Experience of handicap and anxiety in phobic postural vertigo

CONCLUSIONS: We found a difference in gender distribution in a population of phobic postural vertigo patients compared with dizzy patients seen in general neuro-otological practice. It appears as if women with phobic postural vertigo suffer more and are more handicapped by dizziness than both men with phobic postural vertigo and a population with dizziness. These differences may reflect other causes of phobic postural vertigo besides anxiety, such as gender-related coping behaviour and postural strategy. OBJECTIVE: Anxiety influences the degree of suffering and handicap in dizzy patients. Experiences of anxiety and handicap were investigated among a population with phobic postural vertigo. MATERIAL AND METHODS: Using the Dizziness Handicap Inventory, the Vertigo Symptom Scale and the Vertigo Handicap Questionnaire, 34 consecutive patients with phobic postural vertigo were compared with a population of 95 consecutive patients seen at a balance disorder clinic. RESULTS: Patients with phobic postural vertigo scored higher than the control subjects with respect to all parameters with the exception of the physical subscale of the Dizziness Handicap Inventory. Because there were significantly more women in the control group we performed a gender-specific analysis of the results. The higher test scores among patients with phobic postural vertigo can be explained by the higher scores among women in this group, while the test results for men were more similar to those of the control group.     

Exploratory factor analysis of the Dizziness Handicap Inventory (German version)

Background

The Dizziness Handicap Inventory (DHI) is a validated, self-report questionnaire which is widely used as an outcome measure. Previous studies supported the multidimensionality of the DHI, but not the original subscale structure. The objectives of this survey were to explore the dimensions of the Dizziness Handicap Inventory - German version, and to investigate the associations of the retained factors with items assessing functional disability and the Hospital Anxiety and Depression Scale (HADS). Secondly we aimed to explore the retained factors according to the International Classification of Functioning, Disability and Health (ICF).

Methods

Patients were recruited from a tertiary centre for vertigo, dizziness or balance disorders. They filled in two questionnaires: (1) The DHI assesses precipitating physical factors associated with dizziness/unsteadiness and functional/emotional consequences of symptoms. (2) The HADS assesses non-somatic symptoms of anxiety and depression. In addition, patients answered the third question of the University of California Los Angeles-Dizziness Questionnaire which covers the impact of dizziness and unsteadiness on everyday activities. Principal component analysis (PCA) was performed to explore the dimensions of the DHI. Associations were estimated by Spearman correlation coefficients.

Results

One hundred ninety-four patients with dizziness or unsteadiness associated with a vestibular disorder, mean age (standard deviation) of 50.6 (13.6) years, participated. Based on eigenvalues greater one respectively the scree plot we analysed diverse factor solutions. The 3-factor solution seems to be reliable, clinically relevant and can partly be explained with the ICF. It explains 49.2% of the variance. Factor 1 comprises the effect of dizziness and unsteadiness on emotion and participation, factor 2 informs about specific activities or effort provoking dizziness and unsteadiness, and factor 3 focuses on self-perceived walking ability in relation to contextual factors. The first factor correlates moderately with disability and the HADS (values ≥0.6). The second factor is comparable with the original physical subscale of the DHI and factors retained in previous studies.

Conclusions

The results of the present survey can not support the original subscale structure of the DHI. Therefore only the total scale should be used. We discuss a possible restructuring of the DHI.     

The development of the Dizziness Handicap Inventory

Conventional vestibulometric techniques are inadequate for quantifying the impact of dizziness on everyday life. The 25-item Dizziness Handicap Inventory (DHI) was developed to evaluate the self-perceived handicapping effects imposed by vestibular system disease. The development of the preliminary (37 items) and final versions (25 items) of the DHI are described. The items were subgrouped into three content domains representing functional, emotional, and physical aspects of dizziness and unsteadiness. Cronbach's alpha coefficient was employed to measure reliability based on consistency of the preliminary version. The final version of the DHI was administered to 106 consecutive patients and demonstrated good internal consistency reliability. With the exception of the physical subscale, the mean values for DHI scale scores increased significantly with increases in the frequency of dizziness episodes. Test-retest reliability was high.     

