A survey using the SF-36 Health Questionnaire reveals that significant quality of life changes can be realized after canalith repositioning by hearing care professionals.

Data on canalith repositioning outcomes for Benign Paroxysmal Positioning Vertigo (BPPV) indicate that significant quality of life changes can be realized for patients. Subjects in this investigation showed improvement in overall Quality of Life (Total SF scores), General Health, Mental Health and Vitality after vestibular treatment.

This final article of a three-part series on Benign Paroxysmal Positional Vertigo (BPPV) presents preliminary data on treatment outcomes as measured by using the Medical Outcomes Shortform-36 Health Survey (SF-36). Previous articles in this series discussed BPPV pathophysiology, diagnosis and treatment methodologies.1,2

The American Institute of Balance has treated approximately 530 patients with BPPV using the Semont Liberatory and Canalith Repositioning Maneuvers. Treatment efficacy has previously been established with a patient subjective rating scale of their amelioration of symptoms, as well as clinician’s observation or video-oculographic recording of rotatory nystagmus during positioning maneuvers. The purpose of the present study is to identify the benefit of BPPV treatment on quality of life through the use of clinimetrics, as measured by the SF-36 Health Questionnaire.3


For nearly a decade, there has been an increasing interest in subjective self-assessment scales by patients in rating pre- and post-handicap caused by vestibular dysfunction. The use of clinimetrics, which can best be described as a subjective measurement of health status of patients, has been found to be a highly effective indicator of overall health status and a reliable indicator of treatment efficacy. Numerous well-documented and standardized subjective handicap scales specific to vestibular disorders such as the Dizziness Handicap Inventory4, Activities-Specific Balance Competence Scale35, Vestibular Disorders Activities of Daily Living Scale6, and the Activities of Daily Living Questionnaire7 have shown high levels of validity in establishing not only the debilitating influence of undiagnosed or untreated vestibular disorders, but show a strong correlation with successful treatment outcomes. 

The SF-36 Health Survey Questionnaire is different from the previously mentioned condition-specific assessment tools, as it attempts to evaluate aspects of the patient’s health that are important to all patients, rather than those presenting only with vestibular dysfunction. The SF-36 Health Survey Questionnaire is well recognized among the health care and medical communities and has been used in a wide variety of patients, including those with hearing loss8, cardiac rehabilitation, organ transplant and vestibular Schwannoma.9

Specifically, authors have published results correlating successful treatment of BPPV utilizing self-assessment scales such as the Dizziness Handicap Inventory, and other subjective dizziness or vestibular symptom rating scales.10,11 It is not surprising that with a success rate of better than 95% that patients subjective rating scales agree with amelioration of symptoms.

It is the authors’ intent, by using the SF-36 Health Survey Questionnaire, to better obtain an indication of improvement on the overall quality of life. Today’s medical economics emphasizes cost containment and fiscal accountability. This demands that health care providers be prepared to provide documentation regarding improvement in the patients health status. Third party payors, referral sources and patients themselves are requesting and requiring that health care providers substantiate their treatment outcome claims.

Materials & Methods

The pilot study was performed with patients at the American Institute of Balance in Seminole, FL. Twelve subjects participated in the study: 10 females and two males ranging in age from 51-83 years old, with a mean and median age of 71 and 70 respectively. Subject demographics are presented in Table 1.

All patients had sought treatment or had been referred for a complaint of positional vertigo, as well as other equilibrium-related issues. All patients had the benefit of a medical examination by a Board-Certified otolaryngology physician, and had complete diagnostic electrophysiologic studies including a full array of vestibular function testing, including VNG/ENG and postural stability testing.

The diagnosis of Benign Paroxysmal Positional Vertigo was made utilizing the classic indications of a rotatory nystagmus towards the undermost ear. The nystagmus, which lasted less than 30 seconds and was accompanied by subjective vertigo, was provoked with a modified Hallpike maneuver and documented with video-oculographic recording or direct visual observation. 

