dizziness has a high incidence worldwide , and the impact of vestibular disease on quality of life has been increasingly investigated .
many patients with dizziness restrict their daily activities and leisure in order to reduce the risk of onset of unpleasant and frightening symptoms , as well as to avoid the social embarrassment and stigma that these symptoms may cause1 .
benign paroxysmal positional vertigo ( bppv ) is a disease with a high incidence worldwide , and can be regarded as the most frequent vestibular disease2 .
there are few studies correlating bppv and meniere 's disease ( md ) and their combined influence on the quality of life of patients3 
 4 .
simultaneous diagnosis of bppv and md may worsen symptoms of dizziness and thus worsen the quality of life , because the discomfort caused by these symptoms can significantly change the ability of patients to perform their usual tasks4 . among existing evaluation instruments , the dizziness handicap inventory ( dhi ) is an internationally validated instrument .
this questionnaire assesses patients ' perception of the effects of the disabling vertigo on their quality of life , including the physical , emotional , and functional aspects .
it is important to assess the individual 's condition at the beginning of treatment and to monitor the evolution of the disease course1 ( chart 1 ) . 

legend : physical aspects - questions 1 , 4 , 8 , 11 , 13 , 17 and 25 ; functional aspects - questions 3 , 5 , 6 , 7 , 12 , 14 , 16 , 19 and 24 , emotional aspects - questions 2 , 9 , 10 , 15 , 18 , 20 , 21 , 22 and 23 .
each yes answer  =  4 points ; sometimes  =  2 points ; no  =  0 points .
treatment options for vertigo patients include medications , vestibular rehabilitation ( vr ) and , more rarely , surgical procedures5 .
vr has been used as a strategy for the treatment of vestibular disorders because its goals are to provide security to the patient and integrate them into their social environment .
vr aims to promote visual stabilization , improve static and dynamic balance , decrease sensitivity during head movement , and improve the overall function of the patient via proprioceptive and vestibular visual stimulation maneuvers6 .
the objective of this study was to evaluate the pre- and post - vr quality of life of patients with md - associated bppv by using the brazilian version of the dhi as an evaluation tool .
the study was approved by the ethics in research on humans foundation regional university of blumenau ( furb ) , under protocol 180/09 .
the sample consisted of 12 patients of both genders with a diagnosis of meniere 's disease associated with benign paroxysmal positional vertigo ( bppv ) of the posterior canal , who were seen at the ent clinic during the period from october to december 2009 .
inclusion criteria were as follows : clinical diagnosis of meniere 's disease with complementary electrocochleographic findings , presence of nystagmus triggered by dix hill pike maneuvers and lateral placement test identified under the guidance of videonystagmography , no treatment initiation or maintenance during the period between surveys , agreement to undergo surgery to the ear , and agreement to signing a consent form .
we excluded patients with signs and symptoms of vestibular central origin , those with musculoskeletal abnormalities that impair the performance of the maneuvers ( diagnostic and therapeutic ) , individuals who began vestibular rehabilitation before completing the questionnaire , and patients undergoing vestibular rehabilitation lasting less than 5 sessions , considering the research period .
the sessions were held once a week individually , with each session lasting 1 hour .
vr started with the canalith repositioning maneuver of epley , where the individual sitting on the table adopts a supine position and the therapist rotates the head to the side of the affected labyrinth . after a minute , the head is rotated to the opposite side and the patient is instructed to stay in the same position for another minute , returning to a seated position at the end .
this was followed by the brandt and daroff habituation exercises . from the seated position on the table
, the patient adopts a lateral recumbent position ( first on the side that causes the dizziness ) , maintains the position for 30  seconds or until the dizziness passes , changes to a lateral seated position , waits for the same time period , and then lies on the opposite side and waits for 30 seconds .
each patient was taught the exercises and instructed to repeat them at home 1020 times a day .
in addition , we performed the cawthorne - cooksey visual exercises consisting of up and down and side - to - side eye movements as well as extension of an arm and focusing on the finger as it approaches and moves away from the face .
all movements were repeated 20 times , starting slowly and becoming progressively faster , with the patient sitting or lying down . in another exercise , with the individual sitting or standing ,
only the head moved forward and back , after a back and forth motion ; these motions were first performed slowly and then rapidly , with eyes open and progressing to accomplishment of each movement and with eyes closed for 1 minute . the brazilian version of the dhi was completed by participants before undergoing the first session of vr and after the last treatment session .
subjects were instructed to mark the item that best demonstrated their perception of the influence of vertigo on their quality of life at the time , with doubts addressed by the researchers present during the survey .
no ,  corresponding to 0 ( zero ) , occasional presence of symptoms / problems was reported as  sometimes ,  and was scored as 2 points , and the presence of severe symptoms / problems was marked 
the minimum score of the questionnaire was 0 ( zero ) and the maximum was 100 points , with 7 items referring to physical aspects , 9 to functional aspects , and 9 to emotional aspects7 . for data analysis , we first used the shapiro - wilk test of normality , proceeding with the wilcoxon test for comparisons between samples before and after vestibular rehabilitation , and the friedman test to compare the impact of physical , emotional , and functional scores after standardizing the values by calculating the percentage according to the maximum possible score to be obtained on each item .
