Dizziness Handicap Inventory The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness. Please mark “always”, “sometimes” or “no” to each question. Answer each question as it pertains to your dizziness or balance problem only. ALWAYS SOMETIMES NO P1. Does looking up increase your problem?

E2. Because of your problem, do you feel frustrated?

F3. Because of your problem, do you restrict your travel for business or recreation?

P4. Does walking down the aisle of a supermarket increase your problem?

F5. Because of your problem, do you have difficulty getting into or out of bed?

F6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing or to parties?

F7. Because of your problem, do you have difficulty reading?

P8. Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting dishes away increase your problem?

E9. Because of your problem, are you afraid to leave your home without having someone accompany you?

E10. Because or your problem, have you been embarrassed in front of others?

P11. Do quick movements of your head increase your problem?

ALWAYS SOMETIMES NO F12. Because of your problem, do you avoid heights?

P13. Does turning over in bed increase your problem?

F14. Because of your problem, is it difficult for you to do strenuous housework or yard work?

E15. Because of your problem, are you afraid people may think you are intoxicated?

F16. Because of your problem, is it difficult for you to go for a walk by yourself?

P17. Does walking down a sidewalk increase your problem?

E18. Because of your problem, is it difficult for you to concentrate?

F19. Because of your problem, is it difficult for you to walk around the house in the dark?

E20. Because of your problem, are you afraid to stay home alone?

E21. Because of your problem, do you feel handicapped?

E22. Has your problem placed stress on your relations with members of your family or friends?

E23. Because of your problem, are you depressed?

F24. Does your problem interfere with your job or household responsibilities?

P25. Does bending over increase your problem?

Vertigo Symptom Scale

Please circle the appropriate number to indicate about how many times you have experienced each of the symptoms listed below during the past 12 months (or since the vertigo started, if you have had vertigo for less than one year). The range of responses are:

0 1 2 3 4 Never A few times Several times Quite often Very often (1-3 times (4-12 times (on average, (on average, a year) a year) more than more than once a month) once a week) How often in the past 12 months have you had the following symptoms:

1. A feeling that things are spinning or moving around, lasting: (PLEASE ANSWER ALL THE CATEGORIES) (a) less than 2 minutes 0 1 2 3 4 (b) up to 20 minutes 0 1 2 3 4 (c) 20 minutes to 1 hour 0 1 2 3 4 (d) several hours 0 1 2 3 4 (e) more than 12 hours 0 1 2 3 4

2. Pains in the heart or chest region 0 1 2 3 4 3. Hot or cold spells 0 1 2 3 4

The range of responses are: 0 1 2 3 4

Never A few times Several times Quite often Very often (1-3 times (4-12 times (on average, (on average, a year) a year) more than more than once a month) once a week)

4. Unsteadiness so severe that you actually fall 0 1 2 3 4 5. Nausea (feeling sick), stomach churning 0 1 2 3 4 6. Tension / soreness in your muscles 0 1 2 3 4

7. A feeling of being light-headed, “swimmy” or giddy, lasting:

(PLEASE ANSWER ALL THE CATEGORIES) (a) less than 2 minutes 0 1 2 3 4 (b) up to 20 minutes 0 1 2 3 4 (c) 20 minutes to 1 hour 0 1 2 3 4 (d) several hours 0 1 2 3 4 (e) more than 12 hours 0 1 2 3 4

8. Trembling, shivering 0 1 2 3 4 9. Feeling of pressure in the ear(s) 0 1 2 3 4

The range of responses are:

0 1 2 3 4 Never A few times Several times Quite often Very often (1-3 times (4-12 times (on average, (on average, a year) a year) more than more than once a month) once a week)

10. Heart pounding or fluttering 0 1 2 3 4 11. Vomiting 0 1 2 3 4

12. Heavy feeling in arms or legs 0 1 2 3 4 13. Visual disturbances (e.g. blurring, flickering, spots before the eyes) 0 1 2 3 4 14. Headache or feeling of pressure in the head 0 1 2 3 4 15. Unable to stand or walk properly without support 0 1 2 3 4 16. Difficulty breathing, short of breath 0 1 2 3 4 17. Loss of concentration or memory 0 1 2 3 4

The range of responses are:

0 1 2 3 4 Never A few times Several times Quite often Very often (1-3 times (4-12 times (on average, (on average, a year) a year) more than more than once a month) once a week)

18. Feeling unsteady, about to lose balance, lasting: (PLEASE ANSWER ALL THE CATEGORIES) (a) less than 2 minutes 0 1 2 3 4 (b) up to 20 minutes 0 1 2 3 4 (c) 20 minutes to 1 hour 0 1 2 3 4 (d) several hours 0 1 2 3 4 (e) more than 12 hours 0 1 2 3 4

19. Tingling, prickling or numbness in parts of the body 0 1 2 3 4 20. Pains in the lower part of your back 0 1 2 3 4 21. Excessive sweating 0 1 2 3 4 22. Feeling faint, about to black out 0 1 2 3 4

Vertigo Handicap Questionnaire

The statements below describe ways in which vertigo can affect peoples’ lives. (Throughout the questionnaire the word “vertigo” is used to describe the feelings which you may call dizziness, giddiness or unsteadiness.) We would like you to indicate whether vertigo has affected your life in any of these ways by circling a number between 0 and 4. The response categories are: 0 1 2 3 4 never occasionally sometimes often always Please read each statement and then circle a number to indicate how much of the time (if at all) vertigo affects your life in that way at present.