Gender differences in patients with dizziness and unsteadiness regarding self-perceived disability, anxiety, depression, and its associations

Background

It is known that anxiety and depression influence the level of disability experienced by persons with vertigo, dizziness or unsteadiness. Because higher prevalence rates of disabling dizziness have been found in women and some studies reported a higher level of psychiatric distress in female patients our primary aim was to explore whether women and men with vertigo, dizziness or unsteadiness differ regarding self-perceived disability, anxiety and depression. Secondly we planned to investigate the associations between disabling dizziness and anxiety and depression.

Method

Patients were recruited from a tertiary centre for vertigo and balance disorders. Participants rated their global disability as mild, moderate or severe. They filled out the Dizziness Handicap Inventory and the two subscales of the Hospital Anxiety Depression Scale (HADS). The HADS was analysed 1) by calculating the median values, 2) by estimating the prevalence rates of abnormal anxiety/depression based on recommended cut-off criteria. Mann-Whitney U-tests, Chi-square statistics and odds ratios (OR) were calculated to compare the observations in both genders. Significance values were adjusted with respect to multiple comparisons.

Results

Two-hundred and two patients (124 women) mean age (standard deviation) of 49.7 (13.5) years participated. Both genders did not differ significantly in the mean level of self-perceived disability, anxiety, depression and symptom severity. There was a tendency of a higher prevalence of abnormal anxiety and depression in men (23.7%; 28.9%) compared to women (14.5%; 15.3%). Patients with abnormal depression felt themselves 2.75 (95% CI: 1.31-5.78) times more severely disabled by dizziness and unsteadiness than patients without depression. In men the OR was 8.2 (2.35-28.4). In women chi-square statistic was not significant. The ORs (95% CI) of abnormal anxiety and severe disability were 4.2 (1.9-8.9) in the whole sample, 8.7 (2.5-30.3) in men, and not significant in women.

Conclusions

In men with vertigo, dizziness or unsteadiness emotional distress and its association with self-perceived disability should not be underestimated. Longitudinal surveys with specific pre-defined co-variables of self-perceived disability, anxiety and depression are needed to clarify the influence of gender on disability, anxiety and depression in patients with vertigo, dizziness or unsteadiness.     

Concordance and discordance in patient and provider perceptions of dizziness

PurposeThe purpose of the present investigation was to determine whether there are significant differences in patient/healthcare provider perceptions of patient's dizziness severity, dizziness disability/handicap, anxiety, and signs of autonomic system activation.Materials and methodsThis was a prospective investigation of 30 patient–provider dyads drawn as a sample of convenience from an otology clinic in a large, tertiary care, medical center. Patients completed both the Dizziness Handicap Inventory (DHI) and the Vestibular Symptom Scale (VSS) prior to vestibular function testing. Providers were instructed to complete the same measures following the patient's clinic visit from what they estimated was the patient's point of view. The two measures were analyzed for concordance and discordance.ResultsPatient/provider differences in DHI and VSS vertigo subscale scores were not significantly different. However, difference scores on the VSS anxiety/autonomic subscale indicated that providers significantly under-estimated patient anxiety and symptoms of autonomic system activation.ConclusionsThe results suggest that providers may be missing information pertinent to the role anxiety and autonomic system activation may play in patient visits for complaints of dizziness. We suggest that this problem can be mitigated by administrating to patients prior to their clinic visit a standardized measure that quantifies patient self-report dizziness, vertigo, anxiety and autonomic system arousal. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders that are rooted in clinically significant anxiety either related to, or unrelated to, a history of vestibular system impairment.     

The dizziness handicap inventory and its relationship with functional balance performance.

OBJECTIVE: The purpose of this study was to describe the relation between the Dizziness Handicap Inventory (DHI) and balance performance measures. STUDY DESIGN: Retrospective case series. SETTING: Outpatient balance clinic in a tertiary referral center. PATIENTS: Patients referred with dizziness or imbalance of vestibular and nonvestibular origin. OUTCOME MEASURES: DHI, Romberg with Jendrassik maneuver, standing on foam, tandem Romberg, single-leg stance, the timed up and go test, the Dynamic Gait Index (DGI), tandem gait, and the 10-m walking test. RESULTS: The mean age of participants (n = 214) was 53.9 years. The mean DHI total score was 35.1, ranging from 0 to 96. Spearman rank correlation coefficients (rS) between DHI and the static balance tests were fair and ranged between -0.42 (p < 0.01) for single-leg stance with eyes closed and -0.51 (p < 0.01) for single-leg stance with eyes open. Only the Romberg test with Jendrassik maneuver correlated weakly (rS = -0.25; p < 0.01) with the DHI. Correlations with the walking tests were moderate, the connection with the DGI being the strongest one (rS = -0.69; p < 0.01). Forty-two percent of the variance in DHI scores in our patients was accounted for by the DGI score (r = 0.417). CONCLUSION: Functional balance tests involving locomotion correlate better with DHI scores when compared with static balance measures. The DGI explains a large component of handicap in dizzy and unsteady patients, which advocates its use in these patients.     

