Categorizing individuals based on the severity of Visual Vertigo Analogue Scale symptoms

Abstract

BACKGROUND:

The Visual Vertigo Analogue Scale (VVAS) assesses visual vertigo. Instead of the original scoring methods (positive VVAS > 1), we propose categorizing patients as having No (0), Mild (0.1–40), Moderate (40.01–70), or Severe (70.01–100) symptoms.

OBJECTIVE:

Our primary aim was to validate an alternative interpretation of the VVAS by exploring the relationship between categories of visual vertigo symptoms and measures of activity and participation, dizziness handicap, anxiety, and depression. We aimed to describe the severity of visual vertigo reported by patients in different vestibular diagnostic categories.

METHODS:

Participants with vestibular disorders (n = 250) completed the VVAS, Vestibular Activities and Participation (VAP) Measure, Dizziness Handicap Inventory (DHI), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS:

Patients with central disorders were more symptomatic than those with peripheral vestibular disorders. As evaluated by one-way ANOVA, the scores on the VAP, HADS, and DHI significantly differed among mild, moderate, severe, and no visual vertigo categories (p < 0.001). As VVAS severity increased, activity and participation decreased (r = 0.582, p < 0.001); dizziness handicap increased (r = 0.597, p < 0.001, n = 199); anxiety increased (r = 0.405, p < 0.001); and depression increased (r = 0.521, p < 0.001).

CONCLUSIONS:

The findings of this study support the use of an alternative VVAS interpretation method of categorizing symptoms as none, mild, moderate, and severe visual vertigo.

Keywords

Vestibular visual vertigo assessment classification dizziness vertigo rehabilitation physical therapy

1 Introduction

Visual vertigo is a debilitating symptom induced by exposure to dynamic visual environments, such as busy grocery store aisles and bustling city streets [7]. Individuals with visual vertigo often self-select out of activities that may make them symptomatic, leading to decreases in their quality of life and possible increases in psychosocial complaints [22]. Patients with visual vertigo are known to have higher self-reported dizziness handicap scores than those with vestibular dysfunction without visual vertigo and healthy controls [31]. Additionally, patients with vestibular dysfunction and visual vertigo are known to have increased levels of anxiety and depression [20 , 31]. Anxiety-related gaze instability has been proposed as a possible pathophysiologic mechanism for visual vertigo [25]. Depression scores have been correlated with increased reports of symptoms provoked or aggravated by complex visual stimuli [20].

Individuals with persistent postural-perceptual dizziness (PPPD) report exacerbation of symptoms with exposure to moving visual stimuli or complex visual patterns [22, 26]. Twenty-eight percent of individuals with PPPD reported susceptibility to visual triggers, such as quick movements of surroundings (36%), crowds (24%), design of buildings (22%), and flashes of light (17%) [13]. In fact, increased symptoms with exposure to visual stimuli is included in the diagnostic criteria for PPPD [26]. Therefore, presence of visual vertigo symptoms could assist with differential diagnosis for clinicians. Individuals with migraines are also believed to have an increased risk of reporting visual vertigo symptoms; however, there is a paucity of evidence to describe the presence of visual vertigo symptoms in other central and peripheral vestibular disorders [2, 3]. Without knowing which population is most likely to present with comorbid visual vertigo, clinicians may fail to assess and treat visual vertigo and address the resultant activity limitations and participation restrictions.

Visual vertigo symptom severity can be assessed using the Visual Vertigo Analogue Scale (VVAS), a valid and reliable outcome measure developed by Dannenbaum and colleagues in 2011 [6, 7]. The VVAS is a 9-item designed to record dizziness severity while viewing dynamic visual stimuli such as being a passenger in a car, going down an escalator, and walking over a patterned floor, all of which are known to induce visual vertigo symptoms. The VVAS allows patients to rate the intensity of their dizziness in each situation on a 0–10 analogue scale. The item ratings are then averaged and multiplied by 10 to create the composite score out of 100. If individuals score above 0 on two or more items, they are deemed “visual vertigo positive” [7].

