The DHI is a 25-item self-assessment inventory designed to evaluate the self-perceived handicapping effects imposed by dizziness.
25
10 minutes
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.Updated with references for individuals with vestibular disorders by Tracy Rice, PT, MPH, NCS and Jenny Fay, PT, DPT, NCS and the Vestibular EDGE task force of the Neurology Section of the APTA (2013)
Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.
For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations
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Abbreviations: |
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HR |
Highly Recommend |
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R |
Recommend |
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LS / UR |
Reasonable to use, but limited study in target group / Unable to Recommend |
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NR |
Not Recommended |
Recommendations for use based on acuity level of the patient:
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Acute (CVA < 2 months post) (SCI < 1 month post) (Vestibular < 6 weeks post) |
Subacute (CVA 2 to 6 months) (SCI 3 to 6 months) |
Chronic (> 6 months) (Vestibular > 6 weeks post) |
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Vestibular EDGE |
HR |
HR |
HR |
Recommendations based on level of care in which the assessment is taken:
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Acute Care |
Inpatient Rehabilitation |
Skilled Nursing Facility |
Outpatient Rehabilitation |
Home Health |
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MS EDGE |
NR |
R |
UR |
HR |
UR |
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TBI EDGE |
LS |
LS |
LS |
R |
R
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Recommendations for use based on ambulatory status after brain injury:
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Completely Independent |
Mildly dependant |
Moderately Dependant |
Severely Dependant |
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TBI EDGE |
N/A |
N/A |
N/A |
N/A |
Recommendations based on EDSS Classification:
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EDSS 0.0 – 3.5 |
EDSS 4.0 – 5.5 |
EDSS 6.0 – 7.5 |
EDSS 8.0 – 9.5 |
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MS EDGE |
HR |
HR |
HR |
UR
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Recommendations based on vestibular diagnosis
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Peripheral |
Central |
Benign Paroxysmal Positional Vertigo (BPPV) |
Other |
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Vestibular EDGE |
HR |
HR |
HR |
HR |
Recommendations for entry-level physical therapy education and use in research:
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Students should learn to administer this tool? (Y/N) |
Students should be exposed to tool? (Y/N) |
Appropriate for use in intervention research studies? (Y/N) |
Is additional research warranted for this tool (Y/N) |
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MS EDGE |
Yes |
Yes |
Yes |
No |
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TBI EDGE |
No |
Yes |
Yes |
Not reported |
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Vestibular EDGE |
Yes |
Yes |
Yes |
Yes |
English language.
Spanish version (Perez et al., 2000)
Dutch version (Vereeck et al., 2007)
Norwegian version (Tamber et al., 2009)
Swedish version (Jarlsäter, S., & Mattsson, E. (2003)
Chinese version (Poon et al., 2004)
German version (Kurre et al., 2009)
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.
Whitney at al., 2005 hypothesized that five items of the DHI were predictive of BPPV. The scale is termed the five-item BPPV subscale of the DHI. The five-item BPPV subscale is a summation of the following five items from the DHI: looking up, getting out of bed, quick head movements, rolling over in bed, and bending for a maximum score of 20 points.
The BPPV five-item subscore was a significant predictor of likelihood of BPPV (×2 = 8.35; p<0.01)
Scores of 4 and 8 on the combined items of getting out of bed and rolling over in bed were significantly related to the probability of BPPV. A score of 4 on the combined above stated items was approximately 2.7 times more likely to have BPPV than an individual that scored 0. A score of 4 on the combined items was approximately 4.3 times more likely to have BPPV than an individual that scored 0.
