Quality of life of patients with vestibular and non-vestibular dizziness

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Introduction

Quality of life is understood as an integrated characteristic of the patient's physical, emotional, and social functioning, based on his or her subjective perception. Over the past decades, considerable attention has been paid worldwide to studying the quality of life of patients with various diseases [1].

It is widely known that dizziness is a symptom that significantly reduces the patient’s quality of life, often leading to social maladjustment, loss of ability to work and the inability to perform professional skills, limitation of the usual way of life, dizziness can also cause falls and injuries [2; 3]. Regardless of the etiology of dizziness, patients experience a significant deterioration in their condition during its development [4; 5]. Deterioration in quality of life during dizziness, as well as the high prevalence of this symptom in clinical practice, emphasize the relevance of this issue, the study of which can contribute to increasing the effectiveness of therapy, which is of high medical and social significance [3].

The prevalence of complaints of "dizziness" is high. According to a meta-analysis [6] that included 20 studies of the PubMed, Medline and Cochrane databases on the epidemiology of balance disorders (dizziness and instability), the prevalence of non-systemic dizziness varied from 17 to 30 % among the adult population, and systemic dizziness – from 3 to 10%. A number of studies provide data on the epidemiology of specific diseases with the symptom of dizziness: thus, its prevalence in Meniere's disease was 0.12–0.5 %, in vestibular migraine – 0.98 %, in benign paroxysmal positional vertigo – 0.06–0.6 % over the course of a year, which emphasizes the difficulties of interpreting the symptom of dizziness itself, as well as differential diagnosis of its causes.

A significant proportion of patients with dizziness do not always receive specialized care in a timely manner, which contributes to a decrease in the quality of life with long-term complaints. In the domestic scientific literature, a fairly high prevalence of erroneous diagnosis of diseases that form the basis of balance disorders, as well as the prescription of low-information examination methods that do not provide the opportunity for timely diagnosis of the true cause of the symptom of dizziness and the prescription of adequate therapy is noted [5; 7]. Apparently, this fact can be explained by the limited awareness of doctors about the most common causes of dizziness and methods of diagnosing the main vestibular and balance disorders [7].

According to the results of a large domestic multicenter clinical and epidemiological observational program "GLOBUS", which includes determining the prevalence of dizziness and assessing its treatment regimens at outpatient appointments, which included the participation of 6065 patients and 606 doctors of various specialties from 59 regions of our country, it was established that a patient with complaints of dizziness receives a consultation with a neurologist in 58.3 % of cases, an ophthalmologist – in 30.4 %, an otolaryngologist – in 24.4 %, an endocrinologist – in 14.9 %, a neurosurgeon – in 11.8 %, a therapist – in 11.6 %, a psychiatrist – in 5 % [8]. The diversity of the symptom of "dizziness" requires clarification of the nature of the patient's complaints, selection of adequate patient routing for the purpose of timely diagnosis and initiation of therapy, and in some cases emphasizes the need for interdisciplinary interaction to verify the causes, improve the effectiveness of treatment and the quality of life of patients.

The aim of the study is to assess the quality of life of patients with vestibular and non-vestibular vertigo.

Materials and Methods

The study included 82 patients. In accordance with the characteristics of the presented complaints based on subjective sensations, all patients formed two observation groups: with vestibular dizziness (n = 47) and with non-vestibular dizziness (n = 35). All patients who took part in the study gave voluntary informed consent to participate. The study was approved by the local ethics committee (protocol No. 1 dated 23.01.2019).

When forming the study groups, special attention was paid to the detailing of complaints of dizziness. The first group consisted of patients with complaints of vestibular (systemic, rotational) dizziness (i.e. the illusion of movement and the sensation of rotation of one's own body or objects around), which was the result of pathology of the peripheral part of the vestibular system (labyrinth and / or the VIII pair of cranial nerves): benign paroxysmal positional vertigo (BPPV), n = 35, Meniere's disease (MD), n = 6, vestibular neuronitis (VN), n = 6). The patients were treated in the otolaryngology department of the Perm Regional Hospital or were consulted at the otolaryngology department of the Perm Medical University. All patients were also examined by a neurologist to exclude central causes of dizziness. The first group was conditionally divided into two subgroups; this division was due to the different duration of the vertigo attack: short-term (seconds to a minute; patients with BPPV, n = 35) and long-term (from 20 minutes to a day, patients with MD and VN, n = 12).

