 1 3 Normal vestibular function tests 5 17 Total 30 100
S0196-0709(14)00111-2 doi: 10.1016/j.amjoto.2014.05.003 YAJOT 1392
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Revised date: Accepted date:
26 February 2014 1 May 2014 5 May 2014
Please cite this article as: Jacobson Gary P., Piker Erin G., Watford Kenneth E., Gruenwald Jill, Wanna George B., Rivas Alejandro, Concordance and discordance in patient and provider perceptions of dizziness, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.05.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Concordance and discordance in patient and provider perceptions of dizziness
Gary P. Jacobson, Ph.D., Vanderbilt University Medical Center, Nashville, TN
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Erin G. Piker, Ph.D., Duke University Medical Center, Durham, NC
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Kenneth E. Watford, DNP, Vanderbilt University Medical Center, Nashville, TN Jill Gruenwald, Au.D. , Vanderbilt University Medical Center, Nashville, TN
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George B. Wanna, M.D., Vanderbilt University Medical Center, Nashville, TN
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Alejandro Rivas, M.D., Vanderbilt University Medical Center, Nashville, TN
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Corresponding author: Gary P. Jacobson, Ph.D., Vanderbilt Bill Wilkerson Center, Medical Center East, South Tower, 1215 21st Avenue South, Suite 9302, Nashville, TN
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37232-8025. Phone: 615-322-4568, FAX: 615-936-1640, email:
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[email protected]
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ABSTRACT
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Purpose: The purpose of the present investigation was to determine whether there are
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significant differences in patient/healthcare provider perceptions of patient’s dizziness
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severity, dizziness disability/handicap, anxiety, and signs of autonomic system activation.
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Materials and Methods: This was a prospective investigation of 30 patient-provider
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dyads drawn as a sample of convenience from an otology clinic in a large, tertiary care, medical center. Patients completed both the Dizziness Handicap Inventory (DHI) and the Vestibular Symptom Scale (VSS) prior to vestibular function testing. Providers were
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instructed to complete the same measures following the patient’s clinic visit from what
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they estimated was the patient’s point of view. The two measures were analyzed for
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concordance and discordance.
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Results: Patient/provider differences in DHI and VSS vertigo subscale scores were not significantly different. However, difference scores on the VSS anxiety/autonomic subscale indicated that providers significantly under-estimated patient anxiety and symptoms of autonomic system activation.
Conclusions: The results suggest that providers may be missing information pertinent to the role anxiety and autonomic system activation may play in patient visits for complaints of dizziness. We suggest that this problem can be mitigated by administrating to patients prior to their clinic visit a standardized measure that quantifies patient self-report
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dizziness, vertigo, anxiety and autonomic system arousal. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders
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that are rooted in clinically significant anxiety either related to, or unrelated to, a history
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of vestibular system impairment.
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INTRODUCTION
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There is an increasing body of evidence in areas such as arthritis, pain, and
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cancer that suggests the patient’s health status, self-report symptom severity, disability,
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and handicap are not always concordant with those of the healthcare provider who must evaluate the patient and manage the condition (1-5). Discordant views between the
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patient and provider on the effect that disease has on a patient may negatively influence
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patient outcomes, while concordant views result in better patient outcomes (6). That is, ultimately, it is the view of the provider that is used to formulate the plan of treatment. To
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date, no studies have been conducted to assess patient-provider concordance and discordance in patients with dizziness and vertigo.
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Two psychometrically sound self-report questionnaires for use with dizzy,
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vertiginous, and unsteady patients are the Dizziness Handicap Inventory (DHI)(7) and Vertigo Symptom Scale (VSS)(8). The DHI is 25-item self-report questionnaire designed
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to evaluate self-perceived handicap in dizzy patients (7). The VSS is a 34-item questionnaire designed to quantify the severity of vertigo and the symptoms of anxiety and autonomic arousal in dizzy patients (8). The purpose of this investigation was to extend the use of the DHI and VSS, to measure the concordance/discordance between the patient’s self-report dizziness disability/handicap and dizziness severity, and, the health care provider’s estimate of the same.
METHODS
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Subjects were 30 consecutive patients evaluated at the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences who consented to participate in
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this study. The protocol was approved by the Institutional Review Board (IRB #101126) of the Vanderbilt University School of Medicine. Full informed consent was obtained
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from each patient.
