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The translation of the Vertigo Symptom Scale into Afrikaans: A pilot study
Christine Rogers
Jacques de Wet
Ayanda Gina
Ladine Louw
Musa Makhoba
Lee Tacon
Division of Communication Sciences and Disorders, Department of Health and Rehabilitation Sciences, University of Cape Town
Correspondence to: C Rogers (Christine.Rogers@uct.ac.za)
ABSTRACT
Dizziness is a common clinical problem that is challenging to
diagnose and treat. One of a subset of symptoms that fall under the
encompassing term of dizziness is vertigo, which is the subjective
experience of hallucination of movement, often associated with
vestibular disorders. While dizziness has a broad range of causes, the
association between vestibular disturbance, and its attendant vertigo,
and anxiety is well established. The Vertigo Symptom Scale (VSS) is a
questionnaire that assesses aspects of vertigo and vertigo-related
anxiety. The aim of this study was twofold. In phase 1, a translation
of the VSS into Afrikaans was evaluated using the Delphi consensus
technique and two panels of participants. Panel 1 comprised
first-language Afrikaans speakers who commented on the language,
grammar and vocabulary of the items. Panel 2 were bilingual health care
practitioners with either a psychology background or a special interest
in vertigo. After two rounds of consultation, consensus was achieved
and the final translation of the Afrikaans Vertigo Symptom Scale (AVSS)
was agreed upon, as well as a list of Afrikaans words descriptive of
vertigo. Phase 2 used a descriptive, correlational design. The aim was
to pilot the AVSS with a sample of vertiginous and control participants
to establish its ability to differentiate between the two groups and to
explore experiences of vertigo and anxiety within the two embedded
subscales. The results of the pilot study yielded significant
statistical differences (p<0.001)
between the groups on both subscales of the tool. Preliminary results
suggest that the AVSS is able to identify patients with vertiginous
disturbance and anxiety. The AVSS presents with good sensitivity and
specificity as measured by the receiver-operating characteristic (ROC)
curve.
Afrikaans is the home language of almost 6 million people in South
Africa. The translation of the VSS into Afrikaans presents health care
professionals with a tool with which to assess vertigo and
vertigo-related anxiety in this population.
Keywords: Afrikaans, anxiety, Delphi, dizziness, vertigo, Vertigo Symptom Scale, vestibular disorders
Diagnosis and management of dizziness is challenging and often
a source of frustration for the clinician (Kerr, 2005). Reasons for
this difficulty include the subjective nature of the complaints, issues
that patients have when trying to describe symptoms, and the broad
range of causes, ranging from vestibular to psychological, which could
be responsible for the presence of symptoms. Dizziness is a general
term often used by patients to describe a variety of sensations, which
include light-headedness, presyncope and other experiences including
vertigo. Vertigo is a perception of motion when there is no external
source for that sensation (Yardley, Luxon & Haacke, 1994), and is
classically associated with vestibular disorders. Vertigo may be viewed
as a distinct clinical entity along a continuum of symptoms that are
broadly described as dizziness. The identification of the presence of
vertigo, and its association with vestibular dysfunction, may direct
professionals such as otologists and audiologists in their choice of
investigations, management and subsequent referrals. For example, it
would be mandatory to conduct an audiological assessment in cases of
vertigo, while dizziness related to presyncope or cardiac causes would
not necessitate such tests. Although an appreciation of the difference
between dizziness and vertigo is critical for effective diagnosis and
treatment, the two terms are often used interchangeably and are
confused by both patients and clinicians (McPherson & Whitaker,
2001).
Attacks of vertigo may be distressing because of the associated
autonomic and vegetative symptoms (Mégnigbêto, Sauvage
& Launois, 2001). In addition, vertiginous episodes have been
associated with anxiety, panic and social phobia (Aslan, Ceylan,
Kemaloglu & Goksu, 2003; Tschan et al., 2008; Wiltink et al.,
2009). There is increasing evidence of an association between
vestibular disorders and activation of areas of the brain concerned
with emotion, and in turn with the autonomic nervous system (Best et al., 2006; Meli, Zimatore, Badaracco, De Angelis & Tufarelli, 2007; Wiltink et al.,
2009). An additional concern regarding the psychological sequelae of
vestibular syndromes is that negative or maladaptive coping mechanisms,
which include avoidance of stimulation, may reduce compliance with
vestibular rehabilitation therapy and ultimately delay recovery (Aslan et al., 2003; Cohen & Kimball, 2003; Luxon, 2004; Meli et al.,
2007). It is therefore suggested that the dual elements of vestibular
symptoms and potential psychological involvement are investigated in
all patients who present with vertigo.