The second study group included patients complaining of non-vestibular (non-systemic, non-rotational) dizziness (subjectively in the form of a feeling of instability, swaying, unsteadiness), observed by a neurologist from the outpatient clinic at the Perm Regional Hospital with a diagnosis of chronic cerebrovascular pathology (dyscirculatory encephalopathy (DEP) of the 1st (n = 29) and 2nd (n = 6) stages). All patients with DEP were consulted by an otoneurologist.

The diagnosis of the underlying disease with the clinical picture of dizziness was established based on the analysis of complaints, disease history, objective examination data (with assessment of neurological and otoneurological status), as well as additional instrumental research methods (ultrasound examination of the brachiocephalic arteries, neuroimaging methods – magnetic resonance imaging (MRI)) to exclude pathology of the central nervous system in patients of the first group and to confirm signs of cerebral microangiopathy in case of DEP, to identify the presence of vascular risk factors. Patients were comparable by age and gender, the median age of persons with vestibular dizziness was 58.0 [50.5; 64.0] years (85.1 % of women), with non-vestibular – 59.0 [53.5; 62.0] years (82.9 % of women).

The assessment of quality of life in dizziness was carried out using the Vestibular Rehabilitation Benefit Questionnaire (VRBQ). According to a number of domestic and foreign publications, the VRBQ questionnaire is recognized as more sensitive to changes in quality of life in dizziness than the widely used DHI (Dizziness Handicap Inventory), VSS (Vertigo Symptom Scale) questionnaires and the SF-36 (Social Functioning) quality of life questionnaire [1; 9; 10]. The first section of the questionnaire specifies the patient's sensations (dizziness, Dizziness, or D), and also characterizes the changed integrative indicators of quality of life caused by the development of this symptom: physical discomfort (limitation of motor activity due to provocation of imbalance, Motion-provoked dizziness (M)) and emotional discomfort (feeling of anxiety, Anxiety (A)). The second section of the questionnaire determines the change in quality of life in connection with the development of the symptom of dizziness (the indicator Quality of life, or Q), determining the percentage indicator of the deficit in quality of life relative to the state of well-being. An indicator greater than 0 (%) suggests the existence of symptoms, loss of function, and a decrease in quality of life when dizziness occurs relative to the state preceding its development (i.e., the health status of a particular patient before the appearance of complaints of dizziness) [9; 10].

Statistical analysis of the obtained data was performed using the Statistica 12.0 package program. Nonparametric methods were used, taking into account the absence of a normal distribution in the sample. Quantitative variables were calculated using the median (Me) and quartiles [Q₁; Q₃]. When comparing two quantitative indicators, the Mann-Whitney (U) criteria were used, and when comparing three or more, the Kruskal-Wallis (H) criteria were used. Statistically significant differences were considered at p < 0.05. To identify the presence of correlations, the Spearman correlation coefficient (r) was used.

Results and Discussion

Patients with vestibular dizziness showed a 53.2 [30.4; 73.0] % deterioration in quality of life compared to their health status. Patients with non-vestibular dizziness also noted a decrease in quality of life relative to their health status, with a median deficit of 39.5 [33.4; 51.7] %. Despite the higher percentage deficit in quality of life in vestibular dizziness, the difference in the indicators in the groups was significantly insignificant (U = 159.0; p = 0.067; Table 1).

 

Table 1

Quality of life and symptom scores according to VRBQ

Parameter, %	Patients with vestibular dizziness, n = 47	Patients with non-vestibular dizziness, n = 35	р-value
Quality of life (Q)	53.2 [30.4; 73.0]	39.5 [33.4; 51.7]	p = 0.067
Overall quality of life (Q+D+A+M)	52.2 [44.1; 66.1]	35.7 [29.6; 43.3]	p = 0.002
Dizziness (D)	66.7 [50.0; 72.3]	50.0 [33.4; 55.6]	p = 0.002
Psycho-emotional discomfort/ anxiety (A)	33.4 [16.7; 55.6]	33.4 [27.8; 50.0]	p = 0.815
Physical discomfort/ movement (M)	40.1 [30.1; 63.5]	17.7 [17.4; 34.7]	p = 0.005
Total Symptom Sum (D+A+M)	47.1 [33.4; 57.8]	31.9 [27.4; 38.0]	p = 0.002

Note: p ˂ 0.05 – statistically significant differences.

 

In patients with vestibular vertigo, statistically significant differences were obtained in relation to the contribution of the vertigo symptom itself (p = 0.002), limitation of motor activity due to its possible provocation (p = 0.005) and the total sum of symptoms (p = 0.002) relative to such parameters in individuals with non-vestibular vertigo. All of the listed indicators were significantly higher in patients of the first study group. Probably, the obtained results can be explained by the prevailing pathology in the form of BPPV in patients of the first group, who have a positional nature of complaints and the dependence of rotation attacks on movement.