Both the DHI and VSS were mailed to patients prior to their clinic visits. These
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were collected from the patients at the time of their balance function testing. Patients
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then were evaluated by their healthcare providers. At the conclusion of the appointment
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the healthcare provider completed their versions of the DHI and VSS.
Questionnaires
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The DHI is a 25-item self-report questionnaire that provides a method to quantify
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the impact that dizziness, unsteadiness and vertigo have on a patient’s normal daily activities and psychosocial function(7). It is significant to note that in order to extend its
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potential usefulness, the words “dizzy,” “vertigo,” or “unsteady” were not used in the questions. Instead the words, “your problem” were substituted (e.g. “Because of your problem is it difficult for you to concentrate?”). In this manner it was hoped the DHI could be used with all patients who were dizzy, vertiginous or unsteady. Items from the DHI were developed based on case-history reports of patients with dizziness. Each of the 25 questions is answered “yes,” “sometimes,” or “no.” A “yes” response is awarded 4 points, a “sometimes” response is awarded 2 points and a “no” response is awarded 0 points. The maximum score is 100 points representing severe self-report dizziness disability/handicap and the minimum score is zero points representing no self-report
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dizziness disability/ handicap. The DHI as originally conceived consisted of three subscales assessing the functional, emotional and physical effects of dizziness/vertigo on
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everyday life. Subsequent to the publication of the initial report other investigators showed that the subscale structure does not, in fact, exist (9,10). Accordingly, the DHI is
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best reported as a single total score. The DHI is shown in Appendix A. The VSS is a 34-item inventory designed to measure symptoms associated with
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dizziness (8). The VSS consists of 2 subscales. The vertigo severity subscale (VSSVER) consists of 19 items that target the physical symptoms associated with vertigo and
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dizziness (e.g. “unable to stand or walk properly without support”). The anxiety/autonomic symptom scale (VSS-AA) consists of 15 items that assess anxiety and
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somatic symptoms often reported by dizzy patients (e.g. “heart pounding or fluttering”).
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Items comprising the VSS were developed based on patient interviews (8). Patients are asked to respond to each symptom on a 5 point Likert scale about how often they
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experience each symptom. The scale is anchored on one end with “Never” (i.e. 0 points)
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and on the opposite end with “Very often” (i.e. 4 points). Thus, the absolute range of scores for the AA subscale is 0 - 60 points and the range for the VER subscale is 0 - 76 points. Alternatively, the VSS subscales can yield normalized scores, ranging from 0 - 4. High scores suggest over-reporting due to excessive attention to physical status, emotional distress, or general concern about health. The VSS is shown in Appendix B. For each of the patient versions of the DHI and VSS a healthcare provider version was created. For the DHI-p and VSS-p this was accomplished by replacing the word “you” or “your” with the words “my patient.” The healthcare provider versions of the DHI-p and VSS-p are shown in Appendices C and D.
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Statistical Analysis
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Basic demographic information was gathered for the patients including age and sex. Scores on the DHI and VSS for the patient and healthcare provider were collected
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and tabulated for analysis. Descriptive statistics were used to characterize the study population. Paired t-tests were used to determine whether there were statistically
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significant differences between patient and provider ratings. Pearson correlation
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provider’s reports.
RESULTS
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The study sample consisted of 30 patient-provider dyads (i.e. patient sample mean
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age 56.5 years, ± 16.3 years, 8 male). There were three providers who participated in this investigation (i.e. mean age 42.3 years, ± 4.8 years, all providers were male). The
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distribution of diagnoses for these patients is shown in Table 1. The most common diagnoses in this cohort were migrainous vertigo, Meniere’s Disease, benign paroxysmal positional vertigo (BPPV), and vestibular neuritis.
DHI The mean patient DHI total score was 43.80 points (± 21.9) and mean DHI-p total score was 48.27 points (± 22.2; see Figure 1A). Healthcare providers tended to slightly overestimate self-report dizziness disability handicap, but there was no significant difference between the two groups (t = -1.077, df = 29, p = .290). There was a significant
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moderate positive predictive relationship (r = .472, p = .008) between the total DHI
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scores volunteered by patients and estimated by their healthcare providers (see Figure 2).