All patients in this study were identified as presenting with a posterior canalithiasis form of BPPV. A single clinician conducted all diagnostic recordings, treatments and follow-up. Subsequently, the patients were treated with a modified Canalith Repositioning Maneuver as described by the author in the second article of this series.2 Patients were placed in a soft cervical collar and provided with written and verbal instructions as to limiting their activities for the following 24 hours, and instructed not to sleep on the affected side for at least three nights.12

The patients returned approximately 7-14 days post-treatment to confirm that the condition had been extinguished or ameliorated. The absence of rotatory nystagmus and subjective vertigo with placement into the provocative positions was required to consider the condition successfully treated.

The average number of treatments necessary to produce the amelioration of the symptoms was 1.3 treatments. This was identical to the Institute’s average number of required treatments of 530 patients previously treated for BPPV since 1994. Eleven of the 12 patients presented with a unilateral BPPV, and one of the patients was bilateral. The bilateral patient, as would be expected, required two treatment sessions. Eight of the 12 unilateral patients required one treatment, and three of the remaining unilateral patients required two treatments for successful amelioration of the symptoms.

Fig. 1. Total and individual subscale SF-36 scores for the pre- and post- vestibular treatment conditions. 

The SF-36 Health Survey

The Medical Outcomes Short Form-36 Health Survey, or SF-36, is an 11-question standardized questionnaire that assesses both physical and psychosocial function in a behavioral context. The individual items are weighted and grouped into eight subscales: physical functioning, role limitations due to physical and/or emotional difficulties, social functioning, bodily pain, mental health, vitality and general health perceptions. Each question contains 2-10 items, for a total of 35 items. The 36th item of the questionnaire is a health transition rating, whereby the respondent is asked to rate their current health status compared to their health status one year ago. Overall, the lower the SF-36 scores in each subscale, the greater the functional impairment. The SF-36 has been shown to be a valid, reliable measure in assessing sickness-related dysfunction, including end-stage renal disease, myocardial infarction, chronic obstructive pulmonary disease, and rheumatoid arthritis.

Administration of Questionnaires: The SF-36 questionnaires were administered to each subject on two separate occasions: 1) Pre-canalith repositioning treatment, and 2) 30-45 days post-canalith repositioning treatment. Subjects were instructed to complete the forms according to its specific printed instructions and were asked to complete all questions. Moreover, subjects were encouraged to inquire about questions that were confusing or uncertain to them. All subjects completed the forms utilizing a paper/pen format. The SF-36 took approximately 15 minutes for the subjects to complete.

Total and individual subscale SF- 36 scores for the pre- and post- vestibular treatment conditions are presented in Fig. 1. In addition, these data are presented numerically in Table 2. All SF-36 raw scores were normalized via test protocols to fit on a 1 to 100 scale. 

SF-36 scores improved for each subscale for the post treatment conditions, indicating an improvement in functional health status. Moreover, Total SF-36 scores showed an improvement in post-treatment conditions. Statistical analysis, using paired-comparison t-Tests, indicated that these differences were statistically significant for the following subscales: General Health (t =-3.45; df = 1,12; p = 0.005), Mental Health (t =-2.17; df = 1,12; p = 0.05); and Vitality (t =-2.62; df = 1,12; p = 0.022). Total SF-36 Scores also indicated a significant improvement between pre- and post-vestibular treatment conditions (t = -2.98; df =1, 12; p = 0.012). Finally, an examination of individual subject data for Total SF-36 scores indicated that all but one of the subjects obtained higher (improved functional health status) scores after canalith repositioning.


Results of this investigation revealed that canalith repositioning could significantly improve quality of life measures in individuals experiencing Benign Paroxysmal Positioning Vertigo. Specifically, individuals in this investigation showed a significant improvement in overall quality of life (Total SF-36 scores), General Health, Mental Health and Vitality after vestibular treatment. These data should not be surprising as it is reasonable to assume that impairments in vestibular function can adversely influence an individual’s perception of their overall quality of life, general health status and physical vitality. Moreover, it is well recognized that deficits in physical health processes can deleteriously affect psychosocial function, such as mental health status. 

These data suggest that, through appropriately administered canalith repositioning treatment, hearing care professionals can positively affect not only an individual’s vestibular impairment, but also their overall quality of life. w


The authors gratefully acknowledge the contribution of Patricia Harrington-Gans, AuD, and her assistance in collating the subject SF-36 Health Survey Questionnaire data.


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