1. I find that the vertigo does restrict me socially. (Never) 0 1 2 3 4 (Always) *2. I can still take part in active leisure pursuits

(e.g. swimming, dancing, sports). (Never) 0 1 2 3 4 (Always) 3. Some of my friends or relations get impatient

because of the vertigo. (Never) 0 1 2 3 4 (Always) *4. I can move around quickly and freely. (Never) 0 1 2 3 4 (Always)

5. I feel less confident than I used to. (Never) 0 1 2 3 4 (Always) *6. I am happy to go out alone. (Never) 0 1 2 3 4 (Always)

7. My vertigo means that my family life is restricted. (Never) 0 1 2 3 4 (Always) 8. I find some of my less active hobbies difficult

(e.g. sewing, reading). (Never) 0 1 2 3 4 (Always) *9. I am still able to travel despite the vertigo. (Never) 0 1 2 3 4 (Always)

10. I try to avoid bending over. (Never) 0 1 2 3 4 (Always) *11. My family takes the vertigo in its stride. (Never) 0 1 2 3 4 (Always)

12. My friends are unsure how to react and do not really understand. (Never) 0 1 2 3 4 (Always)

13. I think that there may be something seriously wrong with me. (Never) 0 1 2 3 4 (Always)

*14. People are understanding about the problems that the vertigo causes. (Never) 0 1 2 3 4 (Always)

The statements below describe ways in which vertigo can affect peoples’ lives. (Throughout the questionnaire the word “vertigo” is used to describe the feelings which you may call dizziness, giddiness or unsteadiness.) We would like you to indicate whether vertigo has affected your life in any of these ways by circling a number between 0 and 4. The response categories are: 0 1 2 3 4 never occasionally sometimes often always Please read each statement and then circle a number to indicate how much of the time (if at all) vertigo affects your life in that way at present.

15. I get anxious in case I have an unexpected attack of vertigo. (Never) 0 1 2 3 4 (Always)

*16. During an attack of vertigo I can carry on with whatever I am doing. (Never) 0 1 2 3 4 (Always)

17. I find the attacks frightening. (Never) 0 1 2 3 4 (Always) *18. I am able to walk long distances. (Never) 0 1 2 3 4 (Always)

19. The vertigo worries me. (Never) 0 1 2 3 4 (Always) 20. I avoid making plans in advance in case I cannot get

there on the day. (Never) 0 1 2 3 4 (Always) *21. I find I can carry out everyday activities without

difficulty (e.g. shopping, gardening, jobs around the house). (Never) 0 1 2 3 4 (Always)

22. I am afraid of spoiling things for others. (Never) 0 1 2 3 4 (Always) 23. I get rather depressed because of the vertigo. (Never) 0 1 2 3 4 (Always)

*24. During an attack of vertigo, if I just sit down I am fine. (Never) 0 1 2 3 4 (Always) 25. If I have an attack of vertigo in public I get embarrassed. (Never) 0 1 2 3 4 (Always)

26. Are you currently employed? Yes________ No ________

If you answered “yes” to #26, please answer question (b) and (c) only. If you answered “no” to #26, please answer question (a) only.

(a) Did you give up work because of vertigo? Yes ________ No ________ (b) Have you changed the kind of work you do because of vertigo? Yes ________ No ________ (c) Does vertigo cause you any difficulties at work? Yes ________ No ________

TINETTI ASSESSMENT TOOL

Initial Instructions: Subject is seated in hard, armless Initial Instructions: Subject stands with examiner, chair. The following maneuvers are tested. walks down hallway or across room, first at “usual” pace then back

at “rapid” but safe pace (using usual walking aid). 1. _____Sitting Balance 0= leans or slides in chair 1= steady, safe

10. _____Initiation of Gait (Immediately after told to “go”) 0= any hesitancy or multiple attempts to start 1= no hesitancy

2. _____Arises 0= unable without help 1= able, uses arms to help 2= able without using arms 3. _____Attempts to Arise 0= unable without help 1= able, requires > 1 attempt 2= able to arise, 1 attempt

11. _____ Step Length and Height 0= right swing foot does not pass left stance foot with step 1= right foot passes left stance foot 0= right foot does not completely clear floor with step 1= right foot completely clears floor 0= left swing foot does not pass right stance foot with step 1= left foot passes right stance foot 0= left foot does not completely clear floor with step 1= left foot completely clears floor

4. _____Immediate Standing Balance (first five seconds) 0= unsteady (swaggers, moves feet, trunk sway) 1= steady but uses walker or other support 2= steady without walker or other support

12. _____Step Symmetry 0= right and left step length not equal (est) 1= right and left step appears equal

5. _____Standing Balance 0= unsteady 1= steady but wide stance (medial > 4 in. apart) and uses cane or other support 2= narrow stance without support

13. _____Step Continuity 0= stopping or discontinuity between steps 1= steps appear continuous

6. _____Nudged (Subject at maximum position with feet as close together as possible, examiner pushes lightly on subject’s sternum with palm of hand 3 times.) 0= begins to fall 1= staggers, grabs, catches self 2= steady

14. _____Path (Estimated in relation to 12-inch floor tiles. Observe excursion of one foot over about 10-ft of the course.) 0= marked deviation 1= mild/mod deviation or uses walking aid 2= straight, without walking aid

7. _____Eyes Closed (At maximum position number 6.) 0= unsteady 1= steady

15. _____ Trunk 0= marked sway or uses walking aid 1= no sway but flexion of knees or back, or spreads out while walking 2= no sway, no flexion, no use of arms, no use of walking aid

8. _____Turning 360 degrees 0= discontinuous steps 1= continuous steps 0= unsteady (grabs, staggers) 1= steady

16. _____ Walking Time 0= heels apart 1= heels almost touching while walking

9. _____ Sitting Down 0= unsafe (misjudged distance, falls into chair) 1= uses arms or not a smooth motion 2= safe, smooth motion

BALANCE SCORE: /16

GAIT SCORE: /12 BALANCE + GAIT SCORE: /28

Key: Below 19= High Risk of Falling Score 19-24= Greater Chance of Falling but Not High Risk Reference: Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 1986, 34: 119-126.

