Pyykkő e al. Sp inge Plus (2015) 4:717
DOI 10.1186/s40064-015-1527-0
RESEARCH
Impac e alua ion andassocia ion
wi hEu oQol 5D heal h- ela ed u ili y alues
inMéniè e’s disease
Ilma i Pyykkő1, Vinaya Manchaiah2,3,4* , Hilla Le o5 and E na Ken ala5
Abs ac
The s udy was aimed a e alua ing he alidi y o impac measu es among pa ien s wi h Méniè e’s disease (MD) wi h
ou come a iables o Eu oQol gene ic heal h- ela ed quali y o li e (HRQoL) measu es (i.e., EQ-5D) by using Visual
Analogue Scale (VAS) and EQ-5D index alues. 183 membe s (ou o 200 con ac ed) o he Finish Méniè e Associa-
ion e u ned he ques ionnai es ha hey had illed ou . Va ious open-ended and s uc u ed ques ionnai es ocus-
ing on diagnos ic aspec s o symp oms and impai men caused by he disease we e used. Fo ac i i y limi a ion and
pa icipa ion es ic ion, s anda dized ques ionnai es we e used. Open-ended ques ions on impac o he disease
we e asked, and subsequen ly classi ied based on he WHO-ICF classi ica ion. The gene al HRQoL was e alua ed wi h
EQ-5D index alue and EQ VAS ins umen s. Co ela ion and linea eg ession analyses we e used o explo e he asso-
cia ion be ween HRQoL and o he aspec s. Based on he explana o y powe o di e en models he disease speci ic
semeionic model p o ides he mos accu a e p edic ion in EQ-5D index calcula ions (38 % o he a iance explained).
In EQ VAS sco es, HRQoL is mos accu a ely de e mined by pa icipa ion es ic ion (53 % o he a iance explained),
bu he wo s p edic ion was in ICF-based limi a ions (8 % o he a iance explained). In e es ingly, a i ude and
pe sonal ai explained he educ ion o HRQoL somewha be e han ICF-based a iables. Ac i i y limi a ion and
pa icipa ion es ic ions a e signi ican componen s o MD, bu a e less equen ly ecognized as signi ican ac o s
in sel -e alua ing he e ec o MD on he quali y o li e. The cu en s udy esul s sugges ha MD pa ien s seem o
ha e p oblem iden i ying ac o s causing ac i i y limi a ion and pa icipa ion es ic ions and hence use he semio ic
desc ip ion ocusing on complain s.
Keywo ds: Méniè e’s disease, Quali y o li e, Eu oQol, EQ-5D, ICF, Ac i i y limi a ions, Pa icipa ion es ic ions
© 2015 Pyykkő e al. This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License
(h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium,
p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license,
and indica e i changes we e made.
Backg ound
Méniè e’s disease (MD) is commonly app oached as an
o gan speci ic disease o he inne ea , and is assessed
based on e igo, inni us, and hea ing loss; al hough, he
beha io al es ic ions a e a mo e ex ensi e (O ji 2014).
Conside ing he di e si y o his condi ion, quan i ying
he impac o disease- ela ed di icul ies on measu es o
quali y o li e (QoL) and heal h s a us u ili y ep esen s a
con inuing challenge o esea che s.
QoL is he pe cei ed quali y o an indi idual’s daily li e,
and i can be measu ed by using s anda dized ins u-
men s. A good QoL in ela ion o an indi idual e e s o
a pe son managing daily li e ac i i ies and social ela ion-
ships well (Williams 1985). The heal h- ela ed quali y
o li e (HRQoL) is mo e speci ic and is ela ed o physi-
cal, men al, emo ional, and social unc ioning; how-
e e , a heal h s a us e e s o a holis ic concep , which
is de e mined by ac o s which a e mo e han he p es-
ence o absence o any disease. I is o en summa ized by
li e expec ancy o sel -assessed heal h s a us, and mo e
b oadly includes indica ions o unc ioning, physical ill-
ness, and men al well being. Al hough he de ini ions o
hese wo cons uc s a e simila , QOL and heal h s a us
a e dis inc cons uc s (Smi h e al. 1999). Fo example,
Open Access
*Co espondence: inaya.manchaiah@lama .edu
2 Depa men o Speech and Hea ing Sciences, Lama Uni e si y,
Beaumon , TX, USA
Full lis o au ho in o ma ion is a ailable a he end o he a icle
Page 2 o 9
Pyykkő e al. Sp inge Plus (2015) 4:717
when a ing QOL, pa ien s gi e g ea e emphasis o men-
al heal h han o physical unc ioning. Howe e , his pa -
e n is e e sed o app aisals o heal h s a us, o which
physical unc ioning is mo e impo an han men al
heal h (Smi h e al. 1999).
The impac o MD can be e alua ed by using com-
plain s a ed on he basis o se e i y (Le o e al. 2010), by
di e en impai men ques ionnai es (Le o e al. 2013), o
by using disease speci ic measu es (S ephens e al. 2010;
Ka o e al. 2004). Va ious gene al measu es ha e been
used o assess he e ec on HRQoL on MD pa ien s (Le o
e al. 2012; Ande son and Ha is 2001; Sode man e al.
2002; Ya dley e al. 2003), bu only a ew s udies ha e
explo ed he ac o s associa ed and esul ing in educed
QoL (Le o e al. 2012; Ande son and Ha is 2001; Kin-
ney e al. 1997). The disease-speci ic ins umen s end o
be mo e esponsi e o psychological s a es and o symp-
oms o MD, as compa ed o gene al heal h measu es
ha ocus on b oade aspec s o he condi ions (Ka o
e al. 2004; Le o e al. 2012; Diaz e al. 2007). Howe e ,
he applica ion o gene al heal h- ela ed ins umen s
may miss clinically signi ican changes in QoL in a spe-
ci ic illness because he ques ions a e oo b oad (G een
e al. 2007). Mo eo e , he QoL measu es also seem o
be in luenced by a i ude owa d he illness, o example,
posi i e hinking (S ephens e al. 2010). Hence, a mo e
ocused app oach may be necessa y o unde s and he
impac o he diso de .
