Abstract
Objective. To study the diagnostic panorama at a primary health care centre where the physiotherapist is specialized in dizziness. To study balance measures of dizzy patients as well as measures of self-perceived handicap and to analyse whether these measures correlate. Design. Retrospective study of computerized medical records. Setting. A primary health care centre in Malmö, Sweden. Subjects. A total of 119 patients with dizziness, 73 women and 46 men, aged from 22 to 90 years.Main outcome measures. Diagnoses according to specified criteria. Four balance measures: tandem standing, standing on one leg, walking in a figure of eight, and walking heel to toe on a line. The Dizziness Handicap Inventory (DHI). Results. Six different groups of diagnoses were found: multisensory dizziness, peripheral vestibular disorder, dizziness as a symptom caused by whiplash-associated disorder, unspecific dizziness, phobic postural vertigo, and dizziness of cervical origin. The group with multisensory dizziness performed poorer on the balance measures than the other groups. The group with phobic postural vertigo had the highest total scores on DHI, while the vestibular group had the lowest total score. Subjects over 65 years old had more disturbances in balance, but a lower level of self-perceived handicap, than subjects aged 65 or younger. DHI did not correlate with any of the balance measures. Conclusions. Self-perceived handicap, measured with DHI, and disturbed balance measured with clinical methods, do not necessarily correlate. Elderly patients with dizziness seem to have more disturbances in balance than younger patients but a lower level of self-perceived handicap.
Dizziness and vertigo are conditions responsible for about 2% of the consultations in primary health care Citation[1]. Among these, a variety of diagnoses are represented, most of them benign, whereas life-threatening conditions are rare Citation[2]. Dizziness can originate from peripheral structures, have a central origin or can be caused by other diseases such as multiple sensory deficits or cardiac disease Citation[3]. In an epidemiological study Citation[4], 19–29% of all women and 3–14% of all men complained of dizziness, and, in another Citation[5], 40% of the women and 30% of the men over 75 years reported disturbances in balance, related to concepts such as unsteadiness, feeling of rotation, impending fainting, dizziness, or vertigo.
Recent research shows that physical activity and specific treatment for dizziness are effective Citation[6], Citation[7], and also that assessment and, when appropriate, treatment by a physiotherapist is beneficial Citation[8]. Thorough and elaborated assessment of the dizzy patient is important in order to provide proper rehabilitation Citation[9] and the general practitioner's (GP's) knowledge of the patient's self-assessed health is crucial in clinical practice Citation[10]. The assessment often includes various balance measures, of which there is a diversity available Citation[11–16]. Which of these to use depends on the context and on the condition of the patient.
Dizziness and disturbances in balance have an impact on everyday life and correlation between functional impairment and perceived handicap among patients with vestibular dysfunction has been shown in a tertiary balance outpatient centre Citation[17]. The correlation between impact on everyday life and disturbances in balance in primary care patients with dizziness has not, to our knowledge, been studied sufficiently. However, the clinical work of one of the authors (EEH, a physiotherapist specialized in assessment and treatment of dizzy patients) has given us the opportunity to describe balance measures and perceived handicap among dizzy patients in primary health care.
The aim of this study was therefore to describe different causes of dizziness in primary health care and to describe the outcome of balance measures and measures of self-perceived handicap. We also wanted to analyse whether different balance measures and the patients’ self-perceived handicap correlate, and to see if there were any differences between older and younger persons.
Material and method
Data were compiled from computerized medical records of patients with dizziness, assessed by a physiotherapist (EEH) at a primary health care centre in Malmö (population 270 000), Sweden. This type of data collection has been shown to be feasible and of high accuracy Citation[18]. Patients from the whole city are admitted to the physiotherapy department at this centre. The physiotherapist is specialized in dizziness and has therefore developed a standardized assessment, including anamnesis, examination with balance measures, the Dix–Hallpike manoeuvre Citation[19] and the Dizziness Handicap Inventory (DHI) Citation[20]. Data were obtained retrospectively from computerized medical records of patients visiting the centre during the period from June 2003 to May 2004. For all patients presenting with dizziness as a symptom data were collected, including age, gender, diagnoses of dizziness, duration of dizziness, results of balance measures, and results of DHI.