spearman correlation was used to evaluate the relationship between aspects , the total score , and the characteristics of the sample test .
all analyses were processed in 4.0 bioestat considering significance at p  <  0.05 .
in the stipulated period for data collection , 12 individuals fulfilled the criteria for inclusion and exclusion .
there were 4 ( 33.33% ) men and 8 ( 66.66% ) women , all caucasian , aged between 35 and 86 years ( mean , 53.17    15.75 years ) .
three ( 25% ) were less than 40 years old , 6 ( 50% ) were aged between 40 and 59 years , and 3 ( 25% ) were aged 60 years or more ( table 1 ) .
there was a significant reduction in all dhi values after vr , independent of the aspect .
the median final values were 0 ( zero ) for the physical aspect , 1 for the emotional aspect , and 1 for the functional aspect , demonstrating the favorable impact of vr on the quality of life of our patients ( table 2 ) .
generally , the score must be reduced by at least 18 after treatment to be indicative of benefit1 . in our series ,
7 ( 58.33% ) patients showed a reduction greater than 18 points , 5 ( 41.67% ) did not show a reduction greater than 18 points , and 3 ( 25% ) did not achieve a pre - vr score large enough to show such a reduction . in the evaluation of post - vr scores , 2 ( 16.6% ) patients who had scores less than 18 pre - vr , despite showing an improvement in the aspects evaluated , did not show score reductions of the specified magnitude .
p  <  0.01 when compared to before . to compare the effects on the different aspects ,
the raw score values were normalized as percentage values , with 100% indicating the maximum score in every aspect .
next , we compared the pre- and post - vr scores . in the preoperative evaluation
, we noted that the diseases had a greater impact on physical and functional aspects than on the emotional aspect .
although none of the aspects showed a predominant effect of vr , the differences in the pre- and post - vr values showed that vr had the greatest influence on the physical aspect ( table 3 ) .
p  <  0.05 when compared to emotional aspect in the first evaluation ( pre - vr ) , the correlation between the physical and functional aspects was moderately positive , and that between the emotional and functional aspects was strongly positive , indicating the interrelationship of these factors on quality of life of the volunteers , i.e. , the functional aspect influences and is influenced by physical and emotional aspects .
however , analysis of the difference ( pre - post ) showed a weak positive correlation between the emotional and functional aspects ( table 4 ) . in the pre- and post - vr analyses
, there was a lack of correlation between age and gender with the dhi scores , indicating that the results of the vr were not affected by these characteristics ( table 5 ) .
it should be noted that the sample size did not allow generalization of the results ; however , considering the results , the importance of vr is evident . in another study with 15 subjects who were diagnosed as having bppv associated with mnire 's disease ,
the physical aspect was the most affected4 , but there are few studies analyzing both conditions together and using vr for the treatment of this combination .
regarding gender , there was a predominance of women ( 75% ) in the sample , which agrees with previous studies that found a prevalence of dizziness and bppv in 61.3% to 62.5% of female patients8 
 9 
 10 .
some authors suggest that the variations in natural hormones in women could be related to this increased incidence , but did not elucidate this theory11 . as for meniere 's disease ( md ) alone , there are reports of an equal distribution between genders12 .
the most prevalent age group in this study also coincides with the findings obtained by other authors , who indicated that 48% to 60% of subjects were between 41 and 60 years of age4 
 7 .
other studies have also reported the coexistence of these 2 diseases , with patients initially presenting symptoms of md followed by symptoms of bppv13 
 14 .
one hypothesis for this relationship between the 2 diseases is the possible release of otoconia by damage to the utricle by endolymphatic hydrops and hypertension3 .
the dhi - brazilian version was used to assess the impact of vr on the quality of life of patients and , based on the significant score decrease in most patients , it is argued that vr is favorable for these patients .
the dizziness and other symptoms that often accompany vestibular disorders may manifest during social , familial , and professional activities , thus causing physical , financial , and psychological distress to the patients15 
 16 
 17 and necessitating interventions to eliminate or minimize these symptoms .
individuals end up restricting their head movements and activities to prevent vertigo , thereby imposing physical constraints that lead to functional loss and consequent emotional turmoil , which explains the damage caused by these disorders .
we found that pre - vr , the greatest impact was noted on the physical and functional aspects while after vr , the greatest influence was noted on the physical aspect , despite the reduction of the values in the functional and emotional aspects as well . it was noted that after the improvement in physical symptoms , individuals were able to resume their routine activities that were previously restricted due to dizziness or fear of symptoms , and this improvement consequently improved functional and emotional aspects , which are dependent on the physical aspects .
this result contrasts the results of a previous study18 , where a sample of 6 patients , aged 4370 years , with complaints of dizziness and tinnitus showed no significant improvement in the functional and emotional aspects and no improvement in the physical aspect after vr .
it should be noted that apart from vertigo , some individuals had age - related comorbidities ( such as osteoarthritis and osteoporosis ) , which by itself has limited some of the emotional issues such as fear of high places and fear of being alone at home or going out unaccompanied .
