, Antonio Cesarani2 and Guido Brugnoni3
(1)
“Don Carlo Gnocchi” Foundation, Milano, Italy
(2)
UOC Audiologia Dip. Scienze Cliniche e Comunità, Università degli Studi di Milano, Milano, Italy
(3)
Istituto Auxologico Italiano, Milano, Italy
Abstract
Quantification of rehab outcome is particularly important to evaluate efficacy and efficiency of rehab protocols. Questionnaires about activities of daily living (ADL) may be used but the Visual Analogue Scale (VAS) is the easiest way to quantify, on a decimal scale, the global impression of the patient about his/her global disturbance, that is to say, the overall impact of symptoms on patient’s life. Lesion may be quantified by means of a semi-subjective scale, the vestibular index, developed by Haid and Wigand to quantify the impact of eighth nerve schwannoma on vestibular function. To get better objective estimations of balance dysfunction, several scales have been developed, but, in our experience, Equiscale developed by Tesio fits the scope of vestibular rehabilitation functional outcome measurement. Disability may be quantified by means of the Dizziness Handicap Inventory proposed by Jacobson and Newman, reduced in a short form (13 items) by Tesio et al.
The combination of VAS, Vestibular Index, Equiscale and DHIsf allows estimation of the effects of rehab on the overall impact of balance disorders, the intensity of vestibular lesion, the level of dysfunction and the perceived handicap induced by vertigo, dizziness and unsteadiness.
15.1 Introduction
Quantification of rehabilitation outcome is particularly important to evaluate efficacy and efficiency of rehab protocols. We have many times underlined the importance of distinguishing between lesion, impairment and disability and that human balance is mainly a behaviour rather than a complex function. Thus, it is possible that the adopted protocol is able to solve the impairment of that specific patient but not her/his specific disability nor her/his handicap. Sometimes it is not possible to completely solve the disability; thus in this case it is important to teach to the patient how to cope and how to manage her/his balance handicap.
On the basis of these considerations, also rehab outcome has to be planned in order to collect information about lesion–impairment–disability and the level of coping and/or management of the residual handicap. Furthermore, the outcome planning we propose is inspired by the same concept of efficacy and efficiency, that is to say, to collect the most useful information in the simplest way.
15.2 The Overall Impact of Balance Disturbances
The overall impact of balance disturbances, vertigo and/or dizziness and/or unsteadiness (VDU), can be quantified using questionnaires about activities of daily living (ADL) [1–5]. As with functional scales, there is a tendency to use different standards, depending on the type of lesion one aims to study. However, the usefulness of ADLQ estimations should not be underestimated. The clinician may well use this expertise to enhance the objective assessment of the patients. Basic activities of daily living (ADL) consist of activities that are performed daily, habitually and universally, such as dressing, bathing and eating (Table 15.1). In contrast, instrumental ADL require organization and planning and include such tasks as shopping, using transportation, preparing meals, handling finances, keeping the house and using a telephone. However, such estimations may be biased and they cannot easily be quantified or documented for studies or evaluation of the effect of treatment.
Table 15.1
Activities of daily living questionnaire (ADLQ)
Instructions: circle one number for each item |
1. Self–care activities |
A. Eating |
0 = No problem |
1 = Independent, but slow or some spills |
2 = Needs help to cut or pour; spills often |
3 = Must be fed most foods |
9 = Doesn’t know |
B. Dressing |
0 = No problem |
1 = Independent, but slow or clumsy |
2 = Wrong sequence; forgets items |
3 = Needs help with dressing |
9 = Doesn’t know |
C. Bathing |
0 = No problem |
1 = Bathes self, but needs to be reminded |
2 = Bathes self with assistance |
3 = Must be bathed by others |
9 = Doesn’t know |
D. Elimination |
0 = Goes to the bathroom independently |
1 = Goes to the bathroom when reminded; some accidents |
2 = Needs assistance for elimination |
3 = Has no control over either bowel or bladder |
9 = Doesn’t know |
E. Taking pills or medicine |
0 = Remembers without help |
1 = Remembers if dose is kept in a special place |
2 = Needs spoken or written reminders |
3 = Must be given medicine by others |
9 = Does not take regular pills or medicine OR doesn’t know |