The Wo ld Heal h O ganisa ion (WHO) has ecom-
mended he In e na ional Classi ica ion o Func ion-
ing, Disabili y and Heal h (ICF) o be used o desc ibe
he complex associa ion among ac o s such as impai -
men , unc ioning, ac i i y limi a ions, and pa icipa ion
es ic ions caused by a diso de on human well-being
[Wo ld Heal h O ganiza ion (WHO) 2001]. To pe o m
such analysis in MD, Le o e al. (2010) used da a om
open-ended ques ionnai es and classi ied he impai -
men s wi h he ICF amewo k. The p edic ion o impac
on QoL was less e icien when using ICF based classi i-
ca ion when compa ed o using impai men ques ion-
nai es, which deli e ed somewha di e en explana o y
a iables (Le o e al. 2013; S ephens and Pyykko 2011).
Also, i is impo an o no e ha using he ICF ame-
wo k may p o ide much b oade unde s anding o he
condi ion’s impac when compa ed o using disease-spe-
ci ic ins umen s.
The EQ-5D is a widely used su ey ins umen o
measu ing economic p e e ences o heal h s a es. I
is one o se e al such ins umen s ha can be used o
de e mine he quali y-adjus ed li e yea s associa ed wi h
a heal h s a e. When epo ing he gene al heal h EQ-
5D-3L (3L— e e ing o h ee le els in he esponse
scale) esul s, usually ei he EQ-5D index alue o Visual
Analogue Scale (EQ VAS) alue has been epo ed. The
index alue and VAS e alua ions may di e be ween sub-
jec s due o a ious easons as dynamic a ia ions o he
disease (Bagus and Beale 2005). O he easons may be
due o changes in social communica ion, pe sonal needs,
and accep ance o he impai men . A be e knowledge o
di e ences be ween VAS and EQ-5D index alues could
help in ehabili a ion by p o iding unde s anding o he
need o p ope enablemen p ocedu es o es o e he
quali y o li e. Mo eo e , i is also impo an o unde -
s and he ela ionship be ween di e en e alua ion
app oaches (e.g., b oad s ocused) on he HRQoL.
The aim o he cu en s udy was o e alua e he alidi y
o impac measu es among pa ien s wi h MD wi h ou -
come a iables o Eu oQol gene ic QoL (i.e., EQ-5D-3L)
measu es by using VAS and index alue ins umen s.
Me hod
S udy design andpa icipan s
Pe mission was ob ained om he Finnish Méniè e Fed-
e a ion (FMF) o con ac hei membe s, asking hem o
comple e an ex ensi e ques ionnai e on symp oms ela ed
o MD. Unde Finnish law, his kind o ques ionnai e
s udy pe o med in collabo a ion wi h pa ien associa ion
does no need e hical app o al. Fo his pu pose, e e y
six h name on hei membe ship lis was aken; hus, a
sample composed o 200 indi iduals was con ac ed. They
we e sen a 26-page ques ionnai e by mail as in ou p e-
ious s udies (S ephens e al. 2010, 2012), oge he wi h
a s amped and add essed en elope o hei esponses.
Those no esponding wi hin 12weeks we e sen emind-
e s. E e y e u ned ques ionnai e was examined; i he e
we e missing da a, he esponden was con ac ed by el-
ephone and asked o answe he unanswe ed ques ions so
as o achie e comple e da a. In o al, 186 ou o 200 sen
ques ionnai es we e e u ned, esul ing in a e u n a e o
93%; howe e , 3 ques ionnai es had signi ican amoun o
missing alues and we e emo ed. The 183 pa icipan s
had he mean age o 61.5, and he e we e 36 men and 147
women in he sample, e lec ing he gende sp ead in FMF.
Ques ionnai es
The o al ques ionnai e comp ised he Ve igo Ques ion-
nai e (Ken ala 1996), he EQ-5D-3L measu e (Rabin and
de Cha o 2001), he In e na ional Tinni us In en o y
(ITI;Ché y-c oze and Colle 2005), The Hea ing Disabil-
i y and Handicap Scale (HDHS;Philibe 1994), Localiza-
ion ques ions based on he Hea ing Measu emen Scale
(HMS;Chung and S ephens 1983), a Dizziness Handicap
Ques ionnai e (DHQ;Ya dley e al. 1992), a Pa icipa-
ion Res ic ion Scale (S ephens 2001), and he Sense o
Cohe ence (SOC) Scale-Sho e sion (An ono sky and
Sagy 1986). The e we e also some open-ended ques ions.
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Pyykkő e al. Sp inge Plus (2015) 4:717
The speci ic es ic ion and unc ion limi a ion open-
ended ques ion was wo ded as ollows: Please make
a lis o he main e ec s ha you Méniè e’s disease has
on you li e. W i e down as many as you can hink o . In
his ask, i e lines we e indica ed o each subjec o ill.
The ea e , he i ems we e classi ied based on ICF classi-
ica ion [Wo ld Heal h O ganiza ion (WHO) 2001]. The
classi ica ion was done independen ly by wo esea ch-
e s. Howe e , ou esea che s discussed he analysis and
a consensus was achie ed in ela ion o ICF codes. F om
he 183 subjec s, 176 epo ed some e ec s o MD ha
esul ed in some unc ional limi a ion. The classi ica ion
p o ided 64 di e en en i ies belonging o 6 main ca ego-
ies (Le o e al. 2010).