BALANCE SCALE

1. SITTING TO STANDING: Please stand up. Try not to use your hands for support. 4=able to stand without using hands and stabilize independently 3=able to stand independently using hands 2=able to stand using hands after several tries 1=needs minimal aid to stand or to stabilize 0=needs moderate assist to stand

2. STANDING UNSUPPORTED: Please stand for two minutes without holding. 4=able to stand safely 2 minutes 3=able to stand 2 minutes with supervision 2=able to stand 30 seconds unsupported 1=needs several tries to stand 30 seconds unsupported 0=unable to stand 30 seconds unassisted

3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL: Please sit with arms folded for 2 minutes. 4=able to sit safely and securely 2 minutes 3=able to sit 2 minutes under supervision 2=able to sit 30 seconds 1=able to sit 10 seconds 0=unable to sit without support 10 seconds

4. STANDING TO SITTING: Please sit down. 4=sits safely with minimal use of hands 3=controls descent by using hands 2=uses back of legs against chair to control descent 1=sits independently but has uncontrolled descent 0=needs assistance to sit

5.TRANSFERS: Arrange chairs(s) for a pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use 2 chairs (one with and one without armrests) or a bed and a chair. 4=able to transfer safely with minor use of hands 3=able to transfer safely definite need of hands 2=able to transfer with verbal cuing and/or supervision 1=needs one person to assist 0=needs two people to assist or supervise to be safe

6. STANDING UNSUPPORTED WITH EYES CLOSED: Please close your eyes and stand still for 10 seconds. 4=able to stand 10 seconds safely 3=able to stand 10 seconds with supervision 2=able to stand 3 seconds 1=unable to keep eyes closed 3 seconds but stays safely 0=needs help to keep from falling

7. STANDING UNSUPPORTED WITH FEET TOGETHER: Place your feet together and stand without holding. 4=able to place feet together independently and stand 1 minute safely 3=able to place feet together independently and stand for 1 minute with supervision 2=able to place feet together independently but unable to hold for 30 seconds 1=needs help to attain position but able to stand 15 seconds feet together 0=needs help to attain position and unable to hold for 15 seconds

8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both arms when reaching to avoid rotation of the trunk.) 4=can reach forward confidently (10 inches) 3=can reach forward 5 inches safely 2=can reach forward 2 inches safely 1=reaches forward but needs supervision 0=loses balance while trying/requires external support

9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION: Pick up the shoe/slipper which is placed in front of your feet. 4=able to pick up slipper safely and easily 3=able to pick up slipper but needs supervision 2=unable to pick up but reaches 1-2 inches from slipper and keeps balance independently 1=unable to pick up and needs supervision while trying 0=unable to try/ needs assist to keep from losing balance or falling

10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING: Turn to look directly behind you over toward left shoulder. Repeat to the right. Examiner may pick an object to look at directly behind the subject to encourage a better twist turn. 4=looks behind from both sides and weight shifts well 3=looks behind one side only other side shows less weight shift 2=turns sideways only but maintains balance 1=needs supervision when turning 0=needs assist to keep from losing balance or falling

11.TURN 360 DEGREES: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction. 4=able to turn 360 degrees safely in 4 seconds or less 3=able to turn 360 degrees safely on side only 4 seconds or less 2=able to turn 360 degrees safely but slowly 1=needs close supervision or verbal cuing 0=needs assistance while turning

12. PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED: Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool four times. 4=able to stand independently and safely and complete 8 steps in 20 seconds 3=able to stand independently and complete 8 steps > 20 seconds 2=able to complete 4 steps without aid with supervision 1=able to complete >2 steps needs minimal assist 0=needs assistance to keep from falling/unable to try

13. STANDING UNSUPPORTED ONE FOOT IN FRONT: (Demonstrate to subject) Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the subject’s normal stride width) 4=able to place foot tandem independently and hold 30 seconds 3=able to place foot ahead of other independently and hold 30 seconds 2=able to take small step independently and hold 30 seconds 1=needs help to step but can hold 15 seconds 0=loses balance while stepping or standing

14. STANDING ON ONE LEG: Stand on one leg as long as you can without holding. 4=able to lift leg independently and hold > 10 seconds 3=able to lift leg independently and hold 5-10 seconds 2=able to lift leg independently and hold = or > 3 seconds 1=tries to lift leg unable to hold 3 seconds but remains standing independently 0=unable to try or needs assist to prevent fall

Total Score: __________/56 A Score Below 45 = Risk to Fall Reference: Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada, 1989; 41:304-311.

BALANCE SCALE Total Score: /56 A Score Below 45 = Risk to Fall

1. _____Sit Unsupported 4= able to sit safely 2 minutes 3= able to sit 2 minutes with supervision 2= able to sit 30 seconds 1= able to sit 10 seconds 0= unable to sit without support for 10 seconds

8. _____Turn To Look Behind 4= looks behind both sides, good weight shift 3= looks behind one side only 2= turns sideways only, maintains balance 1= needs supervision while turning 0= needs assistance to prevent fall

2. _____Sit To Stand 4= able to stand, stabilize indep. w/out hands 3= able to stand independently using hands 2= able to stand using hands, more than 1 try 1= minimal assist to stand or stabilize 0= moderate to maximal assist to stand

9. _____Turn 360 Degrees 4= able to turn safely in < 4 seconds, left and right 3= able to turn safely in < 4 seconds, one direction 2= able to turn safely in > 4 seconds 1= needs close supervision or verbal cues 0= cannot perform