As written, the VVAS can be interpreted either by composite score, with higher total scores indicating greater visual vertigo severity, or by VVAS positive or negative. The former method may be enhanced by adding severity classification groups, which may aid in the uniform interpretation of the VVAS composite scores in clinical and research settings. The latter scoring method lacks the sensitivity to differentiate an individual with very mild visual vertigo from one with severe visual vertigo, as all people who score above 0 on two or more items are considered to have visual vertigo.

Our primary aim was to present an alternative method to interpret the VVAS by categorizing individuals based on the severity of VVAS symptoms. Utilizing empirically derived cut-points may better inform treatment decisions and aid in interpreting research study outcomes. We further aimed to explore activity and participation, dizziness-related handicap, anxiety, and depression among those with mild, moderate, and severe levels of visual vertigo symptoms. Our tertiary aim was to describe the severity of visual vertigo reported by patients in vestibular diagnostic categories to help clinicians identify which patient diagnoses may be more likely to experience visual vertigo.

2 Methods

2.1 Participants and study design

This cross-sectional study was a secondary data analysis. In the original study, participants were recruited from a tertiary care balance disorders center (The University of Pittsburgh Medical Center (UPMC) Balance Disorders Clinic) and outpatient vestibular rehabilitation physical therapy clinics (UPMC Centers for Rehab Services) in the Pittsburgh, PA area [9]. Eligibility criteria included the following: ages 18 to 100 years, English-speaking, and cognitively able to answer questions as determined by research staff. Demographic and clinical characteristics, including vestibular diagnosis, comorbid conditions, and medical history, were abstracted from the electronic medical record. All participants provided written informed consent, and the University of Pittsburgh Institutional Review Board approved the study. Participants completed the VVAS [7], Vestibular Activities and Participation (VAP) Measure [1], Dizziness Handicap Index (DHI) [14], and Hospital Anxiety and Depression Scale (HADS) [30].

The VVAS is a 9-item scale to record dizziness severity while viewing dynamic visual stimuli. Individual item scores range from 0–10. The VVAS is scored by multiplying the mean score of the completed analogue scales by 10, which yields a score between 0 (patient does not experience visual vertigo) and 100 (patient has severe visual vertigo). Additionally, individuals can be classified as VVAS positive if they rate two or more items above 0. In individuals with vestibular disorders, the VVAS has excellent internal consistency (Cronbach alpha = 0.94) and excellent predictive validity of the DHI total score (r = 0.67, p < 0.0001) [7].

The VAP was developed to identify activity limitations and participation restrictions present in persons with vestibular disorders [1]. This 34-item measure asks individuals to rate their difficulty performing various tasks on a 5-point scale with 0 indicating no difficulty and 4 indicating an inability to perform the task, with an additional “not applicable” (N/A) option. The composite score for the VAP is calculated by averaging the item scale values, excluding the N/A items, with scores ranging from 0–4. Example tasks include walking varying distances, operating a vehicle, preparing a meal, and engaging in recreational activities. The VAP has demonstrated excellent test-retest reliability (ICC = 0.95) in persons with vestibular disorders [1]. The VAP has a strong correlation with the World Health Organization Disability Assessment Scale-II (WHODAS II) (ρ= 0.70) and moderate to strong correlations with the DHI subscales and total DHI score (ρ= 0.54–0.74) [1]. Higher total scores on the VAP indicate greater activity and participation restrictions.

The DHI is a 25-item self-assessment of the person’s self-perceived handicapping effects of dizziness or vertigo. Patients are asked questions about the impact of their dizziness on their life functionally, physically, and emotionally. Example questions include: “Does your problem significantly restrict your participating in social activities?” and “Because of your problem, do you restrict your travel for business or recreation?” Patients are instructed to answer “yes”, “sometimes”, or “no” for each question. Clinicians then add up all of the responses, where “yes” is worth 4 points, “sometimes” is worth 2 points, and “no” is worth 0 points. The maximum score is 100, with higher scores indicating greater perceived handicap. The DHI has excellent test-retest reliability, content validity, and construct validity [14].