The indi iduals we e asked o a e he impac o MD
by asking, “How much does Méniè e’s disease in luence in
you li e?”. The ques ion was scaled in i e s eps anging
om no a all o e y se e ely. This ques ion was used
as an ou come measu e o disease speci ic impac o MD
on li e. In addi ion, he e ec o ca dinal symp oms on
MD, as e igo, gai , hea ing, inni us, p essu e in he ea ,
hype acusis, and possible o he diso de s we e also a ed
in a i e s ep scale om no e ec o e y se e e e ec .
In modelling o impai men ela ed o MD and i s
es ic ions, we used Eu oQol gene al heal h meas-
u e, he EQ-5D. The EQ-5D ins umen consis s o wo
pa s: i e ques ions ela ing o he dis inc dimensions
o a pa ien ’s unc ional capaci y mobili y, sel -ca e, usual
ac i i ies, pain/discom o , and anxie y/dep ession)
on each o which 3 esponses a e possible, and a isual
analogue scale (VAS) on which he pa ien is asked o
indica e a sel - a ing o hei cu en heal h s a e. The
o me a e combined wi h weigh ings de i ed om a
sample o he gene al Eu opean popula ion o p o ide
a ‘social a i ’ EQ-5D index alue (Dolan e al. 1995).
The la e cons i u es a mo e di ec indica o o pa ien s’
own implici p e e ences. You can ind mo e in o ma ion
abou he ques ions and a ing scale used in he EQ-5D
by isi ing hei websi e (h p://www.eu oqol.o g/).
Da a analysis
The associa ion be ween EQ-5D-3L and o he aspec s (e.g.,
symp oms, ac i i y limi a ions, e c.) was analysed i s by
explo ing associa ions wi h he Pea son co ela ion ma ix
and hen by using he linea eg ession analysis me hod.
In EQ-5D index alue, each s a e o he i e heal h- ela ed
dimensions is assigned a he h ee unc ional le els o no
p oblem, some p oblem, and ex eme p oblem.
Resul s
Fo he whole popula ion, he a e age EQ-5D index alue
alues and EQ VAS alues a e shown in Table1. I also
p o ides he pe cen age o s udy samples in h ee unc-
ional le els in he i e dimensions o he EQ-5D.
Figu e1 p esen s he EQ-5D index alue and EQ-5D
VAS alues in he cu en sample sugges ing skewness in
he EQ-5D index alue alues, whe eas EQ VAS alues
a e domina ed by an e en en h alue in he scale.
When indi idual sco es a e agg ega ed o a popula-
ion sample, he esul an unc ion is inhe en ly nonlin-
ea . Figu es2 demons a es he EQ-5D index alue and
VAS alues o di e en age g oups. In EQ-5D index al-
ues, he e ec o age was no signi ican ly dependen on
age (F=1.206, p=0.305). Howe e , in he heal h sco e
e alua ion on VAS scale in he age g oup o 50yea s, he
VAS alues di e ed signi ican ly om olde age g oups
(F=4.401, p<0.01), wi h olde age g oups sco ing wo se
VAS alues. We he e o e s anda dized he e ec o age
in linea eg ession analysis when he VAS ins umen
was he ou come a iable.
Table 1 The demog aphic de ails andsumma y o EQ-5D quali y o li e alues
Pa ame e Mean (±SD) Lowe ange Uppe ange
Age (in yea s) 61.5 (10.5) 22 91
Symp om du a ion (in yea s) 18.4 (11.1) 1 63
EQ-5D Index alue 0.75 (0.19) 0.29 1.0
EQ-5D VAS alue 71.2 (17.1) 20 100
No p oblem Some p oblem Ex eme p oblem
EQ-5D Dimensions (% o popula ion epo ing he p oblem)
Mobili y 59.6 40.4 0
Sel -ca e 97.3 3.7 0
Usual ac i i ies 74.3 33.4 3.3
Pain/discom o 44.8 50.8 4.4
Anxie y/dep ession (mood) 76.5 22.4 1.1
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Pyykkő e al. Sp inge Plus (2015) 4:717
In e nal associa ion o EQ sco e andi s associa ion
wi h a ious symp oms andcomplain s associa ed
wi hMD
Table 2 p esen s co ela ion esul s o a ious symp-
oms and componen s o MD wi h i e dimensions o
he EQ-5D dimensions. In co ela ion analysis, mo ili y
co ela ed wi h usual ac i i ies (0.55, p<0.001) and pain
( =0.33, p<0.001). The mood co ela ed wi h sel -ca e
(0.20, p<0.001), usual ac i i ies ( =0.25, p<0.001), and
pain ( =0.32, p<0.001). The sel -ca e co ela ed wi h
usual ac i i ies ( =0.29, p<0.001) and mood ( =0.20,
p < 0.001). Only mo ili y was biased by ageing o he
subjec s wi h olde subjec s ha ing mo e p oblems wi h
mobili y. Males also had mo e pain- ela ed complain s
han emales. The du a ion o disease did no co ela e
wi h any o he QoL componen s.
Quali y o li e measu ed wi hICF o ien ed app oach
Table3 demons a es linea eg ession model wi h he
ICF-based limi a ions when EQ-5D index alue and VAS
a e ou come a iables. In VAS e alua ion, he model
consis ing om e igo, hea ing loss, and a sal - ee die
was s a is ically signi ican ( =0.293, p < 0.001) and
explained only 8.6% o a iance in VAS. In EQ-5D index
alue model, wo a iables we e signi ican : impai men
die a y impac and nausea. Also, his model was s a is i-
cally signi ican ( =0.257, p<0.001) and explained 6.6%
o a iance in EQ-5D index alue.