A detailed, systematic and holistic case history, conducted with
insight and an empathic manner, is crucial in every case and most
likely to result in a diagnosis of the cause of vertigo (Bennett,
2008). Reliance on sophisticated clinical or laboratory testing in
place of, or as an adjunct to, the case history will seldom return a
useful diagnosis; indeed, it is the exception that results of formal
vestibular tests would influence, or change, management decisions
(Shepard, 2007). While an accurate case history is essential for
effective treatment, anamnesis may be more problematic when there are
linguistic and cultural differences between the health care
professional and patient, a scenario common in a diverse country such
as South Africa.
A variety of questionnaires have been used in clinical practice in
order to identify or assess vertigo symptoms or handicap, as well as
related issues such as anxiety. One advantage of questionnaires is to
focus patients’ thoughts on their complaints prior to the
consultation, allowing the clinician to highlight relevant issues.
Questionnaires may be used as an entrée to explore areas that
may otherwise be difficult to address, for example, probing symptoms of
panic or anxiety may elicit a guarded or defensive response. Skilfully
selected questionnaires add to the completeness of the case history,
and results may signal the need for further investigations or
referrals. One such questionnaire, the Vertigo Symptom Scale (VSS)
(Yardley, Masson, Verschuur, Haacke, & Luxon, 1992), has two
embedded subscales; one evaluates vertigo severity and the explores
symptoms of somatic anxiety. It was developed after extensive
interviews which explored the experience of patients living with
vertigo. Results from the VSS were correlated with independent scales
of anxiety and vertigo handicap, as well as diagnostic classification
systems and objective testing. The resulting VSS has been researched
extensively and good reliability and concurrent validity have been
established (Yardley et al.,
1992). The VSS is the self-assessment scale targeting vestibular
symptoms most used in clinical practice (Faag, Bergenius, Forsberg
& Langius-Eklöf, 2007). It has been translated into a number
of languages without losing validity (Tschan et al., 2008).
The South African context
In South Africa, almost 6 million people use Afrikaans as their home
language, making it the third most common language spoken. A further 15
million people are proficient in Afrikaans (South Africa Info, 2001).
In the Western Cape, where this study was conducted, the majority
(55.3%) of the population speak Afrikaans (Statistics South Africa,
2004). English language questionnaires exploring health-related quality
of life, functional assessments of chronic illness therapy and measures
of mental health have been translated into Afrikaans using a variety of
methods (Jelsma & Ferguson, 2004; Harpham et al.,
2003; Webster, Cella & Yost, 2003). Efforts have been made to
translate audiological materials, such as stimuli for speech
recognition, into Zulu (Panday, Kathard, Pillay & Govender, 2007).
While many English language questionnaires are available for exploring
aspects of dizziness and vertigo, to the authors’ knowledge none
has been translated into other languages spoken in South Africa. At
present there are no questionnaires available in Afrikaans with which
to explore the experience of symptoms of vertiginous patients
presenting to health care services. Given the large numbers of
Afrikaans speakers nationally and their predominance in the Western
Cape, a self-assessment scale was selected for translation and
validation. The VSS was selected for this research because of its
ability to explore vertiginous symptoms and those of anxiety and panic
simultaneously.
Delphi consensus procedure
The Delphi consensus procedure is a method often used in
health-related research and involves obtaining consensus of opinion
from knowledgeable participants through the use of structured
questioning in a series of rounds (Hasson, Keeney, & McKenna,
2000). Results from the first round of questions are relayed back to
participants in subsequent rounds (De Villiers, de Villiers & Kent,
2005) and in this study suggestions of Afrikaans words that would
capture the essence of the word vertigo were also sought. Delphi
procedures are cost-effective methods of gathering information, and in
contrast to focus groups, participants are not in contact with each
other, or aware of the identities of other panel members (Hardy et al.,
2004; Powell, 2002). Use of Delphi consensus procedures in audiology is
ongoing, with panels currently employing this method to aid the
development of International Classification of Functioning (ICF) health
core sets for hearing loss (Danermark et al., 2010) and vertigo (Podlipny, personal communication, 10 October 2010).