The HADS was administered to assess anxiety and depression. The HADS is a 14-item measure with depression (HADS-D) and anxiety (HADS-A) subscales. Patients are provided with prompts and asked to rate their feelings over the past week. For example, they are asked if “(They) can sit at ease and feel relaxed” or “if (they) can still enjoy the things (they) used to enjoy.” There are four response options for each prompt; based on their response, a score is given between 0–3. The maximal score of each subscale is 21, with higher scores indicating increased anxiety or depression. A cut-off score of 8 or more on each section of the HADS has been used to identify anxiety and depression [5].

2.2 Statistical analysis

Participants were categorized by International Classification of Diseases 10^th Revision (ICD-10) diagnostic code with individuals who had a central and peripheral diagnosis code combined into a mixed peripheral/central disorders group and those with a functional gait disorder, abnormality of gait, gait instability and difficulty walking code combined into a gait disorder group. All codes were cross-checked with the neurologist’s encounter notes for accuracy. When disagreements between the ICD-10 code and the encounter notes occurred, a consensus by a panel of 3 vestibular physical therapists was used to determine the most appropriate categorization. After completing the categorization, descriptive statistics were used to describe the distribution of the VVAS scores and non-parametric Kruskal-Wallis tests were used to compare age distributions between the diagnostic groups.

Determination of cut-off points (CP) was performed as described by Serlin et al. [23]. Based on twenty-four different CP schemes, each patient’s visual vertigo intensity rating on the VVAS was classified into three categories: mild, moderate, and severe. For example, Model 14 classified VVAS scores of 0–30 as mild, 30.01–60 as moderate, and 60.01–100 as severe visual vertigo. To determine which CP scheme best differentiated between the three severity categories, we performed one-way ANOVAs for each classification scheme, with the VVAS severity classifications as the independent variable and the DHI score as the dependent variable. The DHI was chosen as the anchor variable due to its strong correlation with VVAS scores (r = 0.597, p < 0.001), which conforms to the recommendations for establishing CP published by Shi et al. [24]. Statistically significant Welch’s F-statistics indicated a significant difference between the three visual vertigo severity categories in regards to dizziness handicap. The CP scheme with the highest significant Welch’s F-statistic was interpreted as maximizing the intergroup differences optimally. The CP schemes with the highest Welch’s F-statistics were then compared to various outcome measures (VAP, HADS-A, HADS-D) to determine if the CP schemes adequately discriminated between visual vertigo severity using one-way ANOVAs with Games-Howell post-hoc comparisons.

Descriptive statistics were performed for all outcome measures stratified by the optimal VVAS severity CP scheme. Finally, Pearson’s r correlations were obtained between VVAS scores and each outcome measure. All analyses were performed with IBM SPSS v28 (Armonk, NY).

3 Results

3.1 Descriptive and diagnostic categorization of patients

Data was collected on 336 patients. After data screening, we excluded 75 patients who had unspecified dizziness (as this precluded assignment into one of the diagnostic categories) and 11 patients who did not complete the VVAS. The remaining 250 patients were categorized into the following diagnostic categories: bilateral vestibulopathy (n = 14), benign paroxysmal positional vertigo (BPPV) (n = 48), concussion (n = 30), gait disorder (n = 14), Mal de Debarquement Syndrome (n = 3), mixed central/peripheral disorders (n = 18), central disorders (n = 4), PPPD (n = 5), unilateral vestibulopathy (n = 84), and vestibular migraine (n = 30). Demographic characteristics and mean VVAS scores separated by diagnostic category are provided in Table 1 and illustrated in Fig. 1. The mean age of the sample was 53 years old, and 65.2% were female. Non-parametric Kruskal-Wallis testing revealed a significant difference in mean age between the diagnostic groups, H(9) = 65.81, p < 0.001. Pairwise comparisons indicated the significant differences were between the vestibular migraine group and the unilateral vestibulopathy, BPPV, gait disorder, bilateral vestibulopathy, and central disorders groups, as well as between the concussion group and unilateral vestibulopathy, BPPV, and bilateral vestibulopathy groups. The mean VVAS score for the sample was 29 with scores positively skewed toward 0. The diagnostic category with the highest mean VVAS score was central vestibular disorders, and the category with the lowest mean VVAS score was Mal de Debarquement Syndrome.