Fig. 1 Dis ibu ion o EQ-5D Index alues (le ) and VAS sco es ( igh ) among 183 pa icipan s
Fig. 2 Linea eg ession model ou come o age in EQ-5D index alues (le ) and VAS sco es ( igh )
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Pyykkő e al. Sp inge Plus (2015) 4:717
Quali y o li e measu ed wi hsymp oms o ien ed app oach
Table4 demons a es a linea eg ession model consis ing
o symp oms when EQ-5D index alue and VAS ins u-
men s we e ou come a iables. In VAS e alua ion, he
model consis ed o gai p oblems, balance p oblems, phys-
ical s ain induced e igo, and sho age o ene gy. This
model was s a is ically signi ican ( =0.624, p<0.001) and
explained 38.9% o he a iance in VAS. In EQ-5D index
alue model, h ee a iables we e signi ican : impai men
o gai , balance p oblems and sho age o ene gy. Also, his
model was s a is ically signi ican ( =0.634, p<0.001)
and explained 37.8% o he a iance in EQ-5D index alue.
No ewo hy was ha nei he hea ing p oblems no e igo
co ela ed wi h quali y o li e in his s udy.
Quali y o li e measu ed wi hac i i y limi a ions o ien ed
app oach
Fo assessmen o ac i i y limi a ions, inni us was
assessed on a ITI ques ionnai e wi h 8 ques ions. The
unc ional limi a ion o hea ing was assessed by a ques-
ionnai e consis ing o 10 ques ions. Localiza ion o
sound was assessed by a sound localiza ion ques ionnai e
consis ing o 4 ques ions. The e igo was e alua ed wi h
a e igo handicap ques ionnai e consis ing o 8 ques-
ions. A o al o 24 ques ions we e analyzed.
Table5 p esen s he linea s epwise eg ession analysis
o ac o s desc ibing ac i i y limi a ions in MD on VAS
and EQ-5D index based measu es o 5D QoL. The VAS
ins umen based model consis ed o wo e igo linked
a iables (walking on he sidewalk, bending p o oked e -
igo, and ac i i y limi a ion by ea o ha ing an a ack),
one inni us ela ed a iable ( equency o unbea able
inni us), and one hea ing linked a iable (p oblems o
hea ing a doo bell). The model was s a is ically signi ican
( =0.622, p<0.001) and explained 38.7% o he a iance
in VAS. The EQ-5D index alue could be explained by e -
igo-linked a iables ( empo a y ac i i y limi a ions and
walking in open space), and one inni us linked a iable
Table 2 Co ela ion o EQ-5D componen s wi h a ious aspec s o  he Méniè e’s disease includingsymp oms o  he dis-
ease, ac i i y limi a ions andpa icipa ion es ic ions, pe sonal ai s, anda i ude
*p≤0.05; **p≤0.01
Mo ili y Sel -ca e Usual ac i i ies Pain Mood
Ve igo se e i y n.s. 0.19* n.s. n.s. n.s.
Nausea AND omi ing n.s. 0.15* n.s. n.s. n.s.
Tuma kin a ack 0.184* n.s. 0.252** 0.216** n.s.
Balance p oblems 0.496** n.s. 0.451** 0.258** n.s.
Uns eadiness 0.506** 0.198** 0.514** 0.321** n.s.
Mo ing abili y 0.559** 0.357** 0.446** 0.386** n.s.
Chai ise 0.442** 0.271** 0.381** 0.350** 0.176*
Impac o e igo 0.249** 0.158* 0.272** 0.236** n.s.
Tinni us impac 0.156* n.s. n.s. 0.125 n.s.
Balance impac 0.569** 0.327** 0.433** 0.371** 0.225**
Hea ing impac n.s. n.s. n.s. n.s. n.s.
P essu e impac 0.226** 0.229** 0.214** 0.198**
Anxie y/ne ousness 0.181* n.s. 0.219** 0.214** 0.349**
Ene ge ics/ a igue 0.286** 0.159* 0.356** 0.344** 0.316**
Sense o cohe ence −0.185* −0.182* −0.264** −0.272** −0.417**
Table 3 Linea s epwise eg ession analysis o ICF-based limi a ions by he Méniè e’s disease wi hEQ-5D VAS andEQ-5D
index alues asou come a iables
Va iable VAS model, =0.293 EQ-5D index alue model, =0.293
Coe S.E. PCoe S.E. P
Cons an 69.1 1.7 <0.001 0.78 0.02 <0.001
Ve igo −7.6 2.9 0.010 n.s n.s 0.168
Hea ing 6.9 3.9 0.012 n.s n.s 0.192
Die 0.7 4.2 0.022 n.s n.s 0.996
Nausea n.s n.s 0.543 −0.13 0.07 0.011
D ugs n.s n.s 0.161 0.22 0.05 0.003

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Pyykkő e al. Sp inge Plus (2015) 4:717
( equency o unbea able inni us). The model was s a-
is ically signi ican ( =0.558, p<0.001) and explained
29.6% o he a iance in EQ-5D index alue.
Quali y o li e measu ed wi hpa icipa ion es ic ions
o ien ed app oach
The ques ionnai e ocuses on pa icipa ion es ic ions
(consis ing o 30 ques ions) caused by heal h condi ion on
con e sa ions, a eling, shopping, a eling o medical
appoin men s, banks and o ices, a ending lea ning ci -
cles, ela ionship o o he s, wo k ela ed ac i i ies,among
o he s. Table 6 p esen s he linea s epwise eg es-
sion analysis o ac o s desc ibing pa icipa ion es ic-
ion in MD on VAS and EQ-5D index based measu es
o 5D QoL. In VAS based model o quali y o li e, six
a iables u ned ou o be indica i e (see Table6). The
model was s a is ically signi ican ( =0.580, p<0.001)
and explained 33.7% o VAS a iabili y. In EQ-5D index
alue based model, only h ee a iables we e included in
he model ha was s a is ically signi ican ( =0.457).