The aims of this study were to validate a translation of the VSS (Yardley et al.,
1992) into Afrikaans, and to conduct a pilot study of the
translation’s ability to differentiate between participants with
and without complaints of vertigo. The study was conducted in two
phases, which will be presented in the ‘Method’ section.
Method
Study design
In phase 1, a Delphi consensus procedure was used first, to gain
agreement on the translation of the VSS from two panels of
participants. Panel 1 comprised first-language Afrikaans speakers, who
commented on grammar and vocabulary used. Panel 2 were bilingual health
care professionals who had experience in treating patients with
vestibular disorders. In addition both panels were asked to contribute
Afrikaans words that captured the essence of the experience of vertigo.
In phase 2, a descriptive, correlational design was used and the
Afrikaans Vertigo Symptom Scale (AVSS) was piloted among a sample of
participants with and without vertigo.
Phase 1: translation of the VSS and Delphi consensus procedure
The VSS was translated from English into Afrikaans using the steps
depicted in the flow chart (Figure 1). The Delphi procedure was used to
obtain consensus on the translation. Conventional Delphi designs have
four rounds, but this was modified to two rounds as consensus was only
sought on the translation of a pre-exisiting, validated scale.
Phase 1 participants
Two panels were selected through purposive sampling. Panel 1
consisted of 5 first-language Afrikaans-speaking lay participants, and
panel 2 comprised 5 bilingual health care practitioners from a variety
of disciplines, including otolaryngology, audiology, psychology and
aviation medicine, who regularly treated patients with vertigo. All
except the psychologist had received specialised training in vestibular
disorders and were familiar with the VSS.
Phase 1 materials and procedures – Delphi consensus rounds 1 and 2
Panel 1 answered a list of questions on the language, grammar and
vocabulary of items in the translated VSS. As the scale was to be
directed at patients, the translation needed to be comprehensible to
lay individuals. Questions for panel 2 centred on the applicability of
items to the Afrikaans patient population to which practitioners were
exposed, as well as to verify the use of vocabulary chosen to explain
terms such as ‘giddy’. Panel 2 was also polled with regard
to words commonly used by their patients to describe the experience of
vertigo. Both panels were consulted regarding the Afrikaans translation
and equivalence with the English original. Panelists selected answers
from a 5-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’; in addition qualitative comments were invited.
Examples of questions asked of the panels are indicated in Box 1 below.
• A patient who reads
‘swewing’
will make the association with a feeling of ‘swimming, floating or soaring’ (item 7).
• Do you think that
‘dofheid’
encompasses the essence of visual ‘blurring’ (item 13)?
Box 1. Example of questions posed to the panellists participating in the Delphi
consensus procedure, round 1.
There is a lack of agreement in the literature as to what percentage is
acceptable as consensus, with values ranging from 55% to 100% (Powell,
2002). An 80% majority was chosen as it represented a robust majority
leaving less room for errors (Hardy et al.,
2004). When 80% consensus was achieved no changes were made to the
initial translation. Round 2 of the Delphi consensus addressed items
from round 1 upon which consensus had not been achieved. Panel members
were able to re-evaluate their opinion based on the responses and
suggestions from both panels that were presented verbatim (Greatorex
& Dexter, 2000). Respondents had to ‘agree’ or ‘disagree’ with
each item. For round 2 a majority consensus of ≥51% finalised the
changes. An example of one of the questions from round 2 appears in Box
2. The results of the Delphi consensus are the AVSS (Appendix 1), and a
list of Afrikaans words used to describe the subjective experience of
vertigo (see Box 3 in the ‘Results’ section).
For item 4, both panel 1 and panel 2 agreed by majority that ‘
neerval
’
is an appropriate translation for ‘fall’. However, other
suggestions were made. Choose the item that you most agree with.
