Application of the Vestibular Disorders Activities of Daily Living Scale

1. Helen S. Cohen EdD, OTR1,*, 2. Kay T. Kimball PhD2, 3. Angela S. Adams MOT, OTR3 Article first published online: 2 JAN 2009

DOI: 10.1097/00005537-200007000-00026
Copyright 2000 The Triological Society

The Laryngoscope
Volume 110, Issue 7, pages 12041209, 2000

Keywords:

Activities of daily living; disability; functional assessment; handicap; vertigo; vestibular disorders.

Abstract
Objective Existing scales of functional performance are either insufficiently sensitive or

omit some important daily life tasks. This paper demonstrates that a new scale of selfperceived disablement in the vestibularly impaired populationthe Vestibular Disorders Activities of Daily Living Scale (VADL)differentiates between disabled and healthy persons and evaluates the associations of this assessment with other measures of vestibular disorders.
Study Design Prospective. Methods Subjects were 1) asymptomatic, healthy adults, 2) patients with benign

paroxysmal positional vertigo, 3) patients with chronic vestibulopathy excluding Meniere's disease, postsurgical vertigo, and postconcussion vertigo, and 4) family members. Patient were assessed on the VADL, the Dizziness Handicap Inventory, level of vertigo, and computerized dynamic posturography. Healthy subjects and family members completed the VADL.
Results The VADL differentiates healthy persons from patients but does not differentiate

between patient groups. Patients perceived themselves as more independent than their spouses perceived them to be. Scores are weakly correlated with vertigo frequency and posturography scores for conditions with unreliable kinesthesia and absent or unreliable vision. The VADL is more responsive to higher levels of impairment than the Dizziness Handicap Inventory.

Conclusions This well-normed, self-administered scale of self-perceived disablement is

useful for evaluating the functional status of patients with peripheral vestibular disorders. Perceptions of patients and significant others vary, but scores are moderately correlated with some standard measures of vestibular function. As it assesses a different domain of function than do standard diagnostic tests, the VADL will augment these tests during initial evaluation and may be useful for assessing posttreatment change.

INTRODUCTION
With the improvements in health care in this century and since passage of the Americans with Disabilities Act, 1 the United States Congress and the public have been concerned with the disabling effects of various disorders as they affect the quality of life. Although many studies include parameters of interest to scientists and clinicians, most studies omit quality of life, which is probably the most relevant issue to the patient. 2 Few studies have addressed quality of life in people with vestibular disorders. People with Meniere's disease have decreased independence in self care and other activities of daily living 3 and in general people with vestibular disorders have reduced independence in activities of daily living. 4,5 However, little detailed evidence is available on the specific problems caused by vestibular disorders, although this information would be useful in public health planning as the population ages and in treatment planning for individual patients. This problem is compounded by the paucity of normed assessment instruments in the literature. Aside from the Dizziness Handicap Inventory (DHI) 6 and the Activities-specific Balance Confidence Scale, 7 no instruments address functional performance in this population. Both of these tools fill important niches, but neither addresses in detail the problem of self-care skills and mobility skills with a sufficiently fine scale. Furthermore, no studies have evaluated healthy subjects on these scales to determine actual normal performance across the life span. Previous work reported functional limitations after vestibular impairments, 4 but that study was not performed with a well-normed scale and did not allow for comparisons across diagnostic groups. We developed a new, self-administered scale of independence in activities of daily living, the Vestibular Disorders Activities of Daily Living Scale (VADL), the development of which is described elsewhere. 8 Using the VADL we collected data from a large cohort of healthy subjects to determine how independence changes across the life span. We compared the healthy subjects with two patient groups to determine how the patient groups differ from healthy subjects and from each other. We also compared the VADL to other measures of vestibular impairment. Finally, we compared patients' responses to those of their significant others to determine if close family members perceive patients' functional skills in the same way as patients do.