Dizziness Handicap Inventory translations:
French (Appendix 1):
http://www.sciencedirect.com/science/article/pii/S0168605404000029
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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)
Multiple sclerosis (calculated from Cattaneo et al, 2007)
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)
Multiple Sclerosis:
(Cattaneo et al, 2006)
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)
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)
Multiple Sclerosis (MS):
(Cattaneo et al., 2006)
Multiple Sclerosis:
(Cattaneo et al., 2006)
Multiple Sclerosis (MS): (Cattaneo et al., 2006)
Multiple Sclerosis (MS): (Cattaneo et al., 2006)
(Hebert et al., 2011)
Peripheral and central vestibular pathology:
(Jacobson & Newman, 1990; n = 14, mean age 45 (13.48) years)
Peripheral and central vestibular pathology. (Calculated from Jacobson & Newman, 1990)
Vestibular Dysfunction:
(Jacobson and Newman, 1990; n = 14; mean age = 45 (13.48) 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)
Vestibular Rehabilitation:
(Cohen & Kimball, 2003; n = 53 individuals with chronic vertigo due to a peripheral vestibular impairment; mean age = 51.1 years)
DHI scores decreased from pretest to posttest and then continued to decline over the 6-month follow- up period (P = 0.001) Changes on the DHI Total score were highly associated with VADL Total score (P = 0.001) and with VADL Ambulation score (P = 0.001)
(Cowand, et al, 1998; n = 37; mean age = 69.8 (SD = 16.2) years)
The Sign test identified a significant difference between pre-rehabilitation and post-rehabilitation total DHI scores (p < 0.0001). Significant before and after differences were found for the physical (p < 0.0001) and functional subscores (p < 0.0015)
(Jacobson & Calder, 1998).
A four-point change in the DHI-S would be statistically significant at the p = 0.05 level
Vestibular Dysfunction:
(Whitney et al, 2004; n = 85 participants with a variety of vestibular diagnoses; mean age = 61 years)
Vestibular Dysfunction:
(Jacobson and Newman, 1990)
(Jacobson & Calder, 1998)
(Perez et al., 2001)
(Tamber et al., 2009)
(Jarlsäter & Mattsson, 2003)
(Kurre et al., 2009)
(Poon et al., 2004)
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)
(Tamber et al., 2009)
Excellent internal consistency fr the Norwegian Version of the DHI (Cronbach's alpha = 0.88-0.95)
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)
(Fielder et al., 1996; n = 42)
Good to Excellent correlation with SF-36 (r = 0.53-0.72; p < 0.001)
(Jacobson et al., 1991)
Total score DHI demonstrated a moderate statistically significant negative correlation with SOT conditions 2(r = -0.39, p = 0.001); 4(r = -0.36, p = 0.004); 5(r = -0.42, p = 0.0005); and 6(r = -0.35, p = 0.004)
The functional subscale demonstrated a moderate statistically significant negative correlation with SOT conditions 2(r = -0.39, p = 0.001); 3(r = -0.29, p = 0.02); 4(r = -0.40, p = 0.001); 5(r = -0.48, p = 0.0001); and 6(r = -0.41, p = 0.0007)
The emotional subscale demonstrated a moderate statistically significant negative correlation with SOT conditions 2(r = -0.35, p = 0.004); 4(r = -0.30, p = 0.01); 5(r = -0.39, p = 0.001); and 6(r = -0.37, p = 0.003)
The physical subscale demonstrated a moderate statistically significant negative correlation with the equilibrium score on condition 2 of the SOT (r = -0.28, p = 0.02)
(Jacobson & Calder, 1998).
