Rehab Measures - Dizziness Handicap Inventory

Link to instrument

Availabe on Southhampton Hospital's website

Title of Assessment

Dizziness Handicap Inventory

Acronym

DHI

Instrument Reviewer(s)

Initially reviewed by Amy M. Yorke, PT, NCS and the MS EDGE task force and Irene Ward, PT, DPT, NCS and the TBI EDGE taskforce of the Neurology Section of the APTA; Updated by Salomi R. Vora in 10/2012.

Summary Date

2/19/2013

Purpose

A 25-item self-assessment inventory designed to evaluate the self-percieved handicapping effects imposed by dizziness.

Description

25 items
Maximum score of 100 (28 points for physical, 36 points for emotional and 36 points for functional) to Minimum score of 0. The higher the score, the greater the perceived handicap due to dizziness
Item scores are summed
Answers are graded 0 (never), 2 (sometimes) and 4 (always)
Jacobson, G.P., Newman, C.W. (1990). The development of the dizziness handicap inventory. Arch Otolaryngol Head Neck Surg, 116, 424-427.

Area of Assessment

Balance Vestibular; Gait; Quality of Life; Social Relationships; Vestibular

Body Part

Not Applicable

ICF Domain

Body Structure; Body Function; Participation

Domain

Assessment Type

Patient Reported Outcomes

Length of Test

06 to 30 Minutes

Time to Administer

10 minutes

Number of Items

25 items

Equipment Required

Score sheet and pen

Training Required

No Training

Type of training required

No Training

Cost

Free

Actual Cost

available online at multiple sites, Copyrighted 1990, American Medical Association.

Age Range

Administration Mode

Paper/Pencil

Diagnosis

Geriatrics; Multiple Sclerosis; Traumatic Brain Injury; Vestibular Disorders

Populations Tested

Vestibular disorders
Benign Paroxysmal Positional Vertigo (BPPV)
Patients with dizziness
Multiple Sclerosis (MS)
Brain Injury
Geriatrics

Standard Error of Measurement (SEM)

Peripheral and central vestibular pathology: (Jacobson & Newman, 1990; n= 106)

SEM = 6.2

Multiple sclerosis (Cattaneo et al, 2007; n= 25 males = 8 & females = 17; mean age= 41.7 (12.5) years; onset of pathology = 8.7 (8.8) years of relapsing remitting/ secondary progressive type of multiple sclerosis)

SEM= 8.12

Minimal Detectable Change (MDC)

Peripheral and central vestibular pathology. (Calculated from Jacobson & Newman, 1990)

MDC = 17.18

Multiple sclerosis (calculated from Cattaneo et al, 2007)

MDC = 22.50

Minimally Clinically Important Difference (MCID)

Vestibular Dysfunction: (Jacobson and Newman, 1990; n = 106; mean age = 48(15.84) years)

Pretreatment and post-treatment scores would have to differ by at least 18 points (95% confidence interval for a true change before the intervention could be said to have effected a significant change in a self-perceived handicap).

Cut-Off Scores

Multiple Sclerosis (MS): (Cattaneo et al, 2006; n = 51 patients with MS; mean number of falls month prior to evaluation = 0.98(1.8) falls; 16 males, 35 females; mean age = 45.3(18.1) years; mean onset of pathology = 15.6(7.6) years)

Cut off score = <59

Vestibular Dysfunction: (Whitney et al, 2004; n = 85 participants with a variety of vestibular diagnoses; mean age = 61 years)

Mild: 0-30
Moderate: 31-60
Severe: 61-100

Peripheral & Central Vestibular Pathology: (Jacobson & Newman, 1990)

If the score on questionnaire is > 10, then an examination by a specialist is indicated.
A score of >16 indicates that the individual is handicapped by his or her symptoms.