Evaluación de la incapacidad en pacientes con acúfenos

ObjectivesTinnitus handicap evaluation through Spanish validation of the Tinnitus Handicap Inventory. Study Design: Spanish validation of the Tinnitus Handicap Inventory.PatientsEighty patients referred to our Tinnitus Unit in University Hospital, between September and December, (1999). Outcome Measures: The Spanish version of the Thi was administered after translation and retrotranslation. Internal consistency and reliability were established.ResultsSpanish adaptation of the THI and its subscales (functional, emotional and catastrophic) showed a high reliability and internal consistency (Cronbach’s alfa: 0.90).ConclusionsSpanish adaptation of the THI is valid, reliable and can be used in a clinical setting to quantify the impact of tinnitus on patient’s quality of life.     

Use of glycopyrrolate in the treatment of meniere's disease

Objectives/Hypothesis: The objective of this study was to determine whether glycopyrrolate is useful as a vestibular suppressant in patients with Meniere's disease. The tested hypotheses were that glycopyrrolate would decrease the perception of dizziness measured by the Dizziness Handicap Inventory in patients with Meniere's disease and that placebo would cause no such decrease. Study Design: Randomized, prospective. Methods: Thirty-seven subjects with a diagnosis of Meniere's disease were administered either 2 mg of glycopyrrolate or placebo twice daily as needed for vertigo. All were also administered the regimen of 1500 mg sodium/day diet and diuretic. The following indices were examined: Dizziness Handicap Inventory, Tinnitus Handicap Inventory, Modified Somatic Perception Questionnaire, Beck Depression Inventory, hearing examination, and electronystagmography. After 4 to 6 weeks of the drug regimen, Dizziness Handicap Inventory, Tinnitus Handicap Inventory, Modified Somatic Perception Questionnaire, and Beck Depression Scale were reexamined. Paired t tests were performed to verify the significance of improvement before and after treatment. Results: Subjects who received glycopyrrolate had statistically significant reduction in Dizziness Handicap Inventory, Beck Depression Score, and Modified Somatic Perception Score. In the placebo group, no improvement in any index was found. Conclusions: The hypothesis that glycopyrrolate is a useful vestibular suppressant in patients with Meniere's disease was statistically verified. Laryngoscope, 108:1442–1445, 1998     

Head-shaking nystagmus predicts greater disability in unilateral peripheral vestibulopathy

Objectives

The objective of this study was to determine the association of the bedside test of head-shaking nystagmus (HSN) with patients' self-perceived dizziness handicap as well as this test's sensitivity and specificity in unilateral peripheral vestibular hypofunction.

Study Design

A retrospective case-control study was performed.

Setting

The study was held at an academic, tertiary referral center.

Methods

Fifty-three adult patients with unilateral peripheral hypofunction defined by the caloric test of the videonystagmography with documented bedside HSN and who had completed questionnaires of self-perceived dizziness handicap were included. The sensitivity and specificity of the bedside HSN in patients and 10 healthy controls in diagnosing unilateral vestibular hypofunction defined by videonystagmographic caloric testing and by abnormal gain and symmetry of the vestibular-ocular reflex by rotary chair testing were determined. Scores of the screening test of the Dizziness Handicap Index and Functional Level Scale questionnaires were taken.

Results

When using the caloric irrigation test as the reference standard for unilateral vestibular hypofunction, the sensitivity, specificity, and positive predictive value of the bedside HSN were 31%, 96%, and 97%, respectively. When comparing with results of rotational chair testing (vestibular-ocular reflex gain and symmetry), the sensitivity of the HSN test increases to 71%. Patients with positive bedside HSN had higher scores (greater self-perceived dizziness handicap) of the Dizziness Handicap Index (P = .049) and higher (worse) scores of the Functional Level Scale (P = .0377) than those with negative bedside HSN (Wilcoxon rank test).