Do you agree with a) ‘
neerval
’ Agree/ Disagree
Or the suggestion b) ‘
omval
’ Agree/ Disagree
Box 2. Example of questions posed to the panellists participating in the Delphi
consensus procedure, round 2.
Phase 2: pilot study of the AVSS
Phase 2 piloted the AVSS and used descriptive correlational
statistics to analyse the results. There were two aims for phase 2:
first, to assess and describe the relationship between the
participants’ presenting symptoms and their scores on the AVSS
for the anxiety and vertigo subscales; and second, to demonstrate
whether the AVSS could discriminate between vertiginious and control
participants.
Phase 2 participants
As both a non-vertiginous group and group of participants with
vertigo were sought, all adult patients attending ENT outpatient
services were asked if they were interested in enrolling in the
research study. Phase 2 participants who reported that their first
language was Afrikaans and who were capable of completing the AVSS
unassisted were selected using a purposive non-randomised sampling
method. The Delphi consensus procedure generated key terms used to
describe vertigo (see Box 3), and symptoms reported by participants
within the last 3 months had to match one or more of these terms for
participant inclusion in the vertiginous group; control subjects
reported no vertigo within the same period.
Eighty-five patients gave consent; subsequently 13 were excluded
because the questionnaire was returned incomplete. The sample consisted
of 72 participants, of whom 50 were female. Vertigo was present in 41
participants and 31 were controls. The age of participants with vertigo
ranged from 20 to 82 years (mean 49 years), and that of the controls
from 27 to 81 years (mean 45 years). The median schooling level was
grade 10, mode of grade 12 (N=72).
Ethical clearance
The research protocol was designed in accordance with the
Declaration of Helsinki (World Medical Association, 2008). Ethical
clearance was obtained from the institution’s Human Research
Ethics Committee as well as from the two hospitals at which data were
collected. Informed consent was obtained from all participants for both
phases of the study. Professor Lucy Yardley granted permission for the
use of the VSS, its translation and naming as the Afrikaans Vertigo
Symptom Scale (Yardley, personal communication, January 2009).
Phase 2 materials and procedures
Once informed consent was obtained, participants completed the
screening questionnaire assessing the main reason for the visit:
presence of previous and current symptoms of vertigo, panic, anxiety,
depression and medication use. The AVSS was completed and participants
were divided into vertiginous and control groups based on the results
of the screening questionnaire.
Statistical analysis
The diagnosis was recorded from the hospital folder. Data were
initially entered into Microsoft Office Excel 2007 (v. 12.0.6300.5000).
Data from 10% of the sample were re-analysed at random to check for
reliability of data capturing. The Statistica (v. 8) package and
Statistical Package for Social Sciences (SPSS) (v. 15) were used for
statistical analysis. Cronbach’s alpha assessed internal
consistency. The McNemar test determined the classification congruence
between the participants’ presenting complaint of vertigo, or the
lack thereof, and their diagnosis. The adjusted t-test and Mann-Whitney U
were conducted. The receiver-operating characteristic (ROC) curve was
used as a visual index of the accuracy of the AVSS and analysed
sensitivity and specificity.
Results
Phase 1
The researchers who performed the initial translations found that
the two independent preliminary translations were very similar.
Furthermore, no substantial differences were found when the initial
forward and back translations were compared. In round 1, the
first-language Afrikaans panel reached consensus on 22 of 31 items. The
health care professional panel agreed on 22 of 32 questions. Round 2
consisted of 21 questions, 19 of which had suggestions included.
Consensus was achieved for all of the 21 questions in round 2 and the
AVSS was finalised. Participants mentioned that the layout of the AVSS
made it challenging to complete, so the format (but not the content)
was reworked to make it more accessible. For example, response options
were arranged in boxes for participants to tick or circle. The terms
suggested by the panellists for Afrikaans synonyms for vertigo appear
in Box 3.
• Rondomtalie, tuimel, bollemakiesie, mallemeule, tol
• ‘Draai’ (patient or the environment)
• Draaiduiseligheid
• Dronk/kop-dronkheid
• ‘Ek beweeg hierdie kant toe, die wêreld anderkant toe.’
Box
3. Words and terms that were obtained from qualitative feedback in
round 1 of the Delphi technique describing the symptom of vertigo.