3. _____Stand Unsupported 4= able to stand safely 2 minutes 3= able to stand 2 minutes with supervision 2= able to stand 30 seconds unsupported 1= able to stand 30 seconds after several trials 0= requires assist to stand 30 seconds

10. _____Alternating Stool Touch 4= safely completes 8 steps in 20 seconds 3= safely completes 8 steps in > 20 seconds 2= safely completes 4 steps 1= completes 2 steps with supervision or min assist 0= cannot perform

4. _____Stand Eyes Closed 4= stand safely 10 seconds 3= stand 10 seconds with supervision 2= stand 3 seconds 1= able to stand < 3 seconds 0= cannot perform

11. _____Tandem Stance 4= able to place feet indep, hold 30 seconds 3= able to get one foot in front of other, 30 seconds 2= able to take small step indep hold 30 seconds 1= needs assist to place feet, holds 15 seconds 0= cannot perform

5. _____Stand With Feet Together 4= able to place feet together, stand 1 minute 3= as above but requires supervision 2= able to place feet together, stand 30 seconds 1= needs help to assume position, stand 15 seconds 0= cannot perform

12. _____Stand On One Foot 4= able to lift one leg and hold > 10 seconds 3= able to lift one leg and hold 5-10 seconds 2= able to lift one leg and hold 3-4 seconds 1= able to lift one leg and hold < 3 seconds 0= cannot perform

6. _____Forward Reach 4= can reach forward confidently > 10 inches 3= can reach forward safely > 5 inches 2= can reach forward safely > 2 inches 1= can reach forward with supervision 0= needs help to prevent fall

13. _____Stand To Sit 4= sit safely with minimal use of hands 3= controls descent with use of hands 2= uses back of legs against chair to control descent 1= sits indep but has uncontrolled descent 0= cannot perform

7. _____Retrieve Object From Floor 4= able to pick up object and stand safely 3= picks up object but requires supervision 2= unable to retrieve within 2 inches safely 1= unable to retrieve while trying with supervision 0= cannot perform

14. _____Transfers 4= able to transfer safely, minor use of hands 3= able to transfer safely, must use hands 2= able to transfer with verbal cues or supervision 1= one person assist 0= two person assist

Reference: Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada, 1989; 41: 304-311.

1. _____Gait - Level Surface Instructions: Walk at your normal speed from here to the next mark (20 ft.). 3= Normal: Walks 20 ft, no assistive devices, good speed, no evidence for imbalance, normal gait pattern. 2= Mild Impairment: Walks 20 ft, uses assistive devices, slower speed, mild gait deviations. 1= Moderate Impairment: Walks 20 feet, slow speed, abnormal gait pattern, evidence for imbalance. 0= Severe Impairment: Cannot walk 20 feet without assistance, severe gait deviations, or imbalance.

2. _____Change in Gait Speed Instructions: Begin walking at normal pace (for 5 ft.) When I tell you “go” walk as fast as you can (for 5 ft.). When I tell you “slow” walk as slowly as you can (for 5 ft.). 3= Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. 2= Mild Impairment: Is able to change speeds but with mild gait deviations, or no gait deviations but is unable to achieve a significant velocity, or uses assistive device. 1= Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, or changes speed but loses significant gait deviations, or changes speed but loses balance but is able to recover and continue walking. 0= Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught.

3. _____Gait with Horizontal Head Turns Instructions: Begin walking at your normal pace. When I tell you to “look right,” keep walking straight but turn your head to the right. Keep looking to the right until I tell you “look left,” then keep walking straight and turn your head to the left. Keep your head to the left until I tell you, “look straight” then keep walking straight, but return your head to the center. 3= Normal: Performs head turns smoothly with no change in gait. 2= Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid. 1= Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers; can continue to walk. 0= Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside 15 inches of path, loses balance, stops, reaches for wall.

4. _____Gait with Vertical Head Turns Instructions: Begin walking at your normal pace. When I tell you to “look up”, keep walking straight, but tip your head and look up. Keep looking up until I tell you, “look down”. Then keep walking straight, and turn your head down. Keep looking down until I tell you, “look straight,” then keep walking straight, but return your head to the center. 3= Normal: Performs head turns with no change in gait. 2= Mild Impairment: Performs task with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid. 1= Moderate Impairment: Performs task with moderate change in gait velocity, slows down, staggers, but recovers; can continue to walk. 0= Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside 15 inches of path, loses balance, stops, reaches for wall.

5. _____Gait and Pivot Turn Instructions: Begin walking at your normal pace. When I tell you, “turn and stop”, turn as quickly as you can to face the opposite direction and stop. 3= Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance. 2= Mild Impairment: Pivot turns safely > 3 seconds and stops with no loss of balance. 1= Moderate Impairment: Turns slowly, requires verbal cueing; requires several steps to catch balance following turn and stop. 0= Severe Impairment: Cannot turn safely; requires assistance to turn and stop.

6. _____Step Over Obstacle Instructions: Begin walking at your normal speed. When you come to the shoebox, step over it, not around it, and keep walking. 3=Normal: Performs task without changing gait speed; no evidence of imbalance. 2=Mild Impairment: Is able to step over box, but must slow down and adjust steps to clear box safely. 1=Moderate Impairment: Is able to step over box, but must stop, then step over. May require verbal cueing. 0=Severe Impairment: Cannot perform without assistance.

DYNAMIC GAIT INDEX

For each of the following tasks, mark the lowest category that applies.

7. _____Step Around Obstacles Instructions: Begin walking at your normal speed. When you come to the first cone, (about 6 feet away), walk around the right side of it. At the second cone (6 feet past the first one) walk around the left side of it. 3= Normal: Is able to walk around the cones safely without changing gait speed; no evidence of imbalance. 2= Mild Impairment: Is able to step around both cones, but must slow down and adjust steps to clear cones. 1= Moderate Impairment: Is able to clear cones, but must significantly slow speed to accomplish task or requires verbal cueing. 0= Severe Impairment: Unable to clear cones, walks into one or both cones or requires physical assistance.