Table 1
Demographic characteristics and mean VVAS scores separated by diagnostic category

Diagnostic Category Total N Female n (%) Age Mean (SD) VVAS Score Mean (SD)

Bilateral vestibulopathy 14 7 (50.0) 57 (15) 19.3 (30.1)

BPPV 48 31 (64.6) 59 (13) 22.8 (22.6)

Concussion 30 22 (73.3) 43 (18) 33.4 (24.1)

Gait disorder 14 10 (71.4) 60 (20) 24.1 (20.2)

Mal de Debarquement 3 2 (66.7) 41 (6) 15.6 (6.9)

Mixed peripheral/central disorders 18 11 (61.1) 20 (17) 39.3 (30.9)

Central disorders 4 2 (50.0) 67 (10) 46.2 (18.3)

Persistent postural-perceptual dizziness 5 3 (60.0) 51 (12) 35.6 (24.3)

Unilateral vestibulopathy 84 51 (60.7) 57 (15) 29.6 (25.2)

Vestibular migraine 30 24 (80.0) 35 (10) 31.5 (21.8)

Total Sample 250 163 (65.2) 53 (17) 29.0 (24.7)

Diagnostic Category	Total N	Female n (%)	Age Mean (SD)	VVAS Score Mean (SD)
Bilateral vestibulopathy	14	7 (50.0)	57 (15)	19.3 (30.1)
BPPV	48	31 (64.6)	59 (13)	22.8 (22.6)
Concussion	30	22 (73.3)	43 (18)	33.4 (24.1)
Gait disorder	14	10 (71.4)	60 (20)	24.1 (20.2)
Mal de Debarquement	3	2 (66.7)	41 (6)	15.6 (6.9)
Mixed peripheral/central disorders	18	11 (61.1)	20 (17)	39.3 (30.9)
Central disorders	4	2 (50.0)	67 (10)	46.2 (18.3)
Persistent postural-perceptual dizziness	5	3 (60.0)	51 (12)	35.6 (24.3)
Unilateral vestibulopathy	84	51 (60.7)	57 (15)	29.6 (25.2)
Vestibular migraine	30	24 (80.0)	35 (10)	31.5 (21.8)
Total Sample	250	163 (65.2)	53 (17)	29.0 (24.7)

Central disorders: those who did not have a specific central diagnosis such as a concussion or vestibular migraine; BPPV: benign paroxysmal positional vertigo; VVAS: Visual Vertigo Analogue Scale; Gait disorder: ICD-10 codes for functional gait disorder, abnormality of gait, gait instability, and difficulty walking; Mixed peripheral/central disorders: patients with one or more central and peripheral ICD-10 codes, for example, vestibular migraine and peripheral vestibular abnormality.

Fig. 1

Visual Vertigo Analogue Scale scores for 250 patients with vestibular disorders based on diagnostic categorization. Central disorders: those who did not have a specific central diagnosis such as a concussion or vestibular migraine; BPPV: benign paroxysmal positional vertigo; VVAS: Visual Vertigo Analogue Scale; Gait disorders: ICD-10 codes for functional gait disorder, abnormality of gait, gait instability, and difficulty walking; Mixed peripheral/central disorders: patients with one or more central and peripheral ICD-10 codes, for example, vestibular migraine and peripheral vestibular abnormality.

According to the correlation analysis, greater VVAS severity was associated with reduced activity and participation (measured by the VAP) (r = 0.582, p < 0.001), more perceived dizziness handicap (measured by the DHI) (r = 0.597, p < 0.001, n = 199), greater anxiety severity (measured by the HADS-A) (r = 0.405, p < 0.001), and greater depression severity (measured by the HADS-D) (r = 0.521, p < 0.001).

3.2 Determination of Cut-off points

Cut-off points were determined as described in the statistical methods section. Two CP schemes demonstrated high intergroup differences: Model 19 (VVAS mild 0.1–40, moderate 40.01–70, and severe 70.01–100) Welch’s F(3,37.636) = 40.168, p < 0.001 and Model 15 (VVAS mild 0.1–30, moderate 30.01–70, and severe 70.01–100) Welch’s F(3,39.323) = 39.102, p < 0.001. See Table 2 for the one-way ANOVA results for the 10 CP models with the highest Welch’s F-statistics.