The obtained results confirm domestic studies, which noted a percentage deficit in quality of life according to VRBQ data in peripheral vestibular vertigo of up to 60 % [1].

An analysis of the decrease in quality of life in the subgroups of vestibular vertigo showed that the most significant decrease in quality of life in relation to health status is experienced by patients with a long-term episode of vertigo – 73.0 [55.5; 75.2] %, the difference is statistically insignificant when compared with the group of patients with BPPV, but is significant relative to patients with non-vestibular vertigo (Table 2).

 

Table 2

 VRBQ quality of life and symptom scores among vestibular vertigo subgroups

Parameter, %	I subgroup, short-term, n = 35	II subgroup, long-term, n = 12	Non-vestibular dizziness, n = 35
Quality of life (Q)	48.6 [30.4; 65.7]	73.0 [55.5; 75.2]	39,5 [33, 4; 51, 7]
р-value	I–II – 0.104; I–III – 0.265	II–III – 0.015; НI–III = 6.15; р = 0.046
Overall quality of life (Q+D+A+M)	47.1 [43.3; 62.3]	66.1 [53.2; 73.9]	35,7 [29, 6; 43, 3]
р-value	I–II – 0.035; I–III – 0.015	II–III – 0.002; НI–III = 13.09; р = 0.001
Dizziness (D)	66.7 [44.5; 72.3]	69.5 [61.2; 77.8]	50,0 [33, 4; 55, 6]
р-value	I–II – 0.183; I–III – 0.013	II–III – 0.002; НI–III = 11.78; р = 0.003
Psycho-emotional discomfort/ anxiety (A)	33.4 [16.7; 55.6]	36.1 [27.8; 47.3]	33,4 [27, 8; 50, 0]
р-value	I–II – 0.933; I–III – 0.810	II–III – 0.912; НI–III = 0.06; р = 0.969
Physical discomfort/ movement (M)	40.1 [24.1; 53.4]	40.1 [36.7; 73.5]	17,7 [17, 4; 34, 7]
р-value	I–II – 0.263; I–III – 0.032	II–III – 0.004; НI–III = 9.35; р = 0.009
Total Symptom Sum (D+A+M)	44.1 [33.4; 56.2]	54.0 [38.4; 63.1]	31,9 [27, 4; 38, 0]
р-value	I–II – 0.272; I–III – 0.012	II–III – 0.004; НI–III = 8.19; р = 0.017

Note: p ˂ 0.05 – statistically significant differences, I – short-term episode of vertigo, II – long-term episode of vertigo; III – non-vestibular dizziness.

 

It is interesting to note that among subgroups with vestibular dizziness with different episode durations, a reliably significant contribution of the dizziness symptom itself to the reduction in quality of life, as well as motor discomfort that provokes attacks, and the total sum of symptoms relative to patients with non-vestibular dizziness was noted (see Table 2). The obtained results can possibly be explained by a more vivid and significant sensation of the illusion of movement and rotation for the patient, as opposed to a feeling of instability, which probably makes a more significant contribution to the deterioration of the quality of life and, accordingly, requires timely diagnosis, based, among other things, on the detailing of complaints, and adequate treatment measures aimed at more rapid relief of this condition.

The results of the study did not reveal statistically significant differences in the contribution of psycho-emotional discomfort (anxiety) to the total deficit in quality of life depending on the type of dizziness. The effect of anxiety on the reduction in quality of life is equivalent in attacks of vestibular dizziness of varying duration. Thus, with the development of any type of dizziness (vestibular and non-vestibular, short-term or long-term episode of vertigo), the proportion of psycho-emotional discomfort is more than 30 %, which emphasizes the importance of testing the emotional sphere and early detection of affective disorders, regardless of the type of dizziness and the cause underlying its development. Thus, according to the results of a domestic study of the quality of life of patients with recurrent BPPV, a significant impact of the disease on daily activity and the state of the emotional sphere, the presence of a feeling of fear during recurrent attacks was recorded.

It has been suggested that patients with recurrent otolithiasis are more prone to developing functional disorders even after the underlying cause of dizziness has been eliminated [11].

A correlation analysis of the VRBQ questionnaire scores obtained from patients with different types of dizziness was performed. In patients with vestibular dizziness (Table 3), positive correlations were found between the symptom of dizziness and changes in body position (r = 0.580; p ˂ 0.05), between the total score of all symptoms and each of them separately, with the highest correlation observed for the symptom of physical discomfort (motor activity – r = 0.903; p ˂ 0.05).