Phase 2
The VSS evaluates two areas – the experience of vertigo,
dizziness and imbalance (VER subscale) and symptoms of anxiety and
related psychological problems, the Anxiety and Autonomic Symptom Scale
(AA subscale). Cronbach’s alpha indicated good internal
consistency on the VER subscale (α=0.8822) and the AA subscale
(α=0.9248), i.e. the results obtained on the two subscales
indicated that the scale will elicit consistent results, rather than
results obtained by subject or item variance. The McNemar test was used
to analyse the classification congruence between complaints of vertigo
and the expectation of the symptom based on the diagnosis recorded in
the hospital notes. Four of the 72 participants included in the final
analysis (those with complete AVSS scores) were incorrectly categorised
as having vertigo when in fact they did not. The McNemar test (0.98; p=0.3211)
found no significant difference between the participants’
complaint of vertigo and the expectation of the symptom based on
diagnosis. This minimal difference in classification indicated good
categorisation of vertiginous participants and controls, based on
participants’ presenting complaints.
For the vertiginous participants the score of symptoms of dizziness,
vertigo or imbalance was relatively high, with the VER subscale showing
mean 19.902, standard deviation (SD) 12.047, N=41,
where the highest possible score obtainable on the VER is 76. Most of
the vertiginous sample (54%) scored on all three features of dizziness:
a feeling of spinning or moving around, being light-headed, swimmy or
giddy, and a feeling of unsteadiness (items 1, 7 and 18 on the AVSS).
In contrast, no participant from the control group reported all three
classic features of dizziness with increased occurrence (scores of 3 or
4 on the AVSS). The control sample yielded a significantly lower mean
score overall, with the VER subscale showing mean 3.742, SD 3.838, N=31.
This would suggest that the VER is able to differentiate reliably
between those with and without vertigo. Figure 2 shows histograms of
the VER data for both samples.
In addition to the presence of symptoms of dizziness, over one-third
of the vertiginous sample complained of symptoms of autonomic nervous
system arousal and/or anxiety; checking items such as the presence of
hot or cold spells, heart palpitations, and presyncope (items 3, 10 and
22). A relatively high mean score overall for the AA subscale was
obtained (mean 26.829, SD 16.269, N=41),
where the highest possible score on this subscale is 60. The control
group reflected a lower overall mean score, with the following
obtained: mean 13.065, SD 9.284, N=31.
Interestingly, none of the participants in the control group reported
presyncope. Figure 3 shows histograms of the scores obtained on the AA
for both samples.
Successful differentiation between the participant groups was
therefore obtained on both subscales of the AVSS. Further statistical
analysis was conducted, and both the parametric and non-parametric
measures used indicated significant statistical differences on both
subscales between the samples with t-test and Mann-Whitney U values less than p=0.05. Between both samples, the following results were obtained on the adjusted t-test and Mann-Whitney U non-parametric analysis: VER [t (50.25)=-8.065, p<0.001; Mann-Whitney U (49)=0.000, p<0.001] and AA: [t (65.64)=- 4.529, p<0.001; Mann-Whitney U (316.5)=0.000, p<0.001]. The p-scores obtained for the t-test
and Mann-Whitney U are substantially less than 0.001, which is less
than the set criteria for statistical significance, increasing the
significance of the results obtained.
An ROC curve (Figure 4) was constructed in an attempt to establish
cut-off scores that would distinguish between cases of vertigo and
non-cases. The AVSS shows good sensitivity and specificity for both
subscales and as a whole. The VER has better sensitivity in identifying
vertiginous versus control participants than the AA’s ability to
identify those with anxiety from those without. The VER has an optimal
cut-off suggested at 7.5, which yields a sensitivity of 0.902 and
specificity of 0.097. The AA did not indicate an optimal cut-off and
17.5 was suggested, as the best balance for sensitivity is 0.683 and
specificity is 0.258 at this level. To conclude, the entire AVSS
presents with relatively good sensitivity and specificity (demonstrated
by the second line from the reference line on the ROC).