Table 2
One-way ANOVA results for the 10 cut-off point models with the highest Welch’s F-statistics

Possible Cut Points Welch’s F

CP Schemes None Mild Moderate Severe

Model 19 0 0.1–40.00 40.01–70.00 70.01–100 40.168^*

Model 15 0 0.1–30.00 30.01–70.00 70.01–100 39.102^*

Model 10 0 0.1–20.00 20.01–70.00 70.01–100 37.802^*

Model 22 0 0.1–50.00 50.01–70.00 70.01–100 37.639^*

Model 20 0 0.1–40.00 40.01–80.00 80.01–100 36.868^*

Model 8 0 0.1–20.00 20.01–50.00 50.01–100 36.729^*

Model 13 0 0.1–30.00 30.01–50.00 50.01–100 36.433^*

Model 17 0 0.1–40.00 40.01–50.00 50.01–100 36.151^*

Model 18 0 0.1–40.00 40.01–60.00 60.01–100 36.138^*

Model 14 0 0.1–30.00 30.01–60.00 60.01–100 35.541^*

	Welch’s F
Model 19	0.1–40.00	40.01–70.00	70.01–100	40.168^*
Model 15	0.1–30.00	30.01–70.00	70.01–100	39.102^*
Model 10	0.1–20.00	20.01–70.00	70.01–100	37.802^*
Model 22	0.1–50.00	50.01–70.00	70.01–100	37.639^*
Model 20	0.1–40.00	40.01–80.00	80.01–100	36.868^*
Model 8	0.1–20.00	20.01–50.00	50.01–100	36.729^*
Model 13	0.1–30.00	30.01–50.00	50.01–100	36.433^*
Model 17	0.1–40.00	40.01–50.00	50.01–100	36.151^*
Model 18	0.1–40.00	40.01–60.00	60.01–100	36.138^*
Model 14	0.1–30.00	30.01–60.00	60.01–100	35.541^*

Comparison of different cut-off point (CP) schemes for classifying Visual Vertigo Analogue Scale (VVAS) scores as mild, moderate, or severe in terms of dizziness handicap. ^*Significant at p < 0.001.

3.3 Assessment of Cut-off points

Model 19 was then tested for discriminative abilities with one-way ANOVAs and post-hoc comparisons with Games-Howell adjustments. The DHI, VAP, HADS-A, and HADS-D for both CP models demonstrated statistically significant between group differences at p < 0.001. See Table 3 for ANOVA results for each outcome measure. Post-hoc comparisons demonstrated statistically significant differences in dizziness handicap, participation, anxiety, and depression between most severity groups. See Fig. 2 for a visual representation of post-hoc comparison of Model 19. Of note, there was not a statistically significant difference between anxiety (p = 0.093) or depression (p = 0.074) for the moderate and severe visual vertigo severity groups. The scores on the outcome measures differed between VVAS severity categories in the expected direction, with the more severe VVAS groups having higher levels of dizziness handicap, activity and participation limitations, anxiety, and depression than the less severe VVAS groups. Figure 3 shows the distribution of VVAS severity categorization, using model 19, broken up by diagnostic category.

Table 3
Summary statistics and results of the one-way ANOVA for Model 19 cut-points

Visual Vertigo Analogue None Mild Moderate Severe

Scale Severity Classification

Number of Patients 22 147 62 19

Questionnaire Mean (SD) Mean (SD) Mean (SD) Mean (SD) Welch’s F P Value

Dizziness Handicap Inventory 14.67 (10.84) 31.58 (17.16) 50.68 (21.17) 72.29 (21.61) 40.168 < 0.001

Vestibular Activities and Participation 0.42 (0.61) 0.92(0.69) 1.61 (0.72) 2.30 (0.78) 53.445 < 0.001

Hospital Anxiety and Depression Scale: Anxiety Subscale 2.60 (2.95) 6.76 (3.87) 8.72 (4.18) 11.86 (4.06) 52.132 < 0.001

Hospital Anxiety and Depression Scale: Depression Subscale 2.60 (2.69) 4.28 (3.16) 7.40 (3.95) 11.00 (4.80) 51.953 < 0.001