EQ-5D index alue, p<0.001) could explain 17.3% o he
a iabili y o EQ-5D index alue. In ac o ial analysis, he
pa icipa ion es ic ion consis ed o 7 ac o s co e ing
68% o he da a. B oadly, he a iables associa ed wi h
VAS-measu e consis ed o communica ion, lis ening,
daily ac i i ies, social ac i i y, and lea ning es ic ions.
The EQ-5D index alue associa ed a iables consis ed o
es ic ions in social ac i i y and in daily ac i i y. In VAS
measu e he hea ing impai men associa ed es ic ions
domina ed, whe eas in EQ-5D index alue he pa icipa-
ion es ic ion consis ed mainly om balance impai -
men associa ed p oblems.
The di e ence be weenEQ-5D index alue andVAS
measu emen
Table7 p esen s he summa y om he easibili y o di -
e en pa ame e desc ip ions in he e alua ion gene al
HRQoL wi h EQ-5D index alue and VAS ins umen s.
Fo compa ison, a model consis ing o pe sonal ai s
measu ed wi h SOC and sel - a ed anxie y is included.
Based on he explana o y powe o di e en models,
i seems ha he disease symp om speci ic semeionic
model p o ides he mos accu a e p edic ion in EQ-5D
index alue calcula ions (37.8%). In VAS sco es, QoL is
mos accu a ely de e mined by pa icipa ion es ic ion
(53.3%). The wo s p edic ion in bo h EQ-5D index alue
and VAS models was in ICF-based limi a ions (5.6 and
7.9 % espec i ely). In e es ingly enough, a i ude and
pe sonal ai s explained he educ ion o QoL somewha
be e han he ICF-based a iables.
Discussion
The aim o he p esen s udy was o e alua e he alid-
i y o impac measu es among pa ien s wi h MD wi h
Table 4 Linea s epwise eg ession analysis o symp oms o  he Méniè e’s disease wi hEQ-5D VAS andEQ-5D index al-
ues asou come a iables
Va iable VAS model, =0.624 EQ-5D index alue model, =0.558
Coe SE PCoe SE P
Cons an 84.8 1.8 <0.001 0.90 0.02 <0.001
Balance −3.8 1.6 0.017 −0.26 0.11 0.019
Gai −7.6 2.1 <0.001 −0.79 0. 14 <0.001
Physical s ain −3.3 1.3 0.013 n.s. n.s. 0.879
Ene gy −2.5 1.3 0.048 −0.06 0.01 <0.001
Table 5 Linea s epwise eg ession analysis o  ac o s desc ibing ac i i y limi a ions caused by he Méniè e’s disease
wi hEQ-5D VAS andEQ-5D index alues asou come a iables
Va iable VAS model, =0.622 EQ-5D index model, =0.558
Coe SE PCoe SE P
Cons an 91.8 2.9 <0.001 0.94 0.03 <0.001
P oblems wi h gai on sidewalk −6.8 1.6 <0.001 −0.05 0.02 <0.032
Unbea able inni us occu ence −3.9 1.1 0.001 −0.04 0.02 0.020
Bending p o oking e igo −7.4 1.7 <0.001 -0.05 0.02 0.006
Hea ing doo bell inging −3.1 1.3 <0.05 n.s. n.s. 0.522
Ac i i y limi a ion (e.g., shopping) caused by e igo n.s. n.s. 0.144 −0.071 0.022 0.002
Page 7 o 9
Pyykkő e al. Sp inge Plus (2015) 4:717
ou come a iables o Eu oQol gene ic QoL. Fu he -
mo e, di e ences be ween wo gene ic heal h e alua ion
me hods in EQ-5D (EQ-5D index alue and VAS) we e
explo ed. We ound ha he symp om p o ile o he dis-
ease p o ided he majo ou come in gene ic HRQoL.
The VAS ins umen had seemingly an inhe en p op-
e y o include age-associa ed changes in pe o mance
as well as in a i ude and pe sonal ai . I hese a i-
ables we e added in he VAS-ins umen ha con ained
he symp om p o ile, he eg ession (38.9–39.2 %) did
no signi ican ly imp o e. In con as , he EQ-5D index
alue -ins umen was ma kedly imp o ed by a i ude
and pe sonal ai (i.e., 37.8–45.3 %). As hese meas-
u es a e no wi hin he EQ-5D index alue –ins umen ,
he VAS-ins umen p o ides di e en aspec s o QoL
in MD, which can be missed i only one ins umen is
inspec ed. The a i udes owa ds he disease and pe -
sonal ai played a mino ole in he es ima ion o QoL
in MD, which is consis en wi h esul s om p e ious
s udies by Le o e al. (2012) and S ephens e al. (2010).
Vigo and ene gy a e no no mally explo ed in ela ion
o MD, al hough he pa ien o en complains abou a
lack o ene gy (S ephens e al. 2010). This a iable could
pa ly explain he educ ion in QoL, and he di e ence in
EQ-5D index alue and VAS scaling me hods. Values and
alue judgmen s a e in insic o measu emen s o his
so and need o be made explici . The esul s con i m
he p e ious obse a ion ha he e is a sho age o el-
e an and alida ed ques ionnai es assessing he impac
o e igo o dizziness on gene ic QoL (Du acinsky e al.
2007).