Discussion
There are various methods of evaluating the translation of an
instrument, ranging from simple forward- and back-translations to
subjecting the translation to a process of review using a technique
such as the Delphi. In this study a Delphi consensus procedure, using
panels of first-language Afrikaans speakers and bilingual health care
professionals, yielded the AVSS which was piloted with vertiginous and
control participants. Although the focus of the discussion is on the
results of the pilot study, the Delphi is discussed briefly. Delphi
consensus procedures have a number of features that may either enrich
or weaken a study. They are cost-effective, and panel members are
usually selected for their strengths and are not unduly influenced by
each other. However, a lack of standardisation in the method, including
decisions about when consensus has been reached, lack of test-retest
reliability and possible selection bias (Hasson et al., 2000), all warrant concern. Although there is no agreement on what to accept as consensus in the literature (Hasson et al.,
2000), a conservative figure was chosen for consensus in the first
round, favouring caution. In the second round, consensus was achieved
for all items. There were limitations in terms of the small number of
participants on each panel. It is possible that the panels’
opinions were not representative of a wider first-language or expert
population, raising the possibility of selection bias. In addition, the
use of a first-language lay panel could be queried with regard to their
value; however, it was felt that the final translation should be
accessible in terms of vocabulary to a projected patient population,
and that the lay panel would bring a different perspective to that of
the health care professionals. Furthermore, no formal tests to
establish language competence of any of the participants were
conducted. Although the limitations of the Delphi consensus procedure
require acknowledgement, they are somewhat ameliorated by its use only
to confirm a translation of an already validated questionnaire. The
researchers believe that concurrent validity has been established as a
result of the AVSS’s ability to discriminate between individuals
presenting with and without vertigo. Furthermore, Cronbach’s
alpha suggested internal consistency within the scale.
Clinical utility of the AVSS
Because of the array of symptoms and aetiologies with which a
vertiginous patient may present, the underpinning of a competent
assessment is a thorough case history (Mégnigbêto et al., 2001; Yardley et al.,
1992). However, in South Africa clinicians may encounter challenges in
obtaining a case history as a result of linguistic issues. A
questionnaire such as the AVSS explores symptoms of dizziness and
vertigo, associated autonomic nervous system symptoms and
anxiety-related factors. The AVSS has proven reliable and could be
useful for clinicians to categorise patients’ subtypes of
dizziness. It bears reiteration that precise symptom definition, plus
identification of associated symptoms such as anxiety, is essential for
effective diagnosis. Further, self-assessment scales require patients
to be reflective about their complaint. As the AVSS covers a wide range
of symptoms, the patient is asked to consider several aspects of
his/her condition. The AVSS may create an opportunity for the clinician
to explore specific areas, which may assist in keeping the consultation
focused and time-efficient. For example, identification of anxiety is
essential for successful management (Luxon, 2004), and high scores on
the AA subscale would alert the clinician to explore this during the
clinical encounter and refer the patient if necessary. Even when
physical symptoms cannot be controlled optimally, such as in the case
of Ménière’s disease, recognition and management of
psychological distress can result in improvements in the quality of
life (Kirby & Yardley, 2008).
Significant statistical differences were found between the samples
for both subscales embedded in the AVSS. The ROC curve suggested that
the AVSS is sensitive and specific in correctly identifying true cases
of participants complaining of vertigo. However, a clinical tool may
have considerable power in identifying those patients whom it aims to
identify, yet be of little value when it comes to patient care (Zwieg
& Campbell, 1993). As one of the primary concerns in management of
vertigo is delineating its true nature, which in turn will dictate
subsequent treatment and referral options, instruments with a high hit
rate are desirable. The AVSS could be used at various levels of care
and ensure that patients are referred to the appropriate health care
professional – in this case vertiginous patients to audiologists
and otologists.
In spite of the AVSS being statistically robust, it is apparent that
not all tools are suitable for all patients. In this study, 13
participants were excluded because the AVSS had not been completed in
full. Qualitative feedback from these individuals suggested that some
had difficulty with the format, which followed the published English
version. This resulted in a new layout for the scale, with boxes for
participants to enter their responses, which had a clearer appearance.