Visual Vertigo Analogue	None	Mild	Moderate	Severe
Number of Patients	22	147	62	19
Questionnaire	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Welch’s F	P Value
Dizziness Handicap Inventory	14.67 (10.84)	31.58 (17.16)	50.68 (21.17)	72.29 (21.61)	40.168	< 0.001
Vestibular Activities and Participation	0.42 (0.61)	0.92(0.69)	1.61 (0.72)	2.30 (0.78)	53.445	< 0.001
Hospital Anxiety and Depression Scale: Anxiety Subscale	2.60 (2.95)	6.76 (3.87)	8.72 (4.18)	11.86 (4.06)	52.132	< 0.001
Hospital Anxiety and Depression Scale: Depression Subscale	2.60 (2.69)	4.28 (3.16)	7.40 (3.95)	11.00 (4.80)	51.953	< 0.001

Model 19: None 0, Mild Visual Vertigo 0.1–40, Moderate 40.01–70, and Severe 70.01–100.

Fig. 2

Model 19 post-hoc comparison of visual vertigo severity classification groups with Games-Howell adjustment. Model 19: None 0, Mild Visual Vertigo 0.1–40, Moderate 40.01–70, and Severe 70.01–100. ^*The mean difference is significant at p < 0.05.

Fig. 3

Visual Vertigo Analogue Scale categorization distribution. Model 19: None 0, Mild Visual Vertigo 0.1–40, Moderate 40.01–70, and Severe 70.01–100.

4 Discussion

The aim of the current study was to identify the optimal cut-off points for none, mild, moderate, and severe visual vertigo in terms of dizziness handicap, as well as determine the association between these cut-off points and patients’ activity and participation restrictions, anxiety, and depression. Our proposed categorization of VVAS symptoms, model 19, was found to provide the best model fit (none 0, mild 0.1–40, moderate 40.01–70, and severe 70.01–100). Although there was wide variation within the diagnostic groups, VVAS scores were highest in persons with central, mixed central/peripheral disorders, and PPPD. However, some diagnostic categories had a small number of participants. These findings are consistent with other reports that persons with central, mixed central/peripheral, and PPPD are more challenging to treat due to greater symptom burden [8, 28].

We aimed to validate the mild, moderate, or severe VVAS categories by exploring their relationship with measures of activity and participation, dizziness-related handicap, anxiety, and depression. There were differences between reported VAP scores for each VVAS severity category. Individuals with increasing severity of visual vertigo symptoms expressed greater activity and participation restrictions. Many of the items on the VVAS involve activities taking place in the community (walking through a supermarket, riding in a car, watching traffic at an intersection, walking through a shopping mall, going down an escalator, watching a movie at a movie theater), so it is not surprising that those who experience more visually-induced symptoms might self-restrict their activity and participation.

There were also differences between reported DHI scores for each VVAS severity category. Individuals with increasing severity of visual vertigo symptoms expressed greater self-perceived dizziness handicap. Patients with visual vertigo are known to have higher DHI scores than those with vestibular dysfunction without visual vertigo and healthy controls [29, 31]. While Grigol et al. found a moderate relationship between VVAS and DHI scores, different methods between our study and theirs in defining mild, moderate, and severe VVAS scores precludes direct comparison.

There were differences between reported HADS-A and HADS-D scores for each VVAS severity category. Individuals with greater severity of visual vertigo symptoms expressed greater anxiety and depression. Patients with vestibular dysfunction and visual vertigo are known to have increased levels of anxiety and depression [12 , 20]. Individuals with visual vertigo have more anxiety than individuals with vestibulopathy without visual vertigo and healthy controls [31]. Depression scores have been correlated with increased reports of symptoms provoked or aggravated by complex visual stimuli [20]. The increased levels of depression reported by the patients with severe visual vertigo symptoms may be due to the vestibular disorder, activity limitations, and/or participation restrictions [27]. Graham et al. found that patients with a DHI score greater than 60 were likely to have functional or psychiatric disorders [11]. Similarly, a high VVAS score may indicate that the patient has comorbid anxiety and depression, impacting patient management.