Conclusions

Greater perceived handicap was correlated with a positive bedside HSN in patients with unilateral peripheral vestibulopathy. The HSN has sufficient sensitivity to be used as screening test of uncompensated vestibulopathy in this series. However, a negative HSN alone does not rule out the diagnosis of peripheral vestibular dysfunction.     

Effects of T'ai Chi on balance.

OBJECTIVE: To determine if the practice of T'ai Chi significantly improves balance. METHODS: Twenty-two persons with mild balance disorders were studied. Five measures of balance were obtained, including 3 objective measures (moving platform posturography, Romberg testing, and reach testing) and 2 disability questionnaires (Dizziness Handicap Inventory and a modified Medical Outcomes Study general health survey). To be included, patients were required to be able to stand in the eyes-closed regular Romberg position for 30 seconds. The subjects underwent 8 weeks of T'ai Chi training and practice and then were retested. RESULTS: Highly significant improvements were found on both the posturography test and the Dizziness Handicap Inventory questionnaire scores (P<.001 and P=.004, respectively). Trends toward improvement were also noted in Romberg test results and the Medical Outcomes Study survey (P=.03 for both). Reach was not improved. CONCLUSION: These findings suggest that T'ai Chi training improves balance.     

Internal consistency and factor analysis of the Dutch version of the Dizziness Handicap Inventory

CONCLUSIONS: The Dutch (Belgium) translation of the Dizziness Handicap Inventory (DHI) has proven to be as consistent as the original version. In addition to the three original subscales, factor analysis revealed a fourth component scoring self-perceived effects of insufficient functioning of the vestibulo-ocular reflex (VOR). Focus should be on the DHI total score in order to compare future results with the existing literature. OBJECTIVE: To conduct a factor analysis and to determine its internal consistency. MATERIALS AND METHODS: Charts of 214 outpatients, referred with dizziness or imbalance of vestibular and non-vestibular origin, were reviewed. RESULTS: The Cronbach's alpha coefficients for internal consistency were high for the total scale and good for the subscales. Corrected item-total correlations ranged from 0.71 for 'restricted travelling' to 0.29 for 'difficulties reading', when items were correlated with their respective subtotals, and ranged from 0.69 (restricted participation in social activities) to 0.33 (stressed relationships), when correlated with the total score. A principal component analysis with orthogonal rotation was conducted, suggesting a four-factor solution. Two factors were related to vestibular handicap, referring to the original functional and emotional subcategories. The remaining two factors related to vestibular disability, documenting motion sensitivity (original physical subscale) and insufficient VOR functioning.     

Does patient-perceived handicap correspond to the modified clinical test for the sensory interaction on balance?

OBJECTIVE: To determine whether patient self-reported handicap correlates with scores obtained from the modified Clinical Test for the Sensory Interaction on Balance as assessed by the Neurocom VSR Balance Master platform. STUDY DESIGN: Prospective observational. SETTING: Balance clinic in tertiary referral center. PATIENTS: Patients referred with dizziness or imbalance as their primary complaint. OUTCOME MEASURES: The modified Clinical Test for the Sensory Interaction on Balance scores as assessed by the Neurocom VSR Balance Master platform, the Dizziness Handicap Inventory, and the Health Utilities Index Marks 2 and 3. RESULTS: One hundred fifty-nine patients were entered into the study. The mean age of participants was 54.5 years, with a female-to-male ratio of 2.1:1. The scores for the Dizziness Handicap Inventory and Health Utilities Index are similar between sexes, and although the Dizziness Handicap Inventory score did not correlate with age, Health Utilities Index 2 and 3 scores did show a negative correlation with increasing age. There are weak, positive correlations between the Dizziness Handicap Inventory and the firm surface conditions of the modified Clinical Test for the Sensory Interaction on Balance but no useful correlation with the foam conditions. Similar weak negative correlations were found between the Health Utilities Index 2 and 3 and the modified Clinical Test for the Sensory Interaction on Balance scores. CONCLUSION: Patient-perceived handicap of imbalance appears to correlate poorly with assessment of postural stability using the modified Clinical Test for the Sensory Interaction on Balance.     