However, when the challenges of a self-assessment scale in cases where
literacy may be an issue are considered, the AVSS in its present format
may still be too daunting for some patients. For individuals with low
general literacy levels faced with material presented in a different
language, written documents used in health care may give rise to
frustration. Interestingly, clinicians are thought to overestimate
their patients’ literacy skills, leading to more difficulties
(Schmidt von Wühlisch & Pascoe, 2010). It is possible that the
AVSS may not be of practical use in some clinical settings, depending
on the functional and health literacy of the patient population. The
study did not explore the threat to validity should the scale be
administered by a health care professional rather than
self-administered, but this could be investigated at a later stage.
The generalisability of the study is
limited by the size and centralised nature of the sample. Study data
cannot account for the range of dizzy patients who could potentially
consult a clinician. The state hospitals were both located in an urban
centre and it is possible that rural participants may have yielded
substantially different results. In addition participants did not
undergo objective testing, thus limiting the correlation between the
participants’ diagnosis and their presenting complaint of
vertigo, or lack thereof. However, a counter-argument to this is that
objective testing often does not prove a diagnosis or even the presence
of a patient’s symptoms (Kerr, 2005; Mendel, Bergenius &
Langius, 1999). It is possible that a Hawthorne effect exists.
Participants may have reported more symptoms, or more severe symptoms,
on the AVSS in the hope that they might receive preferential treatment
or have their medical needs given more priority. However, it was
pointed out to each potential participant that the researchers would
neither assess nor manage patients’ conditions and that this
would be attended to by the regular staff.
As this was a pilot study, future research should include a larger
sample of participants, from a variety of settings. Furthermore, as
there is no other suitable Afrikaans questionnaire with which to
compare the AVSS, construct validity was not evaluated. It is therefore
recommended that another scale such as the Dizziness Handicap Inventory
(DHI) (Jacobson & Newman, 1990) be translated and piloted. The
results of the two scales could be compared for information regarding
the validity of the AVSS. Furthermore, the results of the
self-assessment scales could be correlated with findings on clinical or
objective examination.
In South Africa, a range of clinicians may be involved in the
management of patients with vestibular involvement, including
otolaryngologists, neurologists, audiologists with vestibular training,
physiotherapists and psychologists. All of these professionals will
approach the vertiginous patient from a different perspective relative
to their training. The study revealed that there does not appear to be
an Afrikaans word that appropriately implies the symptom of vertigo, so
‘draaiduiseligheid’
is suggested as suitable for use within clinical settings. The term
adequately conveys a sense of dizziness or of being light-headed, while
incorporating the vital aspect of a hallucination of movement.
Consistent use of terminology within and between disciplines, as well
as use of the AVSS, may offer something to bridge professional
differences and aid the clinician who is not specialised in the area of
vestibular disorders. Clinical reasoning regarding both the definition
of the presenting symptoms and the results from the subscales of the
AVSS may in turn make referrals more rational and appropriate.
Conclusion
The AVSS is able to detect classic symptoms of vertiginous distress,
which often include associated symptoms of autonomic nervous system
arousal. The ROC measure indicated that the AVSS presents with good
sensitivity and specificity, and therefore demonstrates good
discriminative ability in identifying patients with vertigo. Hence it
is an ideal first option in patient self-assessment and can
appropriately confirm the presence of symptoms, explore facets of
anxiety and direct appropriate management and future referrals. The
AVSS will complement the case history, which in turn will support more
accurate diagnosis. It should be noted that the English and translated
VSS were designed as self-assessment scales, and this could render them
inaccessible for a sizeable proportion of the population who do not
have functional literacy. The word ‘draaiduiseligheid’ is
a useful addition to the clinical armamentarium as it captures a
description of movement and disorientation to the environment. As
symptom definition is a fundamental first step in discriminating
between dizziness and vertigo, and thus directing assessment and
management decisions, it is hoped that this will prove to be a useful
contribution. Considering the wide use of the VSS around the world in
specialist clinics, the AVSS has the potential to enhance the
assessment of vertigo and attendant vertigo-related anxiety in the
Afrikaans-speaking population.
Acknowledgements. The
researchers would like to extend their gratitude to Professor Lucy
Yardley for permission to use and translate the VSS, and Ms Anneli
Hardy for her statistical analysis. We also wish to acknowledge the
contribution of the panellists and the participants at the two
institutions at which the study was conducted, and the two anonymous
reviewers for their constructive comments.