MATERIALS AND METHODS

The VADL 8 was given to four groups of subjects. The 93 patients given the original 31question version of the scale included two groups: 1) 66 patients with chronic vestibulopathy, each of whom was diagnosed with a peripheral vestibular disorder of unknown cause by an otolaryngologist or neurologist (excluding Meniere's disease, postsurgical vertigo, posthead trauma vertigo, bilateral vestibular loss, and benign paroxysmal position vertigo [BPPV]), aged 55 16.6 years (age range, 2592 y), including 21 men and 45 women, and 2) 27 patients with BPPV of the posterior semicircular canal, mean age 52 11.7 years (age range, 3473 y), including 7 men and 20 women. The final 28-question version was administered to 28 more subjects, including 3 patients with chronic vestibulopathy and 25 patients with BPPV, based on availability of subjects. The norming process is described elsewhere. 8 The diagnosis of chronic vestibulopathy was based on two criteria: 1) a complaint of vertigo, i.e., the illusory sense of motion, for 3 months or longer, and 2) positive findings from caloric testing or decreased vestibulo-ocular reflex gains with low-frequency sinusoidal rotations in darkness. 9,10 Patients with chronic vestibulopathy had episodic vertigo varying in frequency from a few episodes per week to more than 10 per day, but all subjects reported having moments in the day while they were sitting still when they did not have vertigo. The diagnosis of BPPV was based on a complaint of vertigo during pitch head rotations and the clinical finding of a positive response to the Dix-Hallpike maneuver, with nystagmus beating upward and a torsional component either counterclockwise in head hanging right or clockwise in head hanging left 11 with a latency to onset of nystagmus and vertigo of 2 to 15 seconds and a duration of no longer than 60 seconds. 12 The healthy subjects included 97 asymptomatic adults with no histories of ear, inner ear, or neurological problems (aged 38 y 13.6; age range 1974 y, 44 men, 53 women). The patients' significant others included 13 spouses or adult children with whom chronic vestibulopathy patients lived. Patients were recruited from the senior author's caseload of patients referred for vestibular rehabilitation; spouses and adult children were recruited from significant others who accompanied chronic vestibulopathy patients to their clinic appointments; healthy subjects were recruited from the community. The self-administered VADL is a check-list of 28 questions on a 10-point qualitative scale with an additional possible rating of not applicable if a subject chooses not to answer or the item does not apply to that individual. The ratings are listed numerically and include written descriptions. The scale has three subtests: functional, ambulation, and instrumental. Medians are calculated for subscores and for the total score. Most

subjects took 5 to 10 minutes to complete the scale. Patients were asked to rate their performance on the day they took the test compared to their premorbid performance, i.e., before the vestibular disorder developed. Healthy subjects were asked to rate their performance on the day of the test. To determine test-retest reliability in healthy subjects, they were asked to take the test again 2 weeks later. Significant others were asked to rate their family members' performance as they perceived it, as compared to their premorbid performance. Patients with chronic vestibulopathy were participants in a larger, on-going study of vestibular rehabilitation. They were asked to rate the usual intensity and frequency of their vertigo episodes on 10-point qualitative scales. They were shown two 15.5 cm 12.5-cm laminated white cards with black, 18-point font showing numbers from 1 to 10, evenly spaced across the card. Subjects were asked to select the level on each scale that most closely matched their perceptions of their usual levels of vertigo intensity and frequency. To determine concurrent validity in reference to the only other normed scale specifically for the vestibularly impaired population, patients with chronic vestibulopathy were also asked to take the DHI, which has a three-point, ordinal scale. 6 Patients with chronic vestibulopathy were also tested on computerized dynamic posturography (Equitest, NeuroCom, Espoo, Finland). The subtest scores from Sensory Organization Test (SOT) conditions 3, 5, and 6 and the composite score were used in the analyses because decrements on these conditions is consistent with a diagnosis of a vestibular disorder, although deficits on this test are not specific to vestibular impairments. 13 In conditions 3 and 6 the visual surround moves in phase with the subject's postural sway, making visual information unreliable. In condition 5, the eyes are closed. Also in conditions 5 and 6, the force platform on which the subject stands moves in phase with the subject's postural sway, making kinesthetic information from the lower extremities unreliable. Nonparametric methods were used when needed to meet assumptions of statistical tests. VADL scores in men and women were compared using Kruskal-Wallis one-way ANOVA. Spearman's correlation coefficients were used to assess the association of independence with perceived necessity of tasks and the association of VADL scores with age, and with other vertigo measures: DHI, frequency and intensity of vertigo, and posturography. Sidak's adjustment for multiple testing was applied when testing the two measures of vertigo and the three measures of posturography to achieve a family-wise error rate of 0.05 for each set of comparisons. The curvilinear association between VADL and DHI scores was further elucidated by fitting a fractional polynomial regression model. 14 VADL scores in the three diagnostic groups were compared using ANOVA with Sidak's adjustment for multiple comparisons. The agreement between the significant other's and the patient's VADL scores was assessed using Lin's concordance

correlation 15 and Bland and Altman's limits-of-agreement procedures. 16 Lin's coefficient measures both accuracy (the concordance coefficient) and precision (the confidence interval [CI]) between the observed measurements and the line of perfect concordance. Bland and Altman's limits-of-agreement procedure complements Lin's concordance in that it reports the amount of difference and 95% CI. Wilcoxon signed-rank tests were used to assess the differences in perceived necessity of the tasks. All statistical tests were two-tailed. The statistical analyses were performed using STATA Release 6.0. 17 The research protocol was approved by the Institutional Review Board for Human Subject Research.