(Lim et al., 2012; n = 32; mean age = 55.6 years individuals with vestibular neuritis)
Discovered varying level of correlation between the DHI and the composite score of the SOT and the equilibrium scores of the HS-SOT conditions 2 and 5 depending on the level of acuity
(Perez et al., 2003; n = 226, mean age = 45.3 ± 9.4 years, individuals with vestibular pathology)
Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 5 at 6 month follow-up (r = -0.394, p < 0.05)
Adequate correlation between DHI total score and UCLA-DQ (r = 0.416; p < 0.01)
Adequate correlation between DHI total score and SOT composite score (r = -0.345; p < 0.01)
Vestibular Dysfunction:
(Jacobson and Newman, 1990)
Adequate relationship between the number of dizzy spells per year and score on DHI (< 12, > 12, and permanent)
(Perez et al., 2001)
Excellent correlation between vestibular handicap factor and DHI emotional (DHIe) subscale r = 0.927 p < 0.001, and DHI functional subscale (DHIf) r = 0.743 p < 0.001
Adequate correlation between vestibular handicap factor and the DHI physical (DHIp) subscale r = 0.317 p < 0.001
Excellent correlation between vestibular disability factor and the DHI emotional r = 0.912 p < 0.001
Poor correlation between vestibular disability factor and the DHIf subscale 0.425 p < 0.001
Adequate correlation between vestibular disability factor and DHI physical subscale r = 0.714, p < 0.001
Vestibular Disorders:
(Alghwiri et al., 2012; n = 17 experts; and n = 58 patients with vestibular disorders)
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)
Vestibular Dysfunction:
(Jacobson and Newman, 1990)
(Jacobson & Calder, 2000)
Self perceived balance handicap (DHI-total and DHI –physical subscale) experienced by patients with bilateral reductions in peripheral vestibular function is significantly greater than that experienced by individuals with balance complaints that have normal balance function tests but is not greater than those individuals that demonstrate unilateral vestibular impairments.
Peripheral and Central Vestibular Rehabilitation: (Enloe et al., 1997; n = 95; mean age = 25 - 88 (14.9) years)
Vestibular Dysfunction
(Perez et al., 2001)
Performed a factor analysis on 337 individuals with dizziness and discovered that the DHI is a multidimensional questionnaire for the assessment of dizziness and has the ability to provide a good model for vestibular handicap and disability.
(Whitney et al., 2000; n = 39, mean age = 54 ± 16 years, individuals with a diagnosis of migraine-related vestibulopathy)
Demonstrated a 12 point average decrease in DHI score (P < 0.01) after a custom-designed physical therapy exercise program performed for a mean of 4.9 visits over a 4 month period
(Wackym et al., 2008; n = 55 individuals with sporadic vestibular schwannomas treated with gamma knife)
Found a significant difference in total DHI score was seen only in the elderly (> 65 years old) patients pre-gamma knife surgery compared with post-gamma knife sugery (t = 1.34, p = 0.05)
Benign Paroxysmal Positional Vertigo:
(Lopez-Escamez, et al, 2003; n = 40 individuals with pSCC BPPV)
Dizziness Handicap Inventory Short Form total score significantly decreased from 18.05 ± 9.91 (mean ± standard deviation) at the first day to 9.54 ± 9.94 at 30 days (p < 0.001)
All 36-Item Short Form Health Survey scale scores were correlated significantly with Dizziness Handicap Inventory Short Form total scores at 30 days after treatment
Benign Paroxysmal Positional Vertigo (BPPV):
(Whitney et al., 2005; n = 383 patients with a variety of vestibular diagnoses; mean age = 61 years)
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.)
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)
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)
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)
Traumatic Brain Injury:
(Gotshall et al., 2003; n = 53 with mild traumatic brain injury)
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)
Elderly:
(Whitney et al., 1999; n = 71, males = 15 & females = 56; age range = 26- 88 years)
Alghwiri, A. A., Marchetti, G. F., et al. (2011). "Content comparison of self-report measures used in vestibular rehabilitation based on the international classification of functioning, disability and health." Physical Therapy 91(3): 346-357.
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
Clendaniel, R. A. (2000). "Outcome measures for assessment of treatment of the dizzy and balance disorder patient." Otolaryngol Clin North Am 33(3): 519-533. Find it on PubMed
Cohen, H. S. and Kimball, K. T. (2003). "Increased independence and decreased vertigo after vestibular rehabilitation." Otolaryngol Head Neck Surg 128(1): 60-70. Find it on PubMed
Cowand, J. L., Wrisley, D. M., et al. (1998). "Efficacy of vestibular rehabilitation." Otolaryngol Head Neck Surg 118(1): 49-54. Find it on PubMed
Duracinsky, M., Mosnier, I., et al. (2007). "Literature review of questionnaires assessing vertigo and dizziness, and their impact on patients' quality of life." Value in health 10(4): 273-284.