8. _____Steps Instructions: Walk up these stairs as you would at home, using the rail if necessary. At the top turn around and walk down. 3= Normal: Alternating feet; no rail 2= Mild Impairment: Alternating feet, must use rail. 1= Moderate Impairment: Two feet to a stair; must use rail. 0= Severe Impairment: Cannot do safely.

TOTAL SCORE /24 Reference: Shumway-Cook A, Baldwin M, Pollisar N, Gruber W. Predicting the Probability of Falls in Community Dwelling Older Adults. Physical Therapy, 1997; 77: 812 - 819

Requrements: A marked 20 ft walkway that is marked with a 12 in width.

Grading: Mark the highest category that applies.

1. ____Gait Level Surface Instructions: Walk at your normal speed from here to the next mark (20ft). 3= Normal: Walks 20 ft in less than 5.5 sec, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 6 in outside of the 12 in walkway width. 2= Mild Impairment: Walks 20 ft in less than 7 sec but greater than 5.5 sec, uses assistive device, slower speed, mild gait deviations, or deviates 6 – 10 in outside of the 12 in walkway width. 1= Moderate Impairment: Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, or deviates 10 – 15 in outside of the 12 in walkway width. Requires more than 7 sec to ambulate 20 ft. 0= Severe Impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside of the 12 in walkway width or reaches and touches the wall.

2. ____Change in Gait Speed Instructions: Begin walking at your normal pace for 5 ft. When I tell you “go”, walk as fast as you can for 5 ft. When I tell you “slow”, walk as slowly as you can for 5 ft. 3= Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. Deviate no more than 6 in outside of the 12 in walkway width. 2= Mild Impairment: Is able to change speed but demonstrates mild gait deviations, deviates 6 – 10 in outside of the 12 in walkway width, or no gait deviations but unable to achieve a significant change in velocity, or uses an assistive device. 1= Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, deviates 10 – 15 in outside the 12 in walkway width, or changes speed but loses balance but is able to recover and continue walking. 0= Severe Impairment: Cannot change speeds, deviates greater than 15 in outside 12 in walkway width, or loses balance and has to reach for wall or be caught.

3. ____Gait with Horizontal Head Turns Instructions: Walk from here to the next mark (20 ft) away. Begin walking at your normal pace. Keep walking straight ; after 3 steps, turn your head to the right and keep walking straight while looking to the right. After 3 more steps, turn your head to the left and keep walking straight while looking left. Continue alternating looking right and left every 3 steps until you have completed 2 repetitions in each direction. 3= Normal: Performs head turns smoothly with no change in gait. Deviates no more than 6 in outside 12 in walkway width. 2= Mild Impairment: Performs head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 6 – 10 in outside 12 in walkway width, or uses an assistive device. 1= Moderate Impairment: Performs head turns with moderate changes in gait velocity, slows down, deviates 10 – 15 in outside 12 in walkway width but recovers, can continue to walk. 0= Severe Impairment: Performs task with severe disruption of gait (eg, staggers 15 in outside 12 in walkway width, loses balance, stops, or reaches for wall).

4. ____Gait with Vertical Head Turns Instructions: Walk from here to the next mark (20 ft). Begin walking at your normal pace. Keep walking straight; after 3 steps, tip your head up and keep walking straight while looking up. After 3 more steps, tip your head down, keep walking straight while looking down. Continue alternating looking up and down every 3 steps until you have completed 2 repetitions in each direction. 3= Normal: Performs head turns with no change in gait. Deviates nor more than 6 in outside 12 in walkway width. 2= Mild Impairment: Performs task with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 6 – 10 in outside 12 in walkway width or uses assistive device. 1= Moderate Impairment: Performs task with moderate change in gait velocity, slows down, deviates 10 – 15 in outside 12 in walkway width but recovers, can continue to walk. 0= Severe Impairment: Performs task with severe disruption of gait (eg, staggers 15 in outside 12 in walkway width, loses balance, stops, reaches for wall).

FUNCTIONAL GAIT ASSESSMENT

5. ____Gait and Pivot Turn Instructions: Begin with walking at your normal pace. When I tell you, “turn and stop”, turn as quickly as you can to face the opposite direction and stop. 3= Normal: Pivot turns safely within 3 sec and stops quickly with no loss of balance. 2= Mild Impairment: Pivot turns safely in greater than 3 sec and stops with no loss of balance, or pivot turns safely within 3 sec and stops with mild imbalance, requires small steps to catch balance. 1= Moderate Impairment: Turns slowly, requires verbal cueing, or requires several small steps to catch balance following turn and stop. 0= Severe Impairment: Cannot turn safely, requires assistance to turn and stop.

6. ____Step Over Obstacle Instructions: Begin walking at your normal speed. When you come to the shoe box, step over it, not around it, and keep walking. 3= Normal: Is able to step over 2 stacked shoe boxes taped together (9 in total height) without changing gait speed; no evidence of imbalance. 2= Mild Impairment: Is able to step over one shoe box (4.5 in total height) without changing gait speed; no evidence of imbalance. 1= Moderate Impairment: Is able to step over one shoe box (4.5 in total height) but must slow down and adjust steps to clear box safely. May require verbal cueing. 0= Severe Impairment: Cannot perform without assistance.

7. ____Gait with Narrow Base of Support Instructions: Walk on the floor with arms folded across the chest, feet aligned heel to toe in tandem for a distance of 12 ft. The number of steps taken in a straight line are counted for a maximum of 10 steps. 3= Normal: Is able to ambulate for 10 steps heel to toe with no staggering. 2= Mild Impairment: Ambulates 7-9 steps. 1= Moderate Impairment: Ambulates 4-7 steps. 0= Severe Impairment: Ambulates less than 4 steps heel to toe or cannot perform without assistance.