Co ela ion analysis indica ed ha mood (e.g., anxie y/
dep ession) was ela ed o e y ew aspec s o complain s
and symp oms, whe eas he o he ou dimensions o
he EQ-5D (mobili y, sel -ca e, usual ac i i ies and pain)
we e associa ed wi h mo e complain s and symp oms o
MD (see Table2). In addi ion, a ious in e nal co ela-
ions we e obse ed (e.g., mo ili y co ela ed wi h usual
ac i i ies and pain; mood co ela ed wi h sel -ca e, usual
ac i i ies, and pain; sel -ca e co ela ed wi h usual ac i i-
ies and mood). Mo eo e , some age and gende e ec s
we e also no iced, al hough he du a ion o he disease
Table 6 Linea s epwise eg ession analysis o  ac o s desc ibing pa icipa ion es ic ions caused by he Méniè e’s dis-
ease wi hEQ-5D VAS andEQ-5D index alues asou come a iables
Va iable VAS model, =0.580 EQ-5D index model, =0.457
Coe S.E. PCoe S.E. P
Cons an 109.7 4.04 <0.001 0.89 0.07 <0.001
Pa icipa ing in lec u es −5.16 1.66 0.007 n.s. n.s. 0.968
Res ic ion on pe o ming household asks −5.50 1.89 0.036 −0.114 0.03 <0.001
Hea ing quie con e sa ion −5.38 1.92 0.006 n.s. n.s. 0.444
P oblems in isi ing doc o −6.22 2.15 0.005 n.s. n.s. 0.917
Loss o in e es in wa ching TV −5.78 1.91 0.003 n.s. n.s. 0.734
Res ic ion on ela ionships o close people by hea ing p oblem 8.22 2.23 <0.000 n.s. n.s. 0.40
Res ic ion on isi ing close people by hea ing p oblem −6.74 1.90 0.001 n.s. n.s. 0.223
T a eling alone n.s. n.s. 0.547 −0.34 0.02 0.059
P oblems s aying home alone n.s. n.s. 0.633 0.138 0.62 0.029
Table 7 Goodness o  i models desc ibing heal h ela ed quali y o li e wi hEQ-5D index alue andVAS ins umen s
whene alua ed wi hICF-based limi a ions, symp om speci ic complain s, ac i i y limi a ions, andpa icipa ion es ic-
ions a iables
Fo compa ison, a i ude and pe sonal ai measu es a e included
Measu able VAS (%) EQ-5D index alue (%) Méniè e impac (%)
ICF-based limi a ions 8.6 7.9 8.7
Symp oms 38.9 34.2 48.3
Ac i i y limi a ions 38.7 32.1 47.2
Pa icipa ion es ic ions 33.7 17.3 53.4
A i ude and pe sonal ai 8.8 22.7 23.4
Symp oms, a i ude and pe sonal ai 39.2 44.8 51.1
Page 8 o 9
Pyykkő e al. Sp inge Plus (2015) 4:717
does no seem o be ela ed o any o he QoL compo-
nen s. These obse a ions p o ide use ul in o ma ion o
clinicians in managemen and ehabili a ion planning o
MD pa ien s. This indica es ha lea ning o cope wi h he
disease (Ken ala e al. 2013) does no necessa ily imp o e
QoL as has been sugges ed (Ty ell e al. 2015).
In he p esen s udy, he indi iduals wi h MD end o
e alua e hei heal h wi h a symp oms based app oach
a he han wi h he limi a ion o unc ion. Con ol o
symp oms may be a mo e unde s andable way o imp o e
he QoL and in luence he ins umen alues when com-
pa ed o he e ec s o limi a ions and a ious es ic ions
expe ienced by he pa ien . In his espec , ou obse a-
ions con i m he concep ha condi ion speci ic symp-
om measu es ha mi o ea men o condi ion o
ce ain illness ha e high accep abili y and ele ance o
pa ien s and doc o s (Kind 2001). They also can be in lu-
enced by ea men , and a e sensi i e o change. In he
he apeu ic p ocess, in e es has he e o e been ocused
o change he medical ac o s educing he EQ-5D index
alue and VAS sco es. Howe e , as indica ed in he p e-
sen s udy, no all he i ems a e ela ed o medical con-
di ions. Some o he VAS and EQ-5D index alue sco es
a e linked o pe sonal ai and a i ude. Pe sonal ai
is, howe e , esis an o changes as SOC is di icul o
change in adul subjec s. Howe e , possibly some a i ude
dependen a iables in ac i i y limi a ion and pa icipa-
ion es ic ion can be in luenced by he apy as sho age
o ene gy, abili y o d i e a ca , capabili y o do shopping,
and he unce ain y wi h managemen a wo k. I medi-
cal condi ions canno be alle ia ed, hen he ehabili a-
i e e o s migh be ocused on hese domains in o de
o imp o e accessibili y and emo e hind ances. One
such e o is a pee suppo sys em, in ol ing pa ien - o-
pa ien help, and also suppo om signi ican o he s can
be enhanced.