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
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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 Calder, J. H. (1998). "A screening version of the Dizziness Handicap Inventory (DHI-S)." Am J Otol 19(6): 804-808. Find it on PubMed
Jacobson, G. P. and Calder, J. H. (2000). "Self-perceived balance disability/handicap in the presence of bilateral peripheral vestibular system impairment." J Am Acad Audiol 11(2): 76-83. 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
Jacobson, G. P., Newman, C. W., et al. (1991). "Balance function test correlates of the Dizziness Handicap Inventory." J Am Acad Audiol 2(4): 253-260. Find it on PubMed
Jarlsäter, S. and Mattsson, E. (2003). "Test of reliability of the Dizziness Handicap Inventory and the Activities-specific Balance Confidence Scale for use in Sweden." Advances in Physiotherapy 5(3): 137-144.
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
Krebs, D. E., Gill-Body, K. M., et al. (1993). "Double-blind, placebo-controlled trial of rehabilitation for bilateral vestibular hypofunction: preliminary report." Otolaryngol Head Neck Surg 109(4): 735-741. Find it on PubMed
Kurre, A., van Gool, C. J., et al. (2009). "Translation, cross-cultural adaptation and reliability of the german version of the dizziness handicap inventory." Otol Neurotol 30(3): 359-367. Find it on PubMed
Lim, H. W., Kim, K. M., et al. (2012). "Correlating the head shake-sensory organizing test with dizziness handicap inventory in compensation after vestibular neuritis." Otol Neurotol 33(2): 211-214. Find it on PubMed
Lopez-Escamez, J. A., Gamiz, M. J., et al. (2003). "Impact of treatment on health-related quality of life in patients with posterior canal benign paroxysmal positional vertigo." Otol Neurotol 24(4): 637-641. Find it on PubMed
Mruzek, M., Barin, K., et al. (1995). "Effects of vestibular rehabilitation and social reinforcement on recovery following ablative vestibular surgery." Laryngoscope 105(7 Pt 1): 686-692. Find it on PubMed
Perez, I. G., Marta García-Granero, Eduardo Martin, Rafael García-Tapia, Nicolas (2001). "Factor analysis and correlation between Dizziness Handicap Inventory and Dizziness Characteristics and Impact on Quality of Life scales." Acta oto-laryngologica 121(545): 145-154.
Perez, N., Martin, E., et al. (2003). "Dizziness: relating the severity of vertigo to the degree of handicap by measuring vestibular impairment." Otolaryngol Head Neck Surg 128(3): 372-381. Find it on PubMed
Poon, D., Chow, L., et al. (2004). "Translation of the dizziness handicap inventory into Chinese, validation of it, and evaluation of the quality of life of patients with chronic dizziness." The Annals of otology, rhinology, and laryngology 113(12): 1006-1011.
Robertson, D. D. and Ireland, D. J. (1995). "Dizziness Handicap Inventory correlates of computerized dynamic posturography." J Otolaryngol 24(2): 118-124. Find it on PubMed
Tamber, A. L., Wilhelmsen, K. T., et al. (2009). "Measurement properties of the Dizziness Handicap Inventory by cross-sectional and longitudinal designs." Health Qual Life Outcomes 7(2): 101. 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
Vereeck, L., Truijen, S., et al. (2007). "Internal consistency and factor analysis of the Dutch version of the Dizziness Handicap Inventory." Acta Otolaryngol 127(8): 788-795. Find it on PubMed
Wackym, P. A., Hannley, M. T., et al. (2008). "Gamma Knife surgery of vestibular schwannomas: longitudinal changes in vestibular function and measurement of the Dizziness Handicap Inventory." J Neurosurg 109 Suppl: 137-143. 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. (2000). "Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with history of migraine." Laryngoscope 110(9): 1528-1534. 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
We have reviewed more than 500 instruments for use with a number of diagnoses including stroke, spinal cord injury and traumatic brain injury among several others.