Normative Data

Multiple Sclerosis: (Cattaneo et al, 2006)

Mean = 38.5 (Non- fallers)
Mean = 56.0 (Fallers)
Statistically significant differences between mean scores of fallers and non- fallers

Traumatic Brain Injury: (Kaufman et al, 2006; n= 10; 6 men and 4 women; community living individuals with normal gait and balance before pathology; average duration since TBI = 2.8 (0.4- 14.4) years)

Mean = 32(23)

Test-retest Reliability

Multiple Sclerosis (MS): (Cattaneo et al, 2007; n = 25 patients with MS; 8 males, 17 females; mean age = 41.7(12.5) years; mean onset = 8.7(8.8) years)

Excellent test-retest reliability (ICC = 0.90, 95% CI 0.77-0.96)

Vestibular Dysfunction: (Jacobson and Newman, 1990)

Excellent test-retest reliability for total score (r = 0.97, df=12, P<0.0001)
Excellent test-retest reliability for sub-scales scores (r = 0.92-0.97, P<0.001)

Interrater/Intrarater Reliability

Not Established

Internal Consistency

Vestibular Dysfunction: (Jacobson and Newman, 1990)

Excellent internal consistency for total score (alpha = 0.89)
Adequate to excellent internal consistency for the 3 sub-scales (alpha = 0.72-0.85)

Multiple Sclerosis: (Hebert et al, 2011; n= 38; 18- 65 years; Intervention= vestibular rehabilitation (6 weeks); follow- up (4 weeks); able to walk 100 m; ≥ 45 on the Modified Fatigue Impact Scale Questionnaire and < 72 on the computerized Sensory Organization test)

Excellent internal consistency (Cronbach’s alpha = 0.91)

Criterion Validity (Predictive/Concurrent)

Multiple Sclerosis (MS): (Cattaneo et al, 2006)

Adequate correlation with Berg Balance Scale (r = -0.32)
Adequate correlation with Dynamic Gait Index (r = -0.39)
Adequate correlation with Timed Up and Go (r = 0.35)
Adequate correlation with Hauser Ambulation Index (r = 0.32)
Excellent correlation with Activities Specific Based Confidence Scale (ABC) (r = -0.70)

Mild Traumatic Brain Injury: (Gottshall et al, 2003; n = 53 male active duty individuals who suffered mild TBI and 46 control subjects without TBI; Glascow Coma Scale score of 14-15; mean age = 22 years)

Statistically significant correlation between all Dynamic Visual Acuity Test results measured and the DHI and the 1 week time point (P<.01)
There was no significant or consistent correlation between the two tests after the 1 week period

Vestibular Dysfunction: (Whitney et al, 1999; n = 71 subjects from a local balance and vestibular clinic; 15 males, 56 females; mean age = 65 (16.8) years)

Excellent correlation with ABC (r = -0.64)

Benign Paroxysmal Positional Vertigo (BPPV): (Whitney et al, 2005; n = 383 patients with a variety of vestibular diagnoses; mean age = 61 years)

5 item BPPV subscale developed from current DHI is a significant predictor of likelihood of having BPPV

Traumatic Brain Injury: (Kaufman et al, 2006; n = 20; 10 patients with TBI (6 men and 4 women) and 10 matched controls for age, gender, weight, and height; mean age = 41 (11) years; Average duration since the TBI was 2.8 years (range 0.4-14.4); 6 subjects with TBI had abnormal imaging studies)

Excellent correlation between physical aspects of the subject's complaints of dizziness on the DHI were related to SOT 6 (platform and surround sway referenced) (r = 0.72, P = 0.02)
Excellent correlation between the physical aspect of the DHI and the A/P motion of the subject (r = 0.83, P = 0.003)
Excellent correlation between the functional aspect of the DHI and the COM M/L velocity (r = 0.65, P = 0.04)
Excellent correlation between the total DHI and the M/L velocity (r = 0.71, P = 0.02)

Construct Validity (Convergent/Discriminant)

Vestibular Dysfunction: (Jacobson and Newman, 1990)

Adequate relationship between the number of dizzy spells per year and score on DHI (<12, >12, and permanent)

Vestibular Disorders: (Alghwiri et al, 2012; n= 17 experts; and n = 58 patients with vestibular disorders)

Adequate to excellent correlation of 0.54 to 0.74 (DHI vs. VAP)

Peripheral and Central Vestibular Pathology: (Fielder et al, 1996; n= 42; Participants with dizziness n= 21 with males = 3 and females = 18; mean age = 55.6 (17.2) years; duration of symptoms = 15.8 (16) months)

Adequate to excellent correlation between scores of DHI and SF- 36 (r = 0.53 to 0.72)
Directly proportional to the number of episodes of dizziness with validity increasing with seriousness.