Quality of life outcomes after transmastoid plugging of superior semicircular canal dehiscence

PurposeThis study was performed to evaluate the effectiveness and impact on quality of life in patients undergoing plugging of superior semicircular canal dehiscence using the transmastoid approach.Materials and methodsRetrospective chart review with prospective outcomes assessment, using validated quantitative scoring systems, was performed on 10 patients (23–76 years) who underwent transmastoid plugging of superior semicircular canal dehiscence between February 2014 and February 2018 at a tertiary referral center. Pre-operative and post-operative autophony and vertigo were measured by The Autophony Index and the Dizziness Handicap Index. Overall quality of life following intervention was measured by the Glasgow Benefit Inventory. Subjective improvement, audiological changes, and subjective quality of life changes were also recorded.ResultsA significant reduction in the total Dizziness Handicap Index was seen following transmastoid repair of superior semicircular canal dehiscence (p = 0.0078). This was also evident when subgroup analysis of the Dizziness Handicap Index was performed, as physical (p = 0.0273), emotional (p = 0.0078), and functional subgroups were all significantly reduced (p = 0.0117). Autophony was also significantly reduced following intervention (p = 0.0312). Overall quality of life was seen to be improved following surgery as measured by the Glasgow Benefit Inventory (p = 0.0345).ConclusionOur data suggest that transmastoid plugging of a dehiscence in the superior semicircular canal is a safe and effective means of improving autophony, dizziness and overall quality of life in these patients. We believe that these results should be taken into consideration in discussions regarding surgical approach for patients who are contemplating this procedure.     

Audiometric and subjective assessment of hearing handicap

This study compares self-perceived assessment of hearing handicap with audiometrically derived measures of hearing handicap in a sample of elderly persons. Subjects were evaluated by traditional audiometric tests, the Speech Perception in Noise test, and the Hearing Handicap Inventory for the Elderly, a self-assessment questionnaire. Hearing handicap was also calculated by the audiometrically derived American Academy of Otolaryngology (1979) method. Our results are consistent with other studies that indicate a low correspondence between audiometric measures of hearing handicap and self-assessment of hearing handicap. Furthermore, if the Hearing Handicap Inventory for the Elderly is considered the true measure of hearing handicap, our data indicate that the American Academy of Otolaryngology method tends to overestimate handicap among persons with no self-perceived hearing handicap and underestimates handicap among persons with significant self-perceived hearing handicap.     

Psychological comorbidities and their relationship to self-reported handicap in samples of dizzy patients

Factors such as anxiety, depression, somatic awareness, autonomic symptoms, and differences in coping strategies are known to affect dizziness handicap. We studied these factors in 63 consecutive "dizzy" patients. This sample was subgrouped into normals and patients with benign paroxysmal positional vertigo, compensated and uncompensated unilateral peripheral vestibular system impairment, or abnormal vestibular evoked myogenic potential as a single significant diagnostic finding. Results showed that (1) anxiety and depression occur with greater frequency in dizzy patients than in the normal population; (2) the magnitude of anxiety, depression, somatization, and autonomic symptoms does not differ significantly in subgroups of patients; (3) women tended to report greater handicap and somatic/autonomic symptoms; and (4) Dizziness Handicap Inventory total scores were correlated with patients' complaints of somatic/autonomic symptoms, anxiety, depression, and coping strategies. These findings suggest that self-reported measures represent unique pieces of information important for the management of dizzy patients.     

Self-perceived balance disability/handicap in the presence of bilateral peripheral vestibular system impairment

The purpose of this report was to characterize the self-perceived balance disability/handicap of patients with bilateral reductions and bilateral complete losses of peripheral vestibular system function. Data from 72 patients whose electronystagmography and rotational examinations suggested normal, unilateral, or bilateral reductions in peripheral vestibular system function were used in the first investigation. Patients also completed a Dizziness Handicap Inventory (DHI). Results demonstrated significant group differences for DHI total and physical subscale scores. There were significant differences between normal and bilateral weakness groups for the total DHI score and between normal and unilateral and normal and bilateral weakness groups for the physical subscale score. In a second investigation, an item analysis of the DHI is presented for five patients with bilateral complete losses of peripheral vestibular system function. Results show that, predictably, these patients have difficulty engaging in activities requiring an intact vestibulocular reflex (e.g., physical activities such as sports, household chores).     