The WHO-ICF is a mul ipu pose classi ica ion
designed o se e a ious disabili ies and heal h con-
di ions [Wo ld Heal h O ganiza ion (WHO) 2001]. I
speci ically aims o p o ide a scien i ic basis o unde -
s anding h ough s udying heal h and heal h ela ed
s a us, ou comes and de e minan s. ICF can be used as
an explana o y amewo k ha may allow mo e com-
p ehensi e unde s anding o he cha ac e o illness,
and how i may be desc ibed and po en ially alle ia ed
(Wade and Halligan 2003). The ICF p o ides a pa ien -
cen e ed illness desc ip ion ha may p o ide use ul
insigh s in o inding solu ions o o e come he impac
o he condi ion. I was, he e o e, in e es ing o s udy
he applicabili y o ICF o be used in a model desc ib-
ing QoL. Wi h EQ-5D index alue and VAS alue, he
ICF based limi a ions p o ides he possibili y o exam-
ine di e ences om pa ien s’ pe spec i es and compa e
hem wi h he pe spec i es o he obse e . Al hough
he VAS and EQ-5D index alue based models yielded
a he poo explana o y powe (8 %), he limi a ions
loaded pa ly di e en ly in o he EQ-5D index and VAS
models. The poo pe o mance in connec ion wi h QoL
ins umen s may be due o wo ac o s: (1) pa ien s had
p oblems iden i ying i ems limi ing hei ac i i ies when
asked open-ended ques ions; o (2) al e na i ely hey
had adap ed o hei cu en si ua ions and had hus no
iden i ied exis ing p oblems i no speci ied by a ques-
ionnai e. The o me op ion migh occu due o empo-
a y changes in he disease, as pa ien s end o ocus on
mo e ecen symp oms. The la e op ion would occu
i he measu es o QoL would e lec o he aspec s o
he illness as, o example, own will ha is no di ec ly
desc ibed in ICF-classi ica ion. Bo h o hese aspec s
may be ue and should be e alua ed in u he s ud-
ies. One way o doing ha migh be o unde s and how
he ICF-based app oach will ela e o QoL measu es
when used wi h open-ended and s uc u ed ques ion-
nai es. Howe e , he cu en s udy esul s indica e ha
he pa ien s we e no able o iden i y he c ucial ac o s
desc ibing he illness, o ha illness has mo e dimen-
sions han de ined by ICF.
In MD, he VAS alues seem o con ain addi ional
i ems ha will con ound he e alua ion o he impac o
he disease. Such con ounde s in he p esen s udy we e
mood, a i ude, expec a ions o p og ess o he disease,
and ageing among o he s. We also obse ed ha VAS
includes some impo an i ems as cogni i e abili y, mem-
o y, i ali y, and a la ge scale o social es ic ions ha
we e no me in EQ-5D index alue -ins umen . In MD,
he EQ-5D index alue measu es complain associa ed
educ ion o ac i i y, and is adap ed o he ageing p o-
cess. The EQ-5D index alue and VAS a e measu ing hus
somewha di e en dimensions o he impac on gen-
e al HRQoL in MD. The ICF-based i ems desc ibed by
he pa ien s did no con ain elemen s ha could explain
educ ion o QoL in he p esen s udy. This seems o be
due o he e ogeneous esponses o he pa ien s exhibi ing
a la ge scale o di e en opics in hei eplies.
Conclusions
The cu en s udy sugges s ha a mo e ocused symp-
om o ien ed app oach is mo e sensi i e in ela ion o
gene al HRQoL, whe eas he mo e comp ehensi e ICF-
based app oach explained less a iance. The s udy iden-
i ied di e ences be ween VAS and EQ-5D index alue,
indica ing ha hey may assis in unde s anding di e en
aspec s o QoL. O e all, hese indings sugges ha MD
pa ien s seem o ha e p oblems iden i ying ac o s caus-
ing ac i i y limi a ion and pa icipa ion es ic ions and
use he semio ic desc ip ion ocusing on complain s.
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Pyykkő e al. Sp inge Plus (2015) 4:717
Au ho s’ con ibu ions
IP w o e he pape , pa icipa ed in collec ion and analysis o he da a. VM pa -
icipa ed in he w i ing o he pape and con ibu ed in hea ing da a analysis.
HL pa icipa ed in he w i ing o he pape and in collec ion and analysis o
he da a. She made he analysis o quali y o li e, au al ullness and ICF s a egy.
EK pa icipa ed in he w i ing o he pape and in collec ion and analysis o he
da a. She made he analysis o pe sonal ai and coping s a egy. All au ho s
ead and app o ed he inal manusc ip .
Au ho de ails
1 Depa men o O ola yngology, Uni e si y o Tampe e, Tampe e, Finland.
2 Depa men o Speech and Hea ing Sciences, Lama Uni e si y, Beaumon ,
TX, USA. 3 Depa men o Beha iou al Sciences and Lea ning, The Swedish
Ins i u e o Disabili y Resea ch, Linköping Uni e si y, Linköping, Sweden.
4 Audiology India, Myso e, Ka na aka, India. 5 Depa men o O ola yngology,
Uni e si y o Helsinki, Helsinki, Finland.
Acknowledgemen s
This s udy has been conduc ed in coope a ion wi h he Finnish Méniè e’s Fed-
e a ion (FMF) and has been inancially suppo ed by he Finnish Slo Machine
Associa ion, RAY. The la e P o esso Da ydd S ephens ( om he Depa men o
Psychological Medicine and Neu ology, School o Medicine, Ca di Uni e si y,
Ca di , Wales) con ibu ed o he s udy, bu passed away du ing p epa a ion
o his manusc ip .
Compe ing in e es s
The au ho s decla e ha hey ha e no compe ing in e es s.