Multiple Sclerosis: (Cattaneo et al, 2006)

Adequate correlation of DHI to Berg Balance (r = 0.32), to Dynamic Gait Index (r = 0.39), to Timed Up and Go (r = 0.35) and to Hauser Ambulation Index (r = 0.32).
Excellent correlation of DHI with Activities Specific Based Confidence Scale (r = ‐0.70)
Adequate relationship exists between the numbers of dizzy spells/year (<12, > 12, and permanent) and score on the DHI.

Elderly: (Whitney et al, 1999; n = 71, males = 15 & females = 56; age range = 26- 88 years)

Excellent negative correlation between scores of DHI and ABC (Activity specific Balance Confidence Scale) (r = 0.64)

Traumatic Brain Injury: (Gotshall et al, 2003; n= 53 with mild traumatic brain injury)

DHI significantly correlated with Dynamic Visual Acuity testing (After one week)

Whiplash Associated Disorders: (Treleaven et al, 2005; n= 100; 50 with dizziness including males = 12 & females = 38 having a mean age = 35.5 (19- 46) years and their time since injury = 1.4 (0.35- 3) years; 50 without dizziness including males = 12 & females = 38 having a mean age = 35 (18-46) years and their time since injury = 1.6 (0.3- 3) years; individuals had to refrain from medications 24 hours prior to study.)

Adequate correlation of DHI to Smooth Pursuit Neck Torsion Test (r = 0.31)

Content Validity

Vestibular Dysfunction: (Jacobson and Newman, 1990)

The total score was show to be significantly poorer for patients reporting more frequent attacks of dizziness or unsteadiness.

Traumatic Brain Injury: (Basford et al, 2003; n = 20, 10 with TBI and complaints on instability, and 10 without TBI; 6 men and 4 women, ranging in age from 18 to 65 years; age, height and gender matched with controls)

DHI scores were consistent with the subjects' complaints of unsteadiness and imbalance

Face Validity

Not Established

Floor/Ceiling Effects

Multiple Sclerosis (MS): (Cattaneo et al, 2006)

· Adequate ceiling effect (1.9%)

Responsiveness

Multiple Sclerosis (MS): (Cattaneo et al, 2006)

· Sensitivity = 50%

· Specificity = 77%

Peripheral and Central Vestibular Rehabilitation: (Enloe et al, 1997; n= 95; mean age = 25-88 (14.9) years)

DHI was found to be moderately responsive. It required 7.24 patients to measure change and had a responsiveness score of 1.66

Multiple Sclerosis: (Hebert et al, 2011)

Highly responsive (Effect size of 1.03 & 1.12 for experimental group vs. exercise control group and wait listed control group respectively at 10 weeks)
Moderately responsive (Effect size of -0.35 and – 0.84 for experimental group vs. exercise control group and wait listed control group respectively at 14 weeks.)

Professional Association Recommendations

Considerations

English language.
The authors found that the frequency of dizziness attacks could not always reflect the perceived severity of the handicap. Patients with fewer dizziness attacks would report that they were severely handicapped and those that had many attacks of dizziness did not necessarily report being severely handicapped. (Jacobson and Newman, 1990)
The Dizziness Handicap Inventory has become very important to diagnose the severity of handicap in the elderly since their post- fall complications are many, but it was still only moderately sensitive in identifying fallers in the population tested.
Since the DHI is a self- administered questionnaire, quantitative information regarding the instability episode cannot be recorded.
There was a higher prevalence of dizziness related episodes in women, whereas men were 2.26 times more depressed about their vertigo and dizziness problems.
The total score of DHI is more reliable than scores for any separate items recorded. (Kammerlind et. al., 2005; n = 50, males = 26 & females = 24; mean age = 63 (13) years; onset of vestibular pathology 3 years.)
Elderly patients >65 years have balance affections due to dizziness but a lower level of self perceived handicap and therefore need to treated more cautiously. (Hansson et. al., 2005; n = 119; males = 46 & females = 73)
With high test- retest reliability and low error of measurement scores, the DHI has become a very useful tool for measurement of dizziness handicap in individuals.