Application of the vestibular disorders activities of daily living scale

OBJECTIVE: Existing scales of functional performance are either insufficiently sensitive or omit some important daily life tasks. This paper demonstrates that a new scale of self-perceived disablement in the vestibularly impaired population-the Vestibular Disorders Activities of Daily Living Scale (VADL)-differentiates between disabled and healthy persons and evaluates the associations of this assessment with other measures of vestibular disorders. STUDY DESIGN: Prospective. METHODS: Subjects were 1) asymptomatic, healthy adults, 2) patients with benign paroxysmal positional vertigo, 3) patients with chronic vestibulopathy excluding Meniere's disease, postsurgical vertigo, and postconcussion vertigo, and 4) family members. Patient were assessed on the VADL, the Dizziness Handicap Inventory, level of vertigo, and computerized dynamic posturography. Healthy subjects and family members completed the VADL. RESULTS: The VADL differentiates healthy persons from patients but does not differentiate between patient groups. Patients perceived themselves as more independent than their spouses perceived them to be. Scores are weakly correlated with vertigo frequency and posturography scores for conditions with unreliable kinesthesia and absent or unreliable vision. The VADL is more responsive to higher levels of impairment than the Dizziness Handicap Inventory. CONCLUSIONS: This well-normed, self-administered scale of self-perceived disablement is useful for evaluating the functional status of patients with peripheral vestibular disorders. Perceptions of patients and significant others vary, but scores are moderately correlated with some standard measures of vestibular function. As it assesses a different domain of function than do standard diagnostic tests, the VADL will augment these tests during initial evaluation and may be useful for assessing posttreatment change.     

Measurement of health status in patients with vertigo

In order to assess how much disability is caused by vertigo, health status scores of patients referred with dizziness or vertigo were compared with local population normative data and with the severity of illness, measured by a disease-specific questionnaire. The questionnaires were administered by post to patients awaiting an ENT out-patient appointment. There was a strong correlation (P= 0.001) between the eight dimensions of the SF-36 (Mos 36 item short-form health survey) and disease severity, measured by the Dizziness Handicap Inventory questionnaire. Compared with the general population, vertigo sufferers had significant role limitation due to physical problems and social functioning (men) and physical problems and vitality (women). General health status is significantly affected by both the presence and severity of vertigo and the SF-36 may prove useful in assessing outcomes.     

Balance impairment after acoustic neuroma surgery.

OBJECTIVE: The aim of this study was to assess the incidence of balance problems after acoustic neuroma surgery, evaluating whether disequilibrium is disabling. STUDY DESIGN: Retrospective observational study. SETTING: Rehabilitation center. PATIENTS: A group of 386 patients who underwent acoustic neuroma surgery. INTERVENTIONS: Patients were selected from a population of 459 subjects who had undergone surgery for acoustic neuroma. MEAN OUTCOME MEASURES: The Dizziness Handicap Inventory, The Activities-specific Balance Confidence Scale (ABC), and a specific questionnaire on oscillopsia. RESULTS: The specific questionnaire emphasized that 39 patients (10.10%) perceived disequilibrium as disabling, and the oscillopsia handicap score result was moderate in 73.32% of the sample, mild in 21.50%, and severe in 5.18% of patients. The Dizziness Handicap Inventory and ABC scales revealed the presence of handicap and disability due to disequilibrium and the influence of some variables such as sex and a higher oscillopsia handicap score. Dizziness Handicap Inventory and ABC scores were higher in symptomatic patients. CONCLUSION: Disequilibrium influences handicap and disability after acoustic neuroma surgery. This symptom is also present after several years since surgery, and some patients perceived disequilibrium as disabling.     

Test-retest reliability of the Hearing Handicap Inventory for the Elderly using two administration approaches

Previous investigation with the Hearing Handicap Inventory for the Elderly demonstrated high test-retest reliability for face to face/face to face and paper-pencil/paper-pencil administration techniques. From a practical standpoint, a face to face administration followed by a paper-pencil readministration may be a preferable method. The present study evaluated the latter administration approach in a sample of hearing-impaired elderly men. The high test-retest reliability correlations which emerged suggest that the face to face/paper-pencil measurement technique can be adopted for quantifying changes in self-perceived hearing handicap following audiologic intervention especially when clients are unable to return for hearing aid follow-up.