This study also described visual vertigo symptom severity reported by patients in different vestibular diagnostic categories. Understanding which patients are most likely to experience visually-induced symptoms may help clinicians provide early diagnosis and intervention, which is known to improve outcomes [16, 19]. We found a pattern that those patients with central diagnoses, with the exception of Mal de Debarquement Syndrome (n = 3), reported higher severity of visual vertigo than patients with peripheral diagnoses. This increased visual vertigo symptomology matches the pattern of greater functional impairments found by Meretta et al. [18]; that those with central disorders performed slower on the Five Times Sit to Stand test and the Timed Up and Go than those with peripheral dysfunction. Additionally, other research has associated central disorders with greater psychological strain and co-morbid psychiatric disorders [4 , 17]. We do not know specifically why those in our sample with central disorders tended to present with higher visual vertigo symptomology, but we do know that generally those with central disorders carry a great symptom burden in many other domains. It would be prudent for clinicians to screen individuals with central diagnoses for visually-induced symptoms to aid in the development of a customized plan of care.

There were some limitations in our study that should be noted. We excluded patients from the analysis for unclear diagnoses and missing VVAS scores. Seventy-five patients in the unspecified diagnostic category were excluded from the analysis. Because it is not known how their health condition(s) might relate to visual vertigo severity, the results of this study may not be generalizable to individuals with an unspecified dizziness diagnosis. Also, the study sample was taken from specialty clinics and, therefore, the results may not be generalizable to all individuals with dizziness who may present to primary care settings.

Another limitation was the small number of participants in some of the diagnostic categories. The 0–100 VVAS scale was broken down into severity categories to improve clinician interpretation of the results. While the categorization of the VVAS scores can help provide clinicians with more detailed information about the severity of visual vertigo symptoms, the categories do not take into consideration types of visual stimuli that provoke symptoms which may also be useful to clinicians. The categorization on the VVAS should be just one component of a comprehensive clinical assessment and clinical judgement should be used when interpreting the scores in the context of the patient. Future studies should validate the mild, moderate, and severe VVAS scoring method in other populations and settings and with other outcome measures commonly used in vestibular clinics. In addition, visual vertigo is likely present in the general population as found by Powell and colleagues and it may be useful to identify the prevalence of mild, moderate, and severe visual vertigo symptoms using a sample without vestibular diagnoses [21].

5 Conclusion

Categorizing persons by mild, moderate, or severe VVAS scores provides data for clinical decision-making, goal development, and a customized plan of care. The VVAS score categories appeared to have face validity. Persons with mild, moderate, and severe VVAS categories had significantly different levels of dizziness handicap, anxiety, depression, and activity and participation restrictions. This study also confirmed that patients with central disorders were more symptomatic than those with peripheral vestibular disorders. The findings of this study support the use of an alternative VVAS interpretation method of No Visual Vertigo (VVAS = 0), Mild Visual Vertigo (VVAS = 0.1–40), Moderate Visual Vertigo (VVAS = 40.01–70), and Severe Visual Vertigo (VVAS = 70.01–100).

Footnotes

Acknowledgments

We thank the Departments of Physical Therapy and Otolaryngology at the University of Pittsburgh for their support of this project.

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	Possible Cut Points				Welch’s F
CP Schemes	None	Mild	Moderate	Severe
Model 19	0	0.1–40.00	40.01–70.00	70.01–100	40.168^*
Model 15	0	0.1–30.00	30.01–70.00	70.01–100	39.102^*
Model 10	0	0.1–20.00	20.01–70.00	70.01–100	37.802^*
Model 22	0	0.1–50.00	50.01–70.00	70.01–100	37.639^*
Model 20	0	0.1–40.00	40.01–80.00	80.01–100	36.868^*
Model 8	0	0.1–20.00	20.01–50.00	50.01–100	36.729^*
Model 13	0	0.1–30.00	30.01–50.00	50.01–100	36.433^*
Model 17	0	0.1–40.00	40.01–50.00	50.01–100	36.151^*
Model 18	0	0.1–40.00	40.01–60.00	60.01–100	36.138^*
Model 14	0	0.1–30.00	30.01–60.00	60.01–100	35.541^*