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The mean VSS-VER subscale score (i.e. physical symptoms) for patients was
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23.23 points (± 15.9) and for providers was 24.73 points (± 16.83; see Figure 1B). There were no significant group differences (t = -.452, df = 29, p = .655). There was a
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significant moderate positive predictive relationship (r = .469, p = .016) between the VSS-VER scores volunteered by patients and estimated by their providers (see Figure 3).
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The mean VSS-AA subscale scores (i.e. anxiety and autonomic symptoms) for patients was 21.27 points (± 12.7) and the mean score on the healthcare provider version
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was 7.23 points (± 5.2) resulting in a significant difference in mean scores between
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groups (t = 7.174, df = 29, p < .001; see Figure 1C). Health care providers significantly rated the patients as having fewer anxiety and autonomic symptoms associated with their
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dizziness and/or vertigo, though patients reported just as many anxiety/autonomic symptoms as they did physical vertigo/dizziness symptoms. There was a significant moderate positive predictive relationship (r = .673, p < .001) between the VSS-AA scores volunteered by patients and their healthcare providers (see Figure 4).
DISCUSSION
The present investigation has shown that, whereas healthcare providers may be concordant with the patient in appreciating the physical manifestations of dizziness and
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vertigo they may have discordant perceptions of the impact of dizziness and vertigo on autonomic system arousal and anxiety. We suggest this has occurred because much of
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vertigo case history-taking is concentrated on eliciting from the patient a description of the characteristics of vertigo symptoms (e.g. duration, precipitating factors, associated
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symptoms). There is some overlap in the items comprising the VER subscale of the VSS and those comprising the “physical” and “functional” subscales of the DHI. Therefore it
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is possible that the provider recalled this information in the process of generating the
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report of their examination.
In contrast, it is likely that signs of anxiety or autonomic system activation could be missed entirely were the items not to be grouped together as a subscale. Recall that
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the items comprising the AA subscale of the VSS include items such as: “pains in the
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heart or chest region”, ” hot or cold spells”, “tension/soreness in your muscles”, “trembling shivering”, “heavy feeling in the arms or legs”, “headache or feeling of
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pressure in the head”, “difficulty breathing”, “short of breath”, “loss of concentration or
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memory”, “feeling faint, about to black out.” While a dizziness case history might include questions regarding whether the patient is short of breath, or has had migraine headaches, it is only by completing a scale like the VSS that it is possible to identify patterns of response suggestive of dizziness occurring as a physiological manifestation of a primary anxiety disorder (e.g. psychogenic chronic subjective dizziness)(11). In this regard, it has been estimated that 16% of dizziness encountered in a specialty clinic has a psychiatric cause (12). The completion by the patient of the VSS prior to the appointment visit is an efficient method of enabling the provider to have access to this information prior to the structured interview. In a similar manner, it would be valuable
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for the clinical neurophysiologist to have access to this information to generate hypotheses during the quantitative assessment as to the possible origins of the patient’s
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complaints.
It is noteworthy that similar findings have been reported across modalities. For
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example, in the area of pain management (i.e. patients suffering from rheumatoid arthritis, osteoarthritis, and fibromyalgia) and cancer, investigators have reported that
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patients and providers often differ on the assessment of the patient’s mental function,
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quality of life, anxiety, and depression (1,3,5,13-15). The magnitude of disagreement has varied with some providers rating the patient as more disabled, and others as less
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disabled, than the patient’s own self-ratings (3). Additionally, providers have been shown to underestimate symptoms of pain in cancer and in post-surgery where providers
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have been shown to underestimate patient pain (16-18). Pain is a symptom that is difficult
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for clinicians to quantify during a physical exam and is most accurately measured by directly asking the patient to perform a subjective rating (e.g. by using a 1-10 scale).
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Similarly, patient anxiety and autonomic symptoms, that occur often in dizzy patients (19), may be overlooked or under-appreciated by healthcare providers since anxiety may not be easily observed during the physical examination. Another possible reason for the discordant views between patients and providers is that the two may focus on different characteristics of health. For example, patients with multiple sclerosis and their providers significantly differ in their opinions regarding what areas of health are most important. That is, healthcare providers rate physical function as the highest priority and patients have been shown to rate mental and emotional health as most important (20). Thus it was shown that patients evaluate the
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personal impact of a disease while providers focus on the resolution of physical symptoms. Yet, we know that the resolution of symptoms does not mean necessarily that
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the patient has been “cured” (21).