RESULTS
Virtually all healthy subjects were independent (score = 1) on the items in this scale. Therefore no differences were found across the adult age span or between men and women. Increases in some of the VADL scores, however, were associated with increasing age in patients for total score (P = .18), functional subscore (P = .33), ambulation subscore (P = .05), and instrumental subscore (P = .05). No differences were found on total score or any subscores between male and female patients. The VADL and DHI total scores were moderately correlated (Spearman's = 0.66, P < . 001). The association was approximately linear up to 3 on the VADL; in this range a 1unit change in VADL was associated with an approximately 20-unit change in DHI. At VADL scores equal to or greater than 4, however, the DHI score remained flat, while the VADL score continued to increase. This association was modeled using a fractional polynomial model that fitted a regression of DHI score on natural log and squared natural log of VADL score.14Figure 1 shows the observed and predicted DHI scores and 95% confidence intervals resulting from the model.
Figure Fig. 1.. Relationship between total scores on the Vestibular Disorders Activities of

Daily Living Scale (VADL) and the Dizziness Handicap Inventory (DHI). Circles are observed data points. The center line represents the predicted DHI score; upper and lower lines represent 95% confidence intervals.

Patients with chronic vestibulopathy, patients with BPPV, and healthy subjects were compared to determine if the VADL scale differentiated among groups. Healthy subjects scored as significantly more independent when compared with chronic vestibulopathy patients and BPPV patients on the total scale and every subscale (P < .0001 on each scale for each diagnosis compared with healthy subjects). Scores for patients with

chronic vestibulopathy and BPPV were not different on the total scale (P = .455), functional subscale (P = .998), ambulation subscale (P = .286), and instrumental subscale (P = .555). The analyses were adjusted for age differences between the healthy subjects and the patient groups (Fig. 2).
Figure Fig. 2.. Box and whisker plots of total scores and subscores showing differences

among healthy subjects, patients with chronic vestibulopathy (CV), and patients with benign paroxysmal position vertigo (BPPV). The horizontal line inside each box is the median or 50th percentile. The upper and lower ends of each box are the upper and lower quartiles, respectively. The vertical lines extending from the ends of the boxes connect points that are within the 1.5 interquartile range beyond the upper and lower quartiles. More extreme points are represented by the open circles.

Many patients attend clinic visits accompanied by their spouses or other family members and clinicians often use significant others as informants. Therefore, knowing the relationship of their perceptions to those of the patients is important. To determine if the perceptions of patients and their significant others are similar, the scores from patients with chronic vestibulopathy were compared with scores from their spouses. Concordance correlations were moderate. Total score:rc = 0.682 (95% CI = 0.369 0.994); functional subscale:rc = 0.661 (95% CI = 0.3480.973); ambulation subscale:rc = 0.632 (95% CI = 0.2870.977); and instrumental subscale:rc = 0.766 (95% CI = 0.534 0.998). The average differences between the spouse's and patient's ratings were 0.308 (95% CI = 0.3160.932) for total, 0.692 (95% CI = 0.1061.278) for functional, 0.769 (95% CI = 0.1261.664) for ambulation, and 0.308 (95% CI = 1.070.458) for instrumental scores. A positive sign on the average difference indicates that the spouse's rating was higher (more dependent) than the corresponding patient's selfrating. In general, patients perceived themselves as more independent than their significant others perceived them. The amount of disagreement, however, was significantly different from zero only for the functional subscore. The small number of patient/spouse pairs (n = 13) that were available for this substudy may account for the size of the confidence intervals (Fig. 3).
Figure Fig. 3.. Concordance correlations between subject and spousal scores. Dashed

line represents perfect agreement or a 45 line through the origin. The solid line represents the major axis of the data. A. Total scale. B.Functional scale. C. Ambulation scale. D. Instrumental scale. Open circles represent individual data points. Some points overlap.