therefore , it is likely that the answers to these questions were influenced by comorbidities , so it is not possible to separate them from the symptom of vertigo / dizziness .
this situation indicates that the analysis of the emotional aspect should be undertaken with care , because if the individual is unable to perform some physical activity for problems not related to dizziness , even after the improvement of vertigo , he / she will be unable to do the same .
the correlation between the physical and functional aspects and between emotional and functional aspects in pre - vr assessments demonstrates the interrelationship of these factors with the quality of life of individuals , i.e. , the functional aspect influences and is influenced by the physical and emotional aspects .
however , this effect appears to be greater when the symptoms are exacerbated by vertigo , since after vr , no such correlation was observed .
the relationship between the functional and physical aspects is also highlighted in other studies , where the similar scores for these aspects were explained by the fact that in bppv , onset of symptoms is closely related to certain positions or head movements , the relevant questions for which are contained in both aspects of ihl - brazilian version19 
 20 .
similarly , studies involving individuals with md associated with higher scores on the physical and functional aspects to the chronic nature of the disease with clinical manifestations floating , recurrent and lasting , that can compromise not only physical , but also the functionality of these patients4 
 21 . in another study with 6 patients aged 4370 years , the analysis of the dhi questionnaire after vr showed that patients experienced an improvement in functional and emotional aspects , although the difference was not significant18 .
furthermore , the relationship of the functional to the emotional aspects can be understood by the rationale that when there is improved functionality , the individual returns to his / her daily habits , accomplishing all movements restricted before the onset of vertigo .
thus , the individual becomes more confident with regard to leaving the house without company and can simply raise the head or turn over in bed without being afraid of triggering symptoms .
the results of vr were not affected by age and/or gender , similar to previous studies that indicate no relationship between improvement in patients with vertigo and after vr with these variables20 
 22 .
in this context , the geriatric population responds to treatment as well as a younger population , but most of the elderly patients require a greater number of treatment sessions to achieve the same result as the young23 .
moreover , other studies describe that age is not necessarily associated with loss of independence in activities of daily living , and therefore , it is not possible to relate the age - diminished ability with greater independence or improvement in vertigo after vestibular alteration24 . on the other hand , dizziness has a more detrimental effect on quality of life of elderly than in younger adults , according to studies with these populations25 
 26 
 27 
 28 . regarding gender , some authors report that the variable is not related to any advantage or disadvantage in relation to response to treatment7 , a fact verified by the results presented here . as individuals in the sample were out of the crisis period during the questionnaire analysis and underwent vr , the results discussed are restricted to perception of symptoms by individuals on a daily basis , whereas in vertigo , the symptoms are exacerbated .
finally , we would like to point out the importance of multidisciplinary medical and physiotherapy in the diagnosis and treatment to achieve greater security and adherence to this treatment modality .
the results obtained through the dhi brazilian version show that the quality of life of patients with bppv associated with md improved after 5 sessions of vr in all aspects analyzed .
we noticed that the diseases had a greater impact on the physical and functional aspects of quality of life before vr , with the highest rate of improvement noted in the perception of physical appearance after the therapy .
although the sample consisted of a small number of patients , the results obtained with vr were surprising and further studies need to be developed , especially involving the 2 pathologies .
moreover , the vr was well accepted by volunteers who showed increased enthusiasm and confidence with the evolution of treatment and reduction of symptoms .
 summary 
 introduction :  vertigo is a symptom that impacts the patients ' quality of life and may force them to cease performing activities of daily living . here , we discuss benign paroxysmal positional vertigo ( bppv ) and meniere 's disease ( md ) , which show exacerbated symptoms when they appear in association . 
 vestibular rehabilitation ( vr ) is an effective treatment in reducing vertigo , especially in conjunction with other therapies . 
 
 aim :  to evaluate the quality of life of patients with bppv and md before and after vr . 
 
 method :  we conducted a descriptive observational qualitative and quantitative case study with 12 patients aged 35 to 86 years . 
 all patients diagnosed with bppv and md received treatment in the ent clinic . 
 the brazilian dhi questionnaire , which assesses the quality of life with a focus on physical , emotional , and functional aspects , was used for data collection , and was completed by patients before the first session and after the fifth session of vr . 
 data were tested using the shapiro - wilk normality test , followed by wilcoxon , friedman , and spearman correlation tests ( p  <  0.05 ) . 
 
 results :  there were significant improvements in scores for all aspects , with median changes ranging from 12 to 0 in the physical , 6 to 1 in the emotional , and 11 to 1 in the functional aspect . 
 there were no correlations between the scores and sample characteristics . 
 
 conclusion :  vr was an effective method for the treatment of patients with bppv and md ; it improves quality of life and shows the maximal influence on physical aspect scores , regardless of age or gender . 