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LIMITATIONS
The study was conducted with a relatively small sample of patient/healthcare
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provider dyads. However, the results of this investigation showed highly significant
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discordance between patients and their healthcare providers on detection of symptoms associated with anxiety and autonomic system arousal. This suggests that the same
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discordance may occur for provider and patient samples located elsewhere. Another limitation is inherent to all studies that aim to measure patient and
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provider concordance. There is no standard definition and no standard method to
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measure discordance, but product-moment correlations have traditionally been used and, accordingly, were used in the current investigation. Correlation values measure the
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strength of a linear association between two variables; however correlations can be misleading if there is systematic bias and they do not offer information for individual patients. In the current investigation, patients consistently scored higher than their providers on the AA subscale of the VSS. There was a systematic patient-provider difference of ~15-20 points (with some individual dyads showing a difference as great as 40 points), but the correlation was still moderately high and statistically significant.
CONCLUSION
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This investigation has illustrated that there can exist both concordance and discordance between the patient and healthcare provider in estimations of the patient’s
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dizziness perceptions. We have reported that patients and providers were congruent in perceptions of dizziness symptoms (i.e. VER subscale of the VSS) and the psychosocial
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impact of dizziness on the patient (i.e. DHI total score). However, in the current sample, we have observed that providers underestimated the magnitude of patient symptoms that
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commonly are manifested by patients who have either, or both, anxiety disorders and
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autonomic system arousal (i.e. AA subscale of the VSS). Awareness of these symptoms can be facilitated by asking patients to complete standardized scales such as the VSS
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prior to their visit with their healthcare provider. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders that are
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rooted in clinically significant anxiety either related to, or unrelated to, a history of
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vestibular system impairment.
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and patient assessment of physical and mental health status. The Journal of rheumatology 1992;19:1031-7.
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Berkanovic E, Hurwicz ML, Lachenbruch PA. Concordant and discrepant views
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of patients' physical functioning. Arthritis care and research : the official journal of the Arthritis Health Professions Association 1995;8:94-101. Barton JL, Imboden J, Graf Jet al. Patient-physician discordance in assessments of
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patients, partners and treating physicians. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 2000;9:1041-52. 6.
Neville C, Clarke AE, Joseph Let al. Learning from discordance in patient and physician global assessments of systemic lupus erythematosus disease activity. The Journal of rheumatology 2000;27:675-9.
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Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Archives of otolaryngology--head & neck surgery 1990;116:424-7.
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Yardley L, Masson E, Verschuur Cet al. Symptoms, anxiety and handicap in dizzy patients: development of the vertigo symptom scale. Journal of
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psychosomatic research 1992;36:731-41.
Asmundson GJ, Stein MB, Ireland D. A factor analytic study of the dizziness
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handicap inventory: does it assess phobic avoidance in vestibular referrals? Journal of vestibular research : equilibrium & orientation 1999;9:63-8. Perez N, Garmendia I, Garcia-Granero Met al. Factor analysis and correlation
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between Dizziness Handicap Inventory and Dizziness Characteristics and Impact on Quality of Life scales. Acta oto-laryngologica. Supplementum 2001;545:145-
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Staab JP. Chronic subjective dizziness. Continuum (Minneap Minn)
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2012;18:1118-41.
Kroenke K, Hoffman RM, Einstadter D. How common are various causes of
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dizziness? A critical review. Southern medical journal 2000;93:160-7; quiz 8. Slevin ML, Plant H, Lynch Det al. Who should measure quality of life, the doctor
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or the patient? British journal of cancer 1988;57:109-12. 14.
Hidding A, van Santen M, De Klerk Eet al. Comparison between self-report measures and clinical observations of functional disability in ankylosing spondylitis, rheumatoid arthritis and fibromyalgia. The Journal of rheumatology 1994;21:818-23.
15.
Suarez-Almazor ME, Conner-Spady B. Rating of arthritis health states by patients, physicians, and the general public. Implications for cost-utility analyses. The Journal of rheumatology 2001;28:648-56.