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Fig. 1. Flow chart depicting the translation of the Vertigo Symptom Scale into
Afrikaans.
Fig. 2. Histograms depicting the spread of scores
obtained on the VER subscale. The control results are in the left
diagram. Scores on the VER are found on the x-axis with the number of
participants found on the y-axis. Note that the control sample’s
scores are substantially lower than those obtained by the vertiginous
sample.
Fig. 3. Histograms depicting the spread of scores
obtained on the AA subscale. Scores for the control group are displayed
in the left diagram. Scores obtained on the AA are found on the x-axis.
Overall, the vertiginous sample scored higher on the AA.
Fig. 4. The ROC curve obtained for the AVSS, including both the VER and AA subscales.
Appendix 1. Afrikaanse Vertigo Simptome Skaal
Instruksies:
Omkring asseblief die gepaste nommer om aan te toon ongeveer hoeveel keer jy die volgende simptome, op die lys, ervaar het gedurende die laaste 12 maande (of sedert die duiseligheid begin het, indien jou duiseligheid minder as ’n jaar gelede begin het).
Die verskeidenheid van keuses is:
0
1
2
3
4
Nooit
Enkele kere
(1 - 3 maal ’n jaar)
Verskeie kere
(4 - 12 maal ’n jaar)
Redelik gereeld (gemiddeld, meer as 1 maal per maand)
Baie gereeld (gemiddeld, meer as 1 maal per week)
Hoe gereeld gedurende die afgelope 12 maande het jy die volgende simptome gehad:
Nooit
Enkele Kere
(1 - 3 maal ń jaar
Verskeie kere
(4 - 12 maal ń jaar
Redelik gereeld (gemiddeld, meer as 1 maal per maand)
Baie gereeld (gemiddeld, meer as 1 maal per week)
1. ’n Gevoel dat alles draai of in die rondte beweeg, vir ’n tydperk van: [beantwoord asseblief a) tot e)]
a) minder as 2 minute
b) tot en met 20 minute
c) 20 minute tot 1 uur
d) ’n aantal ure
e) meer as 12 ure
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
2. Pyn in die hart of bors area
0
1
2
3
4
3. Warm of koue gloede
0
1
2
3
4
4. Onvas op jou voete, so erg dat jy omval
0
1
2
3
4
5. Naarheid (siek voel), ’n draai gevoel in die maag
0
1
2
3
4
6. Spanning/seerheid in jou spiere
0
1
2
3
4
7. ’n Gevoel van lighoofdigheid, ’n gevoel van ‘swewing’ of duiseligheid, vir ’n tydperk van: [beantwoord asseblief a) tot e)]
a) minder as 2 minute
b) tot en met 20 minute
c) 20 minute tot 1 uur
d) ’n aantal ure
e) meer as 12 ure
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
8. Bewerigheid, rillings
0
1
2
3
4
9. ’n Gevoel van drukking in die oor/ore
0
1
2
3
4
10. Hartkloppings of -versnellings
0
1
2
3
4
11. Braking
0
1
2
3
4
12. ’n Swaar gevoel in die arms of bene
0
1
2
3
4
13. Visuele versteurings (bv. dofheid, flikkering, kolle voor die oë)
0
1
2
3
4
14. Hoofpyn of ’n gevoel van drukking in die kop
0
1
2
3
4
15. Onvermoeë om behoorlik, sonder ondersteuning, te staan of te stap
0
1
2
3
4
16. Moeilike asemhaling, kortasem
0
1
2
3
4
17. Verlies van konsentrasie of geheue
0
1
2
3
4
18. Onvas op jou voete, besig om balans te verloor, vir ’n tydperk van: [beantwoord asseblief a) tot e)]
a) minder as 2 minute
b) tot en met 20 minute
c) 20 minute tot 1 uur
d) ’n aantal ure
e) meer as 12 ure
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
19. Tinteling, prikkeling of lamheid in dele van die liggaam
0
1
2
3
4
20. Pyne in jou laerug area
0
1
2
3
4
21. Oormatige sweet
0
1
2
3
4
22. Voel flou, besig om bewussyn te verloor
0
1
2
3
4