Bibliography

Alghwiri, A. A., Whitney, S. L., et al. (2012). "The development and validation of the vestibular activities and participation measure." Arch Phys Med Rehabil 93(10): 1822-1831. Find it on PubMed

Basford, J. R., Chou, L. S., et al. (2003). "An assessment of gait and balance deficits after traumatic brain injury." Archives of Physical Medicine and Rehabilitation 84(3): 343-349. Find it on PubMed

Cattaneo, D., Jonsdottir, J., et al. (2007). "Reliability of four scales on balance disorders in persons with multiple sclerosis." Disability and Rehabilitation 29(24): 1920-1925. Find it on PubMed

Cattaneo, D., Regola, A., et al. (2006). "Validity of six balance disorders scales in persons with multiple sclerosis." Disability and Rehabilitation 28(12): 789-795. Find it on PubMed

Enloe, L. J. and Shields, R. K. (1997). "Evaluation of health-related quality of life in individuals with vestibular disease using disease-specific and general outcome measures." Physical Therapy 77(9): 890-903.

Fielder, H., Denholm, S. W., et al. (1996). "Measurement of health status in patients with vertigo." Clin Otolaryngol Allied Sci 21(2): 124-126. Find it on PubMed

Gottshall, K., Drake, A., et al. (2003). "Objective vestibular tests as outcome measures in head injury patients." Laryngoscope 113(10): 1746-1750. Find it on PubMed

Hansson, E. E., Månsson, N. O., et al. (2005). "Balance performance and self-perceived handicap among dizzy patients in primary health care." Scandinavian journal of primary health care 23(4): 215-220.

Hebert, J. R., Corboy, J. R., et al. (2011). "Effects of vestibular rehabilitation on multiple sclerosis-related fatigue and upright postural control: a randomized controlled trial." Phys Ther 91(8): 1166-1183. Find it on PubMed

Jacobson, G. P. and Newman, C. W. (1990). "The development of the Dizziness Handicap Inventory." Archives of Otolaryngology - Head and Neck Surgery 116(4): 424-427. Find it on PubMed

Kammerlind, A. S., Bergquist Larsson, P., et al. (2005). "Reliability of clinical balance tests and subjective ratings in dizziness and disequilibrium." Advances in Physiotherapy 7(3): 96-107.

Kaufman, K. R., Brey, R. H., et al. (2006). "Comparison of subjective and objective measurements of balance disorders following traumatic brain injury." Medical Engineering and Physics 28(3): 234-239. Find it on PubMed

Treleaven, J., Jull, G., et al. (2005). "Smooth pursuit neck torsion test in whiplash-associated disorders: relationship to self-reports of neck pain and disability, dizziness and anxiety." J Rehabil Med 37(4): 219-223. Find it on PubMed

Whitney, S. L., Hudak, M. T., et al. (1999). "The activities-specific balance confidence scale and the dizziness handicap inventory: a comparison." Journal of Vestibular Research 9(4): 253-259. Find it on PubMed

Whitney, S. L., Marchetti, G. F., et al. (2005). "Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo." Otol Neurotol 26(5): 1027-1033. Find it on PubMed

Whitney, S. L., Wrisley, D. M., et al. (2004). "Is perception of handicap related to functional performance in persons with vestibular dysfunction?" Otol Neurotol 25(2): 139-143. Find it on PubMed

Year published

Instrument in PDF Format

Yes

Approval Status

Approved

Attachments