8. ____Gait with Eyes Closed Instructions: Walk at your normal speed from here to the next mark (20 ft) with your eyes closed. 3= Normal: Walks 20 ft, no assistive devices, good speed, no evidence of imbalance, normal gait pattern, deviates no more than 6 in outside 12 in walkway width. Ambulates 20 ft in less than 7 sec. 2= Mild Impairment: Walks 20 ft, uses assistive device, slower speed, mild gait deviations, deviates 6-10 in outside 12 in walkway width. Ambulates 20 ft in less than 9 sec but greater than 7 sec. 1= Moderate Impairment: Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, deviates 10 – 15 in outside 12 in walkway width. Requires more than 9 sec to ambulate 20 ft. 0= Severe Impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside 12 in walkway width or will not attempt task.

9. ____Ambulating Backwards Instructions: Walk backwards until I tell you to stop. 3= Normal: Walks 20 ft, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 6 in outside 12 in walkway width. 2= Mild Impairment: Walks 20 ft, uses assistive device, slower speed, mild gait deviations, deviates 6-10 in outside 12 in walkway width. 1= Moderate Impairment: Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, deviates 10 – 15 in outside 12 in walkway width. 0= Severe Impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside 12 in walkway width or will not attempt task.

10. ____Steps Instructions: Walk up these stairs as you would at home (ie, using the rail if necessary). At the top turn around and walk down. 3= Normal: Alternating feet, no rail. 2= Mild Impairment: Alternating feet, must use rail. 1= Moderate Impairment: Two feet to a stair; must use rail. 0= Severe Impairment: Cannot do safely

Reference: Wrisley DM, Marchetti GF, Kuharsky DK, Whitney SL. Reliability, internal consistency, and validity of data obtained with the Functional Gait Assessment. Physical Therapy, 2004, 84: 906-918.

Total Score __________/30

MOTION SENSITIVITY TEST

Intensity* (0-5)

Duration (seconds)

5-10 secs=1 point 11-30secs=2 points >30 secs=3 points

Score (I + D)

Baseline Symptoms

1. Sitting to supine

2. Supine to left side

3. Supine to right side

4. Supine to sitting

5. Left Hallpike-Dix

6. Return to sit from left Hallpike-Dix

7. Right Hallpike-Dix

8. Return to sit from right Hallpike-Dix

9. Sitting, head tipped to left knee

10. Head up from left knee

11. Sitting, head tipped to right knee

12. Head up from right knee

13. Sitting, turn head horizontally 5

times

14. Sitting, move head vertically 5 times

15. Standing, turn 180 degrees to right

16. Standing, turn 180 degrees to left

TOTAL SCORE

MSQ

MSQ=Total score x # of positions with symptoms

20.48

*When scoring, make sure to use the change in intensity if baseline symptoms exist.

Gaze Stabilization Exercise This exercise is completed in order to improve your ability to maintain focus on your world while your head is moving. Instructions:

1. Look at a stable object (e.g. business card). 2. Turn head side to side as quickly as you can (approximately 30 degrees

from midline) keeping the object in focus. 3. Complete exercise for 1-2 minutes. 4. Repeat with head moving up and down. 5. Exercise should be completed at least 3 times per day.

Complete this exercise in _______________________ position. To advance, place object of focus on a busy background (e.g. checkerboard).

Advanced Gaze Stabilization Exercise

This exercise is completed in order to improve your ability to maintain focus on your world while your head is moving. Instructions:

1. Hold an object (e.g. business card) in front of you so you can read it. 2. Move the card and your head side to side in opposite directions keeping object in

focus. 1. Complete exercise 1-2 minutes. 2. Repeat with head moving up and down. 3. Exercise should be completed at least 3 times per day.

Complete this exercise in _______________________ position. To advance, place object of focus on a busy background (e.g. checkerboard).

Eye-Head Coordination Instructions:

1. With both arms outstretched in front of you, and your index fingers pointed upward, focus on the right finger.

2. Move eyes to the left finger. 3. Turn the head to the left keeping the eyes focused on the left index finger 4. Move eyes to the right finger. 5. Turn the head to the right keeping the eyes focused on the right index finger. 6. Complete exercise for 5 minutes. 7. Can also repeat exercise moving in the vertical direction.

Complete this exercise in _______________________ position. To advance, place object of focus on a busy background (e.g. checkerboard).

Imaginary Target Instructions:

1. Look at a target. 2. Close eyes and turn head slightly, pretending to keep eyes directly at the target. 3. Open eyes to check to see if target is in focus. 4. Repeat movement in other directions.

Complete this exercise in _______________________ position. To advance, place object of focus on a busy background (e.g. checkerboard).