Recei ed: 12 Oc obe 2015 Accep ed: 10 No embe 2015
Re e ences
Ande son JP, Ha is JP (2001) Impac o Menie e’s disease on quali y o li e. O ol
Neu o ol 22:888–894
An ono sky H, Sagy S (1986) The de elopmen o a sense o cohe ence and i s
impac on esponses o s ess si ua ions. J Soc Psychol 126:213–225
Bagus A, Beale S (2005) Modelling Eu oQol heal h- ela ed u ili y alues o
diabe ic complica ions om CODE-2 da a. Heal h Econ 14:217–230
Chung S, S ephens D (1983) Binau al hea ing aid use and he Hea ing Meas-
u emen Scale. RCS Med Sci Psychol Psychia 11:721–722
Diaz RC, LaRoue e MJ, Boj ab DI e al (2007) Quali y-o -li e assessmen o
Menie e’s disease pa ien s a e su gical laby in hec omy. O ol Neu o ol
28:74–86
Dolan P. CC, Kind P., Williams A. (1995). A social a i o Eu oQol: esul s om
a UK gene al popula ion su ey. Discussion pape no. 138. Cen e o
Heal h Economics, Uni e si y o Yo k 1995
Du acinsky M, Mosnie I, Boucca a D e al (2007) Li e a u e e iew o ques ion-
nai es assessing e igo and dizziness, and hei impac on pa ien s’
quali y o li e. Value Heal h 10:273–284
Gianopoulos Y, Ga ehouse S, S ephens D (2001) Consequences o hea ing loss
on pa icipa ion in li e. In: Pape p esen ed in ICRA symposium, Ca di ,
2001
G een JD J , Ve all A, Ga es GA (2007) Quali y o li e ins umen s in Menie e’s
disease. La yngoscope 117:1622–1628
Hè u R, Louise G, Bead y J, Philibe L (1994) A i udes owa ds co-wo ke s
a ec ed by occupa ional hea ing loss I: Ques ionnai e de elopmen and
inqui y. B J Audiol 28:299–311
Ka o BM, LaRoue e MJ, Boj ab DI, Michaelides EM (2004) E alua ing quali y
o li e a e endolympha ic sac su ge y: he Menie e’s disease ou comes
ques ionnai e. O ol Neu o ol 25:339–344
Kennedy V, Ché y-c oze S, S ephens D, K ame S, Thai an H, Colle L (2005)
De elopmen o he In e na ional Tinni us In en o y (ITI): A Pa ien -
Di ec ed P oblem Ques ionnai e. Audiol Med 3:228–237
Ken ala E (1996) Cha ac e is ics o six o ologic diseases in ol ing e igo. Am J
O ol 17:883–892
Ken ala E, Le o H, Pyykkő I (2013) How one hund ed and eigh y h ee people
wi h Meniè e’s diso de elie e hei symp oms: a andom coho ques-
ionnai e s udy. Clin O ola yngol 38(2):170–174. doi:10.1111/coa.12071
Kind P (2001) Measu ing quali y o li e in e alua ing clinical in e en ions: an
o e iew. Ann Med 33:323–327
Kinney SE, Sand idge SA, Newman CW (1997) Long- e m e ec s o Menie e’s
disease on hea ing and quali y o li e. Am J O ol 18:67–73
Le o H, S ephens D, Poe D, Ken ala E, Pyykkő I (2010) Use o ICF in assess-
ing he e ec s o Menie e’s diso de on li e. Ann O ol Rhinol La yngol
119:583–589
Le o H, S ephens D, Poe D, Ken ala E, Rasku J, Pyykkő I (2012) Eu oQol 5D
quali y o li e in Menie e’s diso de can be explained wi h symp oms and
disabili ies. In J Rehabil Res 35:197–202
Le o H, S ephens D, Poe D, Ken ala E, Pyykkő I (2013) Fa igue in Menie e’s
disease. Hea Balance Commun 11:191–197
O ji F (2014) The in luence o psychological ac o s in Menie e’s disease. Ann
Med Heal h Sci Res 4:3–7
Rabin R, de Cha o F (2001) EQ-5D: a measu e o heal h s a us om he Eu o-
Qol G oup. Ann Med 33:337–343
Smi h KW, A is NE, Assmann SF (1999) Dis inguishing be ween quali y o li e
and heal h s a us in quali y o li e esea ch: a me a-analysis. Qual Li e Res
8(5):447–459
Sode man AC, Bagge -Sjoback D, Be genius J, Langius A (2002) Fac o s in lu-
encing quali y o li e in pa ien s wi h Menie e’s disease, iden i ied by a
mul idimensional app oach. O ol Neu o ol 23:941–948
S ephens DP, Pyykko I (2011) How use ul a e ‘add-on’ ques ions in ques ion-
nai es? Audiol Med 9:1–2
S ephens D, Pyykkő I, Va pa K e al (2010a) Sel - epo ed e ec s o Menie e’s
disease on he indi idual’s li e: a quali a i e analysis. O ol Neu o ol
31:335–338
S ephens D, Pyykko I, Le o H e al (2010b) Posi i e expe iences and quali y o
li e in Menie e’s diso de . In J Audiol 49:839–843
S ephens D, Pyykko I, Yoshida T e al (2012) The consequences o inni us in
long-s anding Menie e’s disease. Au is Nasus La ynx 39:469–474
Ty ell J e al (2015) Men al heal h and Subjec i e well-being o indi iduals
wi h Menie e’s: c oss-sec ional analysis in he UK biobank. O ol Neu o ol
36:854–861
Wade DT, Halligan P (2003) New wine in old bo les: he WHO ICF as an
explana o y model o human beha iou . Clin Rehabil 17:349–354
Williams A (1985) Economics o co ona y a e y bypass g a ing. B Med J (Clin
Res Ed) 291:326–329
Wo ld Heal h O ganiza ion (WHO) (2001) In e na ional classi ica ion o unc-
ioning, disabili y and heal h (ICF). Wo ld Heal h O ganiza ion, Gene a
Ya dley L, Masson E, Ve schuu C e al (1992) Symp oms, anxie y and handicap
in dizzy pa ien s: de elopmen o he e igo symp om scale. J Psycho-
som Res 36:731–741
Ya dley L, Dibb B, Osbo ne G (2003) Fac o s associa ed wi h quali y o li e in
Menie e’s disease. Clin O ola yngol Allied Sci 28:436–441