To determine if VADL scores are related to other frequently used clinical measures, scores of patients with chronic vestibulopathy were compared to vertigo self-ratings and posturography scores. No significant associations were observed between either the VADL total score or subscores and vertigo intensity. Vertigo frequency was measured with a self-rated, 10-point qualitative scale from none (1) to constantly (10). It was weakly correlated with total score (Spearman's = 0.32, P = .04) and with instrumental subscore (Spearman's = 0.42, P = .004). Similarly weak but statistically significant relationships were found between SOT conditions 5 and 6 and VADL total scores and all subscores, and between SOT composite score and the total, functional, and instrumental scores (Table I).

Table Table 1.. Correlations Between Posturography and Vestibular Disorders Activitie Scores.

To determine if perceived necessity of a task is related to perceived independence, patients with chronic vestibulopathy were asked to rate the necessity of each item on a four-point scale (1 = indicated essential; 2 = somewhat essential, must do task periodically; 3 = somewhat discretionary, must do once in a while; and 4 = discretionary, does task only when desired). Most patients (97%) reported functional tasks as level 1 (essential) but ambulation and instrumental tasks were ranked from level 1 to level 4. No association was found between ambulation independence and need (P = .21), but a significant inverse association was found between instrumental independence and perceived need (P = .002). Functional tasks were perceived as more essential than either ambulation tasks (P < .0001) or instrumental tasks (P < .0001). Ambulation and instrumental tasks were perceived similarly (P = .79).

DISCUSSION
The use of a healthy control group is a unique feature of this assessment. Law 18 has pointed out that healthy subjects are assumed to be independent in ADLs. Few reports and none in the vestibular literature, however, have actually tested that hypothesis. This

study provides empirical evidence in support of that previously untested assumption, using a broad age range. This study showed no difference in independence by age or sex in the patient groups. The lack of difference by age confirms the previous finding by Jacobson and Newman 6 and suggests that increasing age itself is not disabling, despite age-related changes in muscle strength, endurance, and other normal changes. Routine activities of daily living are complex but well-learned motor tasks, practiced thousands of times over the course of a lifetime. Continued independence across the life span in healthy people suggests that healthy subjects perform these tasks efficiently, using only minimal energy so that normal, age-related decrements in strength and endurance do not affect the performance of such well-learned tasks. Vestibular disorders may introduce some inefficiency in performance and probably require more use of energy reserves. This idea is supported by the comments of many patients, who complain of fatigue, difficulty concentrating, and decreased attention span. This finding has implications for retraining motor skill during rehabilitation. Therapists should determine the nature of these inefficiencies through careful movement analysis and should direct training of splinter skills toward correcting these problems. The finding of a partial relationship between the VADL and the DHI indicates that at greater levels of independence, i.e., lower levels of disablement, the scales represent self-perceived independence equally well. The changes in the VADL that are not reflected in the DHI show that the VADL has greater responsiveness to lesser levels of independence, i.e., higher levels of disablement. This finding illustrates a limitation of a three-point scale. The VADL distinguishes between healthy and vestibularly impaired subjects. It does not appear to differentiate between two diagnostic groups. Thus the fact of having a vestibular disorder is more significant for the level of functional limitation than the etiology of the disorder. Also patients with BPPV tend to complain of difficulty or discomfort while performing tasks requiring pitch rotations of the head but not with tasks requiring primarily yaw rotations. 19 These tasks probably involve multi-axis head rotations. This issue might bear further examination with a variety of disabilities. The Meniere's disease population, for which the DHI was developed, was not included in this study. Likewise, subjects with total bilateral vestibular loss were not included, although they report having significant functional deficits. Subjects often considered themselves to be more independent than their significant others considered them to be, although the average disagreement was significantly different from zero only for the functional subscore. This trend supports the common clinical observation that, probably in an effort to be helpful and supportive, many family members do things for patients when those patients are capable of performing those