VESTIBULAR QUESTIONNAIRE SYMPTOMS

Chief Complaint:

Description of first episode of dizziness:. (Sudden or Gradual)

Present symptoms better, worse or same as initial occurrence:

Description of present symptoms without using the word “dizzy”:

Severity of symptoms (0 to 10), presently, at worst, at best:

Positions, movements or situations aggravate symptoms:

Duration of symptoms:

Frequency of symptoms:

Visual Symptoms (double vision, increased difficulty focusing with head movement):

Ear Symptoms (fullness, ringing, loss of hearing):

History of previous dizziness: Previous treatment for dizziness

PAST MEDICAL HISTORY AND MEDICATIONS

History of ear surgery, diabetes, neurological disorders, cardiovascular diseases:

Current Medications:

PSYCHOLOGICAL COMPONENTS Feelings of depression or anxiety:

FUNCTION

Current living situation (house, support):

Function prior to dizziness versus present function:

Work history:

Falls, close falls:

Driving/Passenger:

Sleep (# of hrs):

Exercise:

PATIENT GOALS Patient goal by attending therapy:

VESTIBULAR WORKSHEET

System Evaluation (ROM, Muscle Performance, Posture, Coordination, Sensation, Cognition, Vital Signs)

Balance

TEST EYES OPEN EYES CLOSED Romberg

Tandem Romberg

Feet together, Foam surface

One legged stance

Balance and Gait Test

Oculomotor Exam

EXAM ROOM LIGHT

WITH FIXATION (FRENZELS)

Spontaneous Nyst. Gaze Holding Nyst. Smooth Pursuit Saccades VOR to slow head mvmt

VOR to fast head mvmt

Right Hallpike-Dix Left Hallpike-Dix Head-shaking Nyst. Visual Acuity Static Dynamic

Motion Provoked Testing Intensity

(0-5) Duration

(seconds) 5-10 secs=

1 point 11-30secs=2

points >30 secs=3

points

Score (I + D)

Baseline Symptoms 1. Sitting to supine 2. Supine to left side 3. Supine to right side 4. Supine to sitting 5. Left Hallpike-Dix

6. Return to sit from left Hallpike-Dix

7.Right Hallpike-Dix

8. Return to sit from right Hallpike-Dix

9. Sitting, head tipped to left knee

10. Head up from left knee

11. Sitting, head tipped to right knee

12. Head up from right knee

13. Sitting, turn head <-> 5 times

14. Sitting, move head vertically 5 times (pitch)

15. Standing, turn 180 degrees to right

16. Standing, turn 180 degrees to left

TOTAL SCORE MSQ

MSQ=Total score x # of positions with symptoms

20.48 Assessment: Plan:

Vestibular Disorders Activities of Daily Living Scale

This scale evaluates the effects of vertigo and balance disorders on independence in routine activities of daily living. Please rate your performance on each item. If your performance varies due to intermittent dizziness or balance problems, please use the greatest level of disability. For each task indicate the level which most accurately describes how you perform the task. If you never do a particular task, please check the box in column NA. The rating scales are explained on the last page.

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Task 1 2 3 4 5 6 7 8 9 10 F-1 Sitting up from lying down F-2 Standing up from sitting on the bed or chair F-3 Dressing the upper body (e.g., shirt, brassiere, undershirt)

F-4 Dressing the lower body (e.g., pants, skirt, underpants)

F-5 Putting on socks or stockings F-6 Putting on shoes F-7 Moving in or out of the bathtub or shower

F-8 Bathing yourself in the bathtub or shower F-9 Reaching overhead (e.g., to a cupboard or shelf) F-10 Reaching down (e.g., to the floor or a she lf) F-11 Meal preparation F-12 Intimate activity (e.g., foreplay, sexual activit y) A-13 Walking on level surfac es A-14 Walking on uneven surfaces A-15 Going up steps A-16 Going down steps A-17 Walking in narrow spaces (eg, corridor, grocery store aisle)

A-18 Walking in open spaces A-19 Walking in crowds A-20 Using an elevator A-21 Using an escalator I-22 Driving a car I-23 Carrying things while walking (eg, package, garbage bag)

I-24 Light household chores (eg, dusting, putting items away)

I-25 Heavy household chores (eg, vacuuming, moving furniture)

I-26 Active recreation (eg, sports, gardening) I-27 Occupational role (eg, job, child care, homemaking, student)

I-28 Traveling around the community (car, bus)

Explanation of Independence Rating Scale

This scale will help us to determine how inner ear problems affect your ability to perform each task. Please indicate your current performance on each task, as compared to your performance before developing an inner ear problem, by checking one of the columns in the center of the page. Pick the answer that most accurately describes how you perform the task. 1. I am not disabled, perceive not change in performance from before developing an

inner ear impairment. 2. I am uncomfortable performing the activity but perceive no difference in the

quality of my performance. 3. I perceive a decrement in the quality of my performance, but have not changed

the manner of my performance. 4. I have changed the manner of my performance, eg, I do things more slowly or

carefully than before, or I do things without bending. 5. I prefer using an ordinary object in the environment for assistance (eg, stair

railing) but I am not dependent on the object or device to do the activity. 6. I must use an ordinary object in the environment for assistance, but I have not

acquired a device specifically designed for the particular activity. 7. I must use adaptive equipment designed for the particular activity (eg, grab bars,

cane, reachers, bus with lift, wedge pillow). 8. I require another person for physical assistance or, for an activity involving 2

people, I need unusual physical assistance. 9. I am dependent on another person to perform the activity. 10. I no longer perform this activity due to vertigo or a balance problem. NA. I do not usually perform this task or I prefer not to answer this question.

BRANDT - DAROFF HABITUATION EXERCISES

Instructions: Turn your head 45 degrees to the , and then lie down on your side. Return to the middle, turn your head to the , and then lie down on your side. Complete the cycle 5 – 10 times, three times per day. The exercise must be completed quickly enough to cause symptoms.

If you have any questions, please call __________________________at _________________.

Positive and Negative Affective Scale

This scale consists of a number of words that describe different feelings and emotions. Read each item and then mark the appropriate answer in the space next to it. Indicate to what extent you generally feel this way, that is, how you feel on the average. Use the following scale to record your answers. 1 2 3 4 5 very slightly a little moderately quite a bit extremely _____ interested _____ inspired _____ distressed _____ nervous _____ excited _____ determined _____ upset _____ attentive _____ strong _____ jittery _____ guilty _____ active _____ scared _____ afraid _____ irritable _____ hostile _____ alert _____ enthusiastic _____ ashamed _____ proud

Disability Scale

For the following, please pick the one statement that best describes how you feel: Statement Score ____ Negligible symptoms 0 ____ Bothersome symptoms 1 ____ Performs usual work duties but symptoms interfere 2 with outside activities ____ Symptoms disrupt performance of both usual work 3 duties and outside activities ____ Currently on medical leave or had to change jobs 4 because of symptoms ____ Unable to work for over one year or established 5 permanent disability with compensation payments

Place a mark on the line below corresponding to how dizzy you feel

while you are sitting here.