F. Interest in personal appearance |
0 = Same as always |
1 = Interested if going out, but not at home |
2 = Allows self to be groomed or does so on request only |
3 = Resists efforts of caretaker to clean and groom |
9 = Doesn’t know |
2. Household care |
A. Preparing meals, cooking |
0 = Plans and prepares meals without difficulty |
1 = Some cooking, but less than usual or less variety |
2 = Gets food only if it has already been prepared |
3 = Does nothing to prepare meals |
9 = Never did this activity OR doesn’t know |
B. Setting the table |
0 = No problem |
1 = Independent, but slow or clumsy |
2 = Forgets items or puts them in the wrong place |
3 = No longer does this activity |
9 = Never did this activity OR doesn’t know |
C. Housekeeping |
0 = Keeps house as usual |
1 = Does at least half of his/her job |
2 = Occasional dusting or small jobs |
3 = No longer keeps house |
9 = Never did this activity OR doesn’t know |
D. Home maintenance |
0 = Does all tasks usual for him/her |
1 = Does at least half of usual tasks |
2 = Occasionally rakes or some other minor job |
3 = No longer does any maintenance |
9 = Never did this activity OR doesn’t know |
E. Home repairs |
0 = Does all the usual repairs |
1 = Does at least half of usual repairs |
2 = Occasionally does minor repairs |
3 = No longer does any repairs |
9 = Never did this activity OR doesn’t know |
F. Laundry |
0 = Does laundry as usual (same schedule, routine) |
1 = Does laundry less frequently |
2 = Does laundry only if reminded; leaves out detergent, steps |
3 = No longer does laundry |
9 = Never did this activity OR doesn’t know |
3. Employment and recreation |
A. Employment |
0 = Continues to work as usual |
1 = Some mild problems with routine responsibilities |
2 = Works at an easier job or part time; threatened with loss of job |
3 = No longer works |
9 = Never worked OR retired before illness OR doesn’t know |
B. Recreation |
0 = Same as usual |
1 = Engages in recreational activities less frequently |
2 = Has lost some skills necessary for recreational activities (e.g. bridge, golfing); needs coaxing to participate |
3 = No longer pursues recreational activities |
9 = Never engaged in recreational activities OR doesn’t know |
C. Organizations |
0 = Attends meetings; takes responsibilities as usual |
1 = Attends less frequently |
2 = Attends occasionally; has no major responsibilities |
3 = No longer attends |
9 = Never participated in organizations OR doesn’t know |
D. Travel |
0 = Same as usual |
1 = Gets out if someone else drives |
2 = Gets out in wheelchair |
3 = Home or hospital bound |
9 = Doesn’t know |
4. Shopping and money |
A. Food shopping |
0 = No problem |
1 = Forgets items or buys unnecessary items |
2 = Needs to be accompanied while shopping |
3 = No longer does the shopping |
9 = Never had responsibility in this activity OR doesn’t know |
B. Handling cash |
0 = No problem |
1 = Has difficulty paying proper amount, counting |
2 = Loses or misplaces money |
3 = No longer handles money |
9 = Never had responsibility for this activity OR doesn’t know |
C. Managing finances |
0 = No problem paying bills, banking |
1 = Pays bills late; some trouble writing checks |
2 = Forgets to pay bills; has trouble balancing checkbook; needs help from others |
3 = No longer manages finances |
9 = Never had responsibility in this activity OR doesn’t know |
5. Travel |
A. Public transportation |
0 = Uses public transportation as usual |
1 = Uses public transportation less frequently |
2 = Has gotten lost using public transportation |
3 = No longer uses public transportation |
9 = Never used public transportation regularly OR doesn’t know |
B. Driving |
0 = Drives as usual |
1 = Drives more cautiously |
2 = Drives less carefully; has gotten lost while driving |
3 = No longer drives |
9 = Never drove OR doesn’t know |
C. Mobility around the neighbourhood |
0 = Same as usual |
1 = Goes out less frequently |
2 = Has gotten lost in the immediate neighbourhood |
3 = No longer goes out unaccompanied |
9 = This activity has been restricted in the past OR Don’t know |
D. Travel outside familiar environment |
0 = Same as usual |
1 = Occasionally gets disoriented in strange surroundings |
2 = Gets very disoriented but is able to manage if accompanied |
3 = No longer able to travel |
9 = Never did this activity OR doesn’t know |
6. Communication |
A. Using the telephone |
0 = Same as usual |
1 = Calls a few familiar numbers |
2 = Will only answer telephone (won’t make calls) |
3 = Does not use the telephone at all |
9 = Never had a telephone OR doesn’t know
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