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Brunelli C, Costantini M, Di Giulio Pet al. Quality-of-life evaluation: when do terminal cancer patients and health-care providers agree? Journal of pain and
Peteet J, Tay V, Cohen Get al. Pain characteristics and treatment in an outpatient
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cancer population. Cancer 1986;57:1259-65. 18.
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symptom management 1998;15:151-8.
Drayer RA, Henderson J, Reidenberg M. Barriers to better pain control in
Piker EG, Jacobson GP, McCaslin DLet al. Psychological comorbidities and their
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hospitalized patients. Journal of pain and symptom management 1999;17:434-40.
relationship to self-reported handicap in samples of dizzy patients. Journal of the
20.
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American Academy of Audiology 2008;19:337-47. Rothwell PM, McDowell Z, Wong CKet al. Doctors and patients don't agree:
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cross sectional study of patients' and doctors' perceptions and assessments of
Beaton DE, Tarasuk V, Katz JNet al. "Are you better?" A qualitative study of the meaning of recovery. Arthritis and rheumatism 2001;45:270-9.
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21.
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disability in multiple sclerosis. BMJ 1997;314:1580-3.
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FIGURE LEGENDS
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Figure 1: Patient and healthcare provider discordance for A) the DHI total score, B) VER subscale of the VSS, and C) AA subscale of the VSS. Standard deviation bars are shown.
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There was little observed discordance for the DHI scores and VSS-VER subscale scores, but there was significant difference between patient and healthcare provider scores on the
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VSS-AA subscale scores.
Figure 2: Scatterplot of individual patient/healthcare provider dyad scores for the DHI
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total score. Linear regression line best fit to the data is shown (r2 = 0.22).
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Figure 3: Scatterplot of individual patient/healthcare provider dyad scores for the VER
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subscale of the VSS. Linear regression line best fit to the data is shown (r2 = 0.22).
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Figure 4: Scatterplot of individual patient/healthcare provider dyad scores for the AA subscale of the VSS. Linear regression line best fit to the data is shown (r2 = 0.45).
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APPENDIX A Dizziness Handicap Inventory (Jacobson & Newman, 1990)
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Yes (4) P1. Does looking up increase your problem? E2. Because of your problem do you feel frustrated? F3. Because of your problem do you restrict your travel for business or recreation? P4. Does walking down the aisle of a supermarket increase your problem? F5. Because of your problem do you have difficulty getting into or out of bed? F6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing, or to parties? F7. Because of your problem do you have difficulty reading? P8. Does performing more ambitious activities like sports, dancing, and household chores, such as sweeping or putting dishes away, increase your problem? E9. Because of your problem are you afraid to leave your home without having someone accompany you? E10. Because of your problem have you been embarrassed in front of others? P11. Do quick movements of your head increase your problem? F12. Because of your problem do you avoid heights? P13. Does turning over in bed increase your problem? F14. Because of your problem is it difficult for you to do strenuous housework or yardwork? E15. Because of your problem are you afraid people may think that you are intoxicated? P16. Because of your problem is it difficult for you to go for a walk by yourself? P17. Does walking down a sidewalk increase your problem? E18. Because of your problem is it difficult for you to concentrate? F19. Because of your problem is it difficult for you to walk around your house in the dark? E20. Because of your problem are you afraid to stay home alone? E21. Because of your problem do you feel handicapped? E22. Has your problem placed stress on your relationships with members of your family and friends? E23. Because of your problem are you depressed? F24. Does your problem interfere with your job or household responsibilities? P25. Does bending over increase your problem?