tasks unassisted. This behavior and the spousal perceptions found in this study may reflect some profound differences in the way patients and their significant others think of themselves and may also reflect some long-established patterns in some people's interpersonal relationships. We found no statistical relationship between vertigo intensity and VADL scores, replicating the earlier finding of Jacobson and Newman. 6Vertigo frequency is weakly related to self-perceived performance on instrumental tasks. Jacobson and Newman also found an effect of vertigo frequency, although comparing these two sets of results is difficult because the analyses and the make-up of the subscales differed. Nevertheless, the findings from both studies suggest that the fact of having vertigo and the frequency of vertigo episodes are most disabling. The correlations with posturography scores on SOT condition 5 also replicate Jacobson's and Newman's finding. 20 This posturography condition is performed with eyes closed as the force platform moves in phase with the subject's postural sway, so visual input is unavailable and kinesthetic information is not useful. We also found some relationship to the scores from SOT condition 6. This finding is not surprising because scores on conditions 5 and 6 are highly correlated. The patient population from which subjects were recruited is not typical of all patients seen for vertigo, because many patients compensate rapidly and are not referred for rehabilitation. This sample, especially the chronic vestibulopathy subsample, is representative only of more severe cases, i.e., patients who have not compensated independently and who are referred for vestibular rehabilitation. These findings should be interpreted in that context. Furthermore, some patients' median scores on the total scale or on the subscales were 1, indicating that they considered themselves to be independent. A question for future study might be to determine if, in fact, these individuals are actually independent as determined by a therapist's objective observations. An inquiry into a patient's functional limitations should be as context-specific as possible. 21 For that reason, the scale includes questions about ambulation in several settings. Although driving skill is also context-specific and depends on specific road conditions, 22 the question about driving provides some insight into perceived ability. Informal discussions with subjects after filling out the scale suggest that patients usually indicate their performance under the most difficult conditions for them. The answer to the question about driving could be used to indicate the need for a more in-depth objective assessment using a driving simulator or administered by a certified driving instructor. Driving is a particularly problematic skill because the safety of the patient and the public is at risk. Despite recent surveys of physicians' subjective impressions of the influence of

vestibular disorders on driving skill 23,24 we still have no objective information about the actual effects of vestibular disorders on this important task, because physicians and patients do not necessarily agree on their assessments of patients' functional skills. 25 The VADL may be useful in pretreatment and posttreatment vestibular rehabilitation evaluations. As a well-normed instrument, it may provide useful information about the patient's status that may be helpful in disability assessments and in treatment planning. Any subjective assessment of self-efficacy, 7 however, is best used in combination with a objective assessment of functional skills and related perceptual and motor function by a qualified health care professional. A discrepancy between the patient's self-evaluation and the occupational therapist's objective assessment is an indication for intervention because patients seek health care based on their personal impressions. A patient who believes himself to be vertiginous or disabled, despite the physician's or therapist's objective observation to the contrary, may still continue to seek medical care in an effort to ameliorate a sense of decreased selfefficacy.

ACKNOWLEDGMENT
Angela Downs Adams collected the data on healthy subjects for her professional project, submitted in partial completion of the requirements for the MOT degree. We thank Sharon Congdon, Elizabeth Elizalde, and Melody Fregia for technical assistance.

EDITORIAL FOOTNOTE
The methodology of this study raises several concerns. First, the high preponderance of women in the study may bias the results. Second, an additional 28 subjects were tacked onto the original study groups without explanation. The diagnosis of chronic vestibulopathy is also a concern. The patients experienced vertigo for 3 months or longer that the authors admit was most commonly episodic, rather than constant. This may suggest Meniere's disease, which they excluded. Also excluded was a set of patients with chronic loss of balancenot necessarily true vertigothat may have been an excellent group of patients to study. The results do provide us with essential information regarding normative data and it is interesting that the increasing age of the patient population does not seem to affect their responses to the questionnaire. It is also difficult to draw significant conclusions, particularly when the instructions in filling out the questionnaire indicate that the patient's disability should be related to the time when they are most symptomatic. Although the patients may be extremely disabled during these times, the episodes of disability may be very short lived. This is a well administered questionnaire that is evaluating independence and activities of daily living and if the patient experiences vertigo only during limited times, it is very possible that they can

perform most activities, and learn to avoid precipitation movements that elicit the vertiginous response, particularly in patients with benign positional vertigo.
Authors' response: No subjects in this study met the criteria for Meniere's disease, as

defined by the American Academy of Otolaryngology and, in the judgment of their physicians, no subjects had Meniere's disease. Those subjects who did not have BPPV had chronic, recurrent vestibulopathy. This diagnosis, described in 1981 in this journal (LeLiever WC, Barber HO. Recurrent vestibulopathy.Laryngoscope 1981;91:16) and again more recently elsewhere (Schessel DA, Nedzelski JM. Meniere's disease and other peripheral vestibular disorders. In: Cummings CW, ed. OtolaryngologyHead and
Neck Surgery. St Louis: Mosby-YearBook, 1993:31523176) refers to what may be

uncompensated viral labyrinthitis, characterized by brief episodes of vertigo elicited by head movement and disequilibrium. The authors relied on the expert judgment of highly skilled physicians to determine subjects' diagnosis.

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