Diagnostic criteria
Dizziness as a symptom caused by whiplash associated disorder (WAD), where the symptoms occurred in relation to trauma Citation[21].
Dizziness of cervical origin, i.e. neck pain and concomitant dizziness with increased muscle tension and/or muscle stiffness in high-cervical muscles and no vestibular disease Citation[22].
Multisensory dizziness with age as one important factor Citation[19] or central origin, for example stroke or multiple sclerosis Citation[23].
Peripheral vestibular disorder, including vestibular neuronitis Citation[19] and benign paroxysmal positional vertigo (BPPV) Citation[24].
Phobic postural vertigo (PPV) Citation[25].
Dizziness of unspecific origin, where no cause of dizziness could be found with methods available in primary health care.
Balance measures
Tandem standing with eyes open and with eyes closed Citation[16].
Standing on one leg with eyes open (SOLEO) and standing on one leg with eyes closed (SOLEC) Citation[14].
Walking heel to toe on a five-metre-long line Citation[16].
Walking twice in a figure of eight Citation[26].
In walking heel to toe and walking in a figure of eight, the number of steps outside the figure was registered.
Dizziness Handicap Inventory (DHI)
DHI measures self-perceived handicap of dizziness and has been translated into Swedish and the Swedish version has been tested for reliability Citation[29]. The inventory comprises 25 different items, organized in three different dimensions: functional, emotional, and physical. The total maximum score is 100 points; for the functional dimension it is 32 points, the emotional 40 points, and the physical 28 points. The higher the score, the greater the level of self-perceived handicap.
Statistics
Means and standard deviation were calculated and the Pearson correlation was performed to calculate correlations between different variables.
Ethical concerns
The information was gained retrospectively from routine assessment used at the health care centre and therefore no further ethical approval was considered necessary.
Results
Data were collected from the medical records of 119 patients, 73 women and 46 men, aged from 22 to 90 years (mean 61, median 65). Eighty-one patients were referred from primary health care; 38 from the healthcare centre where the physiotherapist works and 43 from 13 of the other primary health care centres in the city. Thirty-four patients were referred from the local hospital, 18 from otolaryngologists at the ENT department, and 16 from the orthopaedic department. Otolaryngologists in private practice referred three patients. The duration of dizziness varied from 2 weeks to 15 years.
The distribution of the various diagnoses is presented in . The diagnoses were set by the physicians who referred the patients. In some cases, the diagnosis was made by the physiotherapist and the GP in cooperation. All patients in the group with phobic postural vertigo (PPV) were diagnosed by an otolaryngologist. In the group with multisensory dizziness, all patients were referred by GPs, and the diagnosis was made by either the GP or the GP and physiotherapist in cooperation. In the group with peripheral vestibular disorder, otolaryngologists made the diagnosis in nine out of 29 cases. In the group with whiplash-associated disorder (WAD), the original diagnosis was made by an orthopaedic surgeon.
Table I. Median age and gender for the study group distributed by diagnoses.
As shown in , the group with multisensory dizziness performed worse on the balance measures than the other groups. This group had the highest median age. Otherwise there were only small differences between the groups.
Table II. Means and standard deviations (SD) for balance measures, calculated in seconds (tandem standing and standing on one leg) and steps (figure of 8 and walking heel to toe). In static measures, the closer to 30 seconds the better balance, in dynamic measures, the closer to zero steps, the better balance.
As can be seen in , the group with PPV had the highest total scores on DHI (mean 73) as well as emotional score (mean 29) while the vestibular group had the lowest total score (mean 35) and the lowest emotional score (mean 10), implying that the PPV group had a greater level of self-perceived handicap.
Table III. Means and standard deviations (SD) for Dizziness Handicap Inventory (DHI). The higher the score, the greater level of self-perceived handicap.
The score on DHI did not correlate with balance measures, as seen in the lower left part of . That is, a poor outcome in balance measures did not necessarily result in a high score on DHI, and vice versa. As expected, the different dimensions of DHI correlated with each other and so did the different balance measures, as seen in the upper left part and lower right part of .
Table IV. Correlation between Dizziness Handicap Inventory (DHI) and balance measures.