Sometimes (2)
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APPENDIX B
1 A few times
2 Several times
3 Quite often
4 Very often
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2 2 2 2 2
3 3 3 3 3
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2. Pains in the heart or chest region 0 3. Hot or cold spells 0 4. Unsteadiness so severe that you actually fall 0 5. Nausea (feeling sick), stomach churning 0 6. Tension/soreness in your muscles 0 7. A feeling of being light-headed, "swimmy", or giddy lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
1 1 1 1 1
2 2 2 2 2
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1 1 1 1 1
2 2 2 2 2
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8. Trembling, shivering 9. Feeling of pressure in the ear(s) 10. Heart pounding or fluttering 11. Vomiting 12. Heavy feeling in arms or legs 13. Visual disturbances (e.g. blurring, flickering, spots)
0 0 0 0 0 0
1 1 1 1 1 1
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0 Never
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2 Several
3 Quite
4 Very
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Vertigo Symptom Scale (Yardley, Masson, et al., 1992)
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How often in the past 12 months have you had the following symptoms:
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1. A feeling that things are spinning or moving around, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
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14. Headache or feeling of pressure in the head 15. Unable to stand or walk properly without support 16. Difficulty breathing, short of breath 17. Loss of concentration or memory 18. Feeling unsteady, about to lose balance, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes b. Up to 20 minutes c. 20 minutes to 1 hour d. Several hours e. More than 12 hours
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Dizziness Handicap Inventory – Physician (adapted from Jacobson & Newman, 1990)
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P1. Does looking up increase your patient’s problem? E2. Because of your patient’s problem, does he/she feel frustrated? F3. Because of your patient’s problem, does he/she restrict travel for business or recreation? P4. Does walking down the aisle of a supermarket increase your patient’s problem? F5. Because of your patient’s problem, does he/she have difficulty getting into or out of bed? F6. Does your patient’s problem significantly restrict his/her participation in social activities, such as going out to dinner, going to the movies, dancing, or to parties? F7. Because of your patient’s problem does he/she have difficulty reading? P8. Does performing more ambitious activities like sports, dancing, household chores, such as sweeping or putting dishes away, increase your patient’s problem? E9. Because of your patient’s problem is he/she afraid to leave home without having someone accompany him/her? E10. Because of your patient’s problem has he/she been embarrassed in front of others? P11. Do quick movements of your patient’s head increase his/her problem? F12. Because of your patient’s problem does he/she avoid heights? P13. Does turning over in bed increase your patient’s problem? F14. Because of your patient’s problem is it difficult for him/her to do strenuous housework or yardwork? E15. Because of your patient’s problem is he/she afraid people may think that he/she is intoxicated? P16. Because of your patient’s problem is it difficult for him/her to go for a walk by himself/herself? P17. Does walking down a sidewalk increase your patient’s problem? E18. Because of your patient’s problem is it difficult for him/her to concentrate? F19. Because of your patient’s problem is it difficult for him/her to walk around the house in the dark? E20. Because of your patient’s problem is he/she afraid to stay home alone? E21. Because of your patient’s problem does he/she feel handicapped? E22. Has your patient’s problem placed stress on his/her relationships with members of his/her family and friends? E23. Because of your patient’s problem is he/she depressed? F24. Does your patient’s problem interfere with his/her job or household responsibilities? P25. Does bending over increase your patient’s problem?
Yes (4)
Sometimes (2)
No (0)
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1 A few times
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4 Very often
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2. Pains in the heart or chest region 0 3. Hot or cold spells 0 4. Unsteadiness so severe that you actually fall 0 5. Nausea (feeling sick), stomach churning 0 6. Tension/soreness in your muscles 0 7. A feeling of being light-headed, "swimmy", or giddy lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
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8. Trembling, shivering 9. Feeling of pressure in the ear(s) 10. Heart pounding or fluttering 11. Vomiting 12. Heavy feeling in arms or legs 13. Visual disturbances (e.g. blurring, flickering, spots)
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How often in the past 12 months has your patient had the following symptoms:
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1. A feeling that things are spinning or moving around, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes 0 b. Up to 20 minutes 0 c. 20 minutes to 1 hour 0 d. Several hours 0 e. More than 12 hours 0
0 0 0 0 0 0
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3 Quite often
4 Very often
0 0 0 0
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14. Headache or feeling of pressure in the head 15. Unable to stand or walk properly without support 16. Difficulty breathing, short of breath 17. Loss of concentration or memory 18. Feeling unsteady, about to lose balance, lasting: (PLEASE ANSWER ALL THE CATEGORIES) a. Less than 2 minutes b. Up to 20 minutes c. 20 minutes to 1 hour d. Several hours e. More than 12 hours
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Table 1. The distribution of diagnoses in the study sample. Diagnoses Number Percent of total Migrainous vertigo 9 30 Meniere's Disease 4 13 Benign Paroxysmal Positional Vertigo 4 13 Vestibular neuritis 4 13 Chronic Subjective Dizziness 1 3 Post-concussion dizziness 1 3 Orthostatic hypotension 1 3 Multisensory system impairment 1 3 Normal vestibular function tests 5 17 Total 30 100