As bad as it can be

No dizziness

Place a mark on the line below corresponding to how dizzy you feel

after turning your head in a “no” motion for 15 seconds.

As bad as it can be

No dizziness

CANALITH REPOSITIONING TREATMENT FOR LEFT SIDED BPPV

1. Sit on the bed with pillows placed toward buttocks and turn head 45° to the left. 2. Lie down with the head hanging down over the edge of the pillows. Keep the head turned 45° to the left. Stay in this position for 20 seconds or until dizziness stops. 3. With the head tilted back, rotate the head 90°, so it is now pointing 45° to the right. Stay in this position for 20 seconds or until dizziness stops. 4. Roll over onto right shoulder and rotate head until it is pointing down 45°. Stay in this position for 20 seconds or until dizziness stops. 5. Slowly sit up with head still rotated to the right.

CANALITH REPOSITIONING TREATMENT FOR RIGHT SIDED BPPV

1. Sit on the bed with pillows placed toward buttocks and turn head 45° to the right. 2. Lie down with the head hanging down over the edge of the pillows. Keep the head turned 45° to the right. Stay in this position for 20 seconds or until dizziness stops. 3. With the head tilted back, rotate the head 90°, so it is now pointing 45° to the left. Stay in this position for 20 seconds or until dizziness stops. 4. Roll over onto left shoulder and rotate head until it is pointing down 45°. Stay in this position for 20 seconds or until dizziness stops. 5. Slowly sit up with head still rotated to the left.

Active Head Movements Following a Slow-Moving Target

This exercise helps to improve your sense of movement in the neck region. Instructions: 1. Wear the eye glasses with the small opening. 2. Have a second person project a light onto a wall with a light pointer. This person will move the light slowly around the wall. 3. Keep the light in focus. Move your eyes and head together to follow the light on the wall.

Complete this exercise in __________________________________ position. To advance, the speed of the light movement can be increased, or the light can be projected onto a patterned background.

Remembered Position

This exercise helps to improve your sense of movement in the neck region. Instructions: 1. Wear the eye glasses with the small opening. 2. Look at the object in front of you. 3. Close your eyes. 4. Turn your head to the right as far as you are comfortable, then turn your head back to the original position while keeping your eyes closed. 5. Open your eyes, note if the original object is in your viewing field. 6. Repeat exercise by turning the head to the left, turning the head back and forth, or turning the head up and down. Always try to return to the original position.

Complete this exercise in __________________________________ position. To advance, the speed of head movement can be increased.

Vestibular Activities and Participation Measure This measure evaluates the effect of dizziness and/or balance problems on your ability to perform activity and participation tasks. Please rate your difficulty without the assistance of other persons on each task. If your performance varies because of intermittent dizziness or balance problems, please select the greatest level of difficulty. If you never do a particular task, please check the box in column NA (not applicable). Because of your dizziness/imbalance, how much difficulty did you have recently in:

None Mild Moderate Severe Unable to do

NA

1. Focusing attention (concentration, remembering)

2. Carrying out your daily routine (managing and completing your daily routine)

3. Handling stress and other psychological demands (driving a vehicle during heavy traffic or taking care of many children)

4. Lying down (get into or out of bed) or turning over in bed

5. Sitting from lying down

6. Moving from sitting to standing

7. Bending over or picking up objects from the ground

8. Lifting and carrying objects

9. Reaching overhead and down

10. Walking short distances (eg, around the house, outside to a nearby car)

11. Walking long distances

Because of your dizziness/imbalance, how much difficulty did you have recently in:

None Mild Moderate Severe Unable to do

NA

12. Walking on different surfaces (icy sidewalks, uneven surfaces)

13. Walking around obstacles: in crowds, across parking lot)

14. Climbing (up and down stairs, elevator, escalator)

15. Running

16. Moving around within the home (eg, moving between rooms or from floor to floor)

17. Moving around within buildings other than your home

18. Moving around using equipment (eg, cane, walker, wheelchair)

19. Using transportation (traveling using private or public transportation – being a passenger)

20. Operating a vehicle: driving a car or riding a bicycle

21. Washing whole body (bathing in a bathtub or shower)

22. Shopping

23. Preparing meals (planning, organizing, cooking, and serving meals for oneself and others)

24. Doing housework: washing and drying clothes and garments; cleaning cooking area and utensils; cleaning living area; and disposing of garbage

Because of your dizziness/imbalance, how much difficulty did you have recently in:

None Mild Moderate Severe Unable to do

NA

25. Taking care of animals (eg, feeding, cleaning, and exercising pets or farm animals)

26. Assisting household members with self-care (eg, eating, bathing, dressing) and/or assisting household members in movement (eg, moving outside the home)

27. Family relationships

28. School education (engaging in all school-related responsibilities and privileges)

29. Vocational training (engaging in all activities at a trade school)

30. Higher education (engaging in all the activities of advanced educational programs beyond high school)

31. Maintaining a job (eg, remunerative employment, nonremunerative employment)

32. Recreation and leisure (engaging in any form of play, recreational, or leisure activities)

33. Sports (engaging in competitive and formal or informal organized games, performed alone or in a group)

34. Socializing (eg, visiting friends or relatives, going to dinner, movies, or parties)