When the study group was divided into two different subgroups, subjects 65 years or younger (n = 61) and 66 or older (n = 58) respectively, significant differences were found in all balance measures (p <0.0001 for all measures), the older group performing worse. The majority of the older group consisted of patients with multisensory dizziness (47/58). Statistically significant differences were found between the two groups in DHI, total score (p = 0.047). In these measurements, the younger group had higher scores, thus implying a higher level of self-perceived handicap in younger persons.
Discussion
In this study, self-perceived handicap, measured with DHI, and disturbed balance, measured with four different balance measures, did not correlate. The elderly with dizziness had more disturbances in balance than younger people with the same symptoms, but a lower level of self-perceived handicap.
The physiotherapist who examined the patients is specialized in dizziness and therefore receives patients from other healthcare centres as well as from the local hospital. This concentration of patients with dizziness provided a unique opportunity to compile information about this condition. However, the diagnostic panorama in this study cannot be applied to primary health care in general.
The various methods of referral resulted in differences in the diagnostic procedure, since only a small number of the patients were assessed with electronystagmography (ENG). In some cases, the physiotherapist confirmed the diagnosis made by the GP, or specified it, namely in those cases where there are diagnostic methods available in primary health care, e.g. using Frenzels when performing the Dix–Hallpike manoeuvre. Also, considering the close cooperation between the physiotherapist and the GPs at the healthcare centre, as well as the long clinical experience of the physiotherapist, we believe that the diagnoses can be considered valid and reliable.
Dizziness is often combined with anxiety, with an impact on everyday life Citation[30]. The experience of the symptom is to a high degree subjective and, consequently, different coping strategies are probably used by different people. Therefore, self-perceived handicap is of interest; the fact that it is possible to have a poor outcome in balance measures and a low rate of self-perceived handicap, and vice versa, probably reflects the importance of individual traits. The lowest level of self-perceived handicap was found in the group with peripheral vestibular disorder, including BPPV. In BPPV, rapid spinning vertigo is triggered by certain movements of the head. The vertigo lasts for less than one minute Citation[19]. However, even though rapid spinning vertigo is very unpleasant, in BPPV it lasts only for a short while and it is also possible to avoid the head movements that provoke vertigo. Therefore, the low score on DHI for the vestibular group is not surprising. In contrast, the PPV group had high scores on DHI, implying a high level of self-perceived handicap. Patients with PPV often experience dizziness, unsteadiness, and disturbed balance. Anxiety and other vegetative symptoms are common Citation[25]. Thus, considering the wide spectrum of symptoms, the high scores on DHI for those with PPV are to be expected.
In multisensory dizziness, a combination of visual, vestibular, and proprioceptive loss causes disturbed balance. Since this group is sufficiently large, the poor outcome in balance measures found for those patients is probably valid for patients with multisensory dizziness in primary health care in general.
The poor outcome in blindfolded balance measures for the group with vestibular disorder is to be expected, since this group of patients has to rely more on vision to maintain postural function.
In this study, the groups with dizziness of cervical origin, PPV, and dizziness of unspecific origin are small, which should be considered when studying the outcome of the different measures in these three groups.
Contrary to the findings in the present study, correlation between functional impairment and perceived handicap has been shown in a tertiary balance outpatient centre, among patients with vestibular dysfunction Citation[17]. The conflicting results may be due to the use of different balance measures and a marked difference in the selection of subjects, i.e. patients from primary health care with a variety of diagnoses versus patients from the tertiary outpatient centre with vestibular dysfunction only.
Our findings show that self-perceived handicap, measured with DHI, and disturbed balance do not necessarily correlate. Elderly persons with dizziness seem to have more disturbances in balance than younger people with the same symptoms, but at the same time a lower level of self-perceived handicap, which should be considered in assessment and treatment of dizzy patients. To our knowledge, means and standard deviations for the balance measures used in this study are not known or known only for healthy subjects. These figures might be useful in future studies on balance.
Key Points
Thorough and elaborated assessment of the dizzy patient is important in order to provide proper rehabilitation.
Self-perceived handicap and disturbed balance do not necessarily correlate.
The elderly with dizziness seem to have more disturbances in balance than younger people with the same symptoms, but a lower level of self-perceived handicap.
Means and standard deviations for the balance measures displayed in this study can be useful in future studies on balance.
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