 

Table 3

 Correlations of quality of life scores (according to VRBQ data) in patients with vestibular dizziness

Parameter	Q	Q+D+A+M	D	A	M	D+A+M
Q	1.000	–0.145	0.058	–0.151	0.051	–0.008
Q+D+A+M	–0.145	1.000	–0.080	0.023	–0.298	–0.3068
D	0.058	–0.080	1.000	0.033	0.580	0.666
A	–0.151	0.023	0.033	1.000	0.021	0.356
M	0.051	–0.298	0.580	0.021	1.000	0.903
D+A+M	–0.008	–0.306	0.666	0.356	0.903	1.000

Note: here and in Table 4: p ˂0.05 – statistically significant differences; Q – quality of life; Q+D+A+M – total quality of life; D – dizziness; A – psycho-emotional discomfort, anxiety; M – movement; D+A+M – total sum of symptoms.

 

In patients with non-vestibular vertigo, a direct correlation was established between quality of life and the symptom of dizziness (r = 0.596; p ˂ 0.05), between the total quality of life indicator and the symptom of dizziness (r = 0.863; p ˂ 0.05), as well as the influence of psycho-emotional discomfort and anxiety (r = 0.598; p ˂ 0.05) (Table 4).

 

Table 4

 Correlations of quality of life scores (according to VRBQ data) in patients with non-vestibular vertigo

Parameter	Q	Q+D+A+M	D	A	M	D+A+M
Q	1.000	0.794	0.596	0.315	0.238	0.451
Q+D+A+M	0.794	1.000	0.863	0.598	0.385	0.703
D	0.596	0.863	1.000	0.489	0.471	0.896
A	0.315	0.598	0.489	1.000	–0.037	0.382
M	0.238	0.385	0.471	–0.037	1.000	0.666
D+A+M	0.451	0.703	0.896	0.382	0.666	1.000

 

In the early stages of chronic cerebral ischemia, patients experience emotional disorders in the form of increased anxiety, emotional lability, and depression [12], while imbalance in the form of frontal dysbasia is characteristic only of the advanced (III) stage of the disease. Cerebral microangiopathy, as it progresses, may underlie the development of instability, in which case it may be associated with the disconnection of the cortical vestibular centers, thalamocortical connections, basal ganglia, frontal gait centers, and be the result of a discrepancy between the planned motor act and sensory feedback [13]. In all likelihood, non-vestibular dizziness in DEP has a multifactorial origin, and in the early stages of development, comorbid functional disorders in the form of probable persistent postural-perceptual dizziness (PPPD) make a greater contribution to the formation of this symptom, in the development of which the connection between the vestibular and limbic systems and the presence of common overlap zones of the cortical centers for maintaining balance and anxiety are widely known [14; 15].

Conclusions

The patient's quality of life is reduced with any type of dizziness relative to the health status. A significant contribution to the deficit in quality of life in vestibular dizziness is made by the sensation of rotation and physical discomfort, causing a limitation of daily activity due to the provocation of attacks. The study did not reveal any data on a significant difference between the contribution of psycho-emotional discomfort (anxiety) to the reduction in quality of life in dizziness of any type, which requires additional research in this area for the purpose of timely correction of affective disorders and early prevention of the formation of functional disorders. Taking into account the obtained correlations between the total deficit in quality of life and the state of anxiety in patients with non-vestibular dizziness diagnosed with DEP, it was revealed that, probably, at the initial stages of chronic cerebral ischemia, this group of patients is subject to a higher risk of developing functional disorders as the leading cause of dizziness, and the contribution of the main pathogenetic mechanism in the form of cortical-subcortical disconnection, including in the balance maintenance structures, is expressed to a lesser extent. The obtained results require further research into the neuropsychological status of patients with dizziness.

About the authors

I. I. Borodulina

E.A. Vagner Perm State Medical University

Email: julia.karakulova@mail.ru
ORCID iD: 0000-0002-3986-4354
Scopus Author ID: 1185430

Assistant of the Department of Otorhinolaryngology

Russian Federation, Perm

Ju. V. Karakulova

E.A. Vagner Perm State Medical University

Author for correspondence.
Email: julia.karakulova@mail.ru
ORCID iD: 0000-0002-7536-2060
Scopus Author ID: 150242

DSc (Medicine), Professor, Head of the Department of Neurology and Medical Genetics

Russian Federation, Perm

References

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