The benefits of betahistine or vestibular rehabilitation (Tetrax biofeedback) on the quality of life and fall risk in patients with Ménière's disease.

OBJECTIVE: This study aimed to evaluate the benefits of betahistine or vestibular rehabilitation (Tetrax biofeedback) on the quality of life and fall risk in patients with Ménière's disease. METHODS: Sixty-six patients with Ménière's disease were randomly divided into three groups: betahistine, Tetrax and control groups. Patients' Dizziness Handicap Index and Tetrax fall index scores were obtained before and after treatment. RESULTS: Patients in the betahistine and Tetrax groups showed significant improvements in Dizziness Handicap Index and fall index scores after treatment versus before treatment (p < 0.05). The improvements in the Tetrax group were significantly greater than those in the betahistine group (p < 0.05). CONCLUSIONS: Betahistine and vestibular rehabilitation (Tetrax biofeedback) improve the quality of life and reduce the risk of falling in patients with Ménière's disease. Vestibular rehabilitation (Tetrax biofeedback) is an effective management method for Ménière's disease.

Living with Ménière's disease: an interpretative phenomenological analysis.

Purpose: To explore the meanings of Ménière's disease from the perspective of people living with this condition and to understand what was considered significant and important in participants' everyday lives.Materials and methods: Four women with Ménière's disease participated in face-to-face semi-structured interviews. Accounts were recorded, transcribed, and analysed using an iterative process integral to Interpretative Phenomenological Analysis.Results: Three interconnected themes were identified. "You have no control whatsoever" conveys participants' perceptions of vertigo as having a disruptive and ongoing impact on physical and psychosocial function in everyday life. "Ménière's takes away your life completely" describes Ménière's as impinging on participants' most meaningful activities and relationships, and as restricting their ability to live their lives on their own terms. "You get on with life" recounts participants' efforts to refashion their lives whilst living with this condition and manage its most harmful effects. The psychosocial impact of living with Ménière's disease and its relevance to rehabilitation is discussed.Conclusions: Ménière's disease has an enduring physical and psychosocial impact. Clinicians who acknowledge and respond to an individual's subjective experience of their condition may be key to their engagement in therapy. Service users should have a voice in health service design and delivery.Implications for rehabilitationMénière's disease is a long-term disabling condition that not only impacts on physical and psychosocial functioning but also restricts quality of life through stigmatisation.Fear of triggering an attack of vertigo may prevent people with Ménière's disease from engaging with rehabilitation.Therapists who adopt a biopsychosocial approach and who recognise patients' efforts to control their symptoms as a positive form of resistance may be better equipped to empathetically support patients to engage in new activities that may be vital to improving their lives.

Low-Frequency Hearing Preservation With Long Electrode Arrays: Inclusion of Unaided Hearing Threshold Assessment in the Postoperative Test Battery.

Purpose The goal of this work was to evaluate the low-frequency hearing preservation of long electrode array cochlear implant (CI) recipients. Method Twenty-five participants presented with an unaided hearing threshold of ≤ 80 dB HL at 125 Hz pre-operatively in the ear to be implanted. Participants were implanted with a long (31.5-mm) electrode array. The unaided hearing threshold at 125 Hz was compared between the preoperative and postoperative intervals (i.e., initial CI activation, and 1, 3, 6, 9, and 12 months after activation). Results Eight participants maintained an unaided hearing threshold of ≤ 80 dB HL at 125 Hz postoperatively. The majority (n = 5) demonstrated aidable low-frequency hearing at initial activation, whereas 3 other participants experienced an improvement in unaided low-frequency hearing thresholds at subsequent intervals. Conclusions CI recipients can retain residual hearing sensitivity with fully inserted long electrode arrays, and low-frequency hearing thresholds may improve during the postoperative period. Therefore, unaided hearing thresholds obtained within the initial weeks after surgery may not reflect later hearing sensitivity. Routine measurement of postoperative unaided hearing thresholds-even for patients who did not demonstrate aidable hearing thresholds initially after cochlear implantation-will identify CI recipients who may benefit from electric-acoustic stimulation. Supplemental Material https://doi.org/10.23641/asha.11356637.

Indicaciones de la rehabilitación vestibular / Indications of vestibular rehabilitation

INTRODUCCIÓN Y OBJETIVO: Desde la aplicación de la rehabilitación vestibular como tratamiento del paciente con mareo, las indicaciones han ido ampliándose en función del avance de los procedimientos aplicados, pasando de una terapia puramente física a otra en la que además, se usan instrumentos que aporta el avance tecnológico. En este capítulo, vamos a presentar las distintas indicaciones que hoy en día se han demostrado eficaces y aquellas que aún no han sido validadas a pesar de que muchos autores las defienden. MÉTODO: revisión narrativa. RESULTADOS: Además de la utilidad de la rehabilitación vestibular en el déficit vestibular agudo, también lo es en diferentes patologías crónicas, aunque siguen quedando pendientes algunas cuestiones como conocer el momento idóneo de su aplicación. DISCUSIÓN Y CONCLUSIONES: la rehabilitación vestibular es fundamental en el tratamiento de muchos tipos de patología vestibular. Es importante tener en cuenta todas las indicaciones posibles para poder ofrecer al paciente un tratamiento adecuado que conlleve un mejor resultado terapéutico

INTRODUCTION AND OBJECTIVE: Since the application of vestibular rehabilitation as a treatment for patients with dizziness, the indications have been extended according to the progress of the procedures applied, going from a purely physical therapy to another in which, in addition, instruments that provide technological advancement are used. In this chapter, we will present the different indications that have proved effective today and those that have not yet been validated despite the fact that many authors defend them. METHOD: narrative review. RESULTS: In addition to the usefulness of vestibular rehabilitation in acute vestibular deficit, it is also useful in different chronic pathologies, although some issues remain pending, such as knowing the appropriate moment of its application. Discussion/conclusions: Vestibular rehabilitation is elementary in the treatment of many types of vestibular pathology. It is important to take into account all possible indications in order to offer the patient an appropriate treatment that leads to a better therapeutic result

Rehabilitación vestibular de la Enfermedad de Meniere en el estadio tardío: Reporte de un caso / Vestibular rehabilitation of Meniere's Disease in its chronic stage: A case report

La enfermedad de Meniere (EM), se caracteriza por ataques fluctuantes de vértigos, hipoacusia y acúfenos. Una vez que se controlan los síntomas agudos, la rehabilitación vestibular es una alternativa de tratamiento efectiva. Se presenta el caso de una mujer de 46 años con EM en la fase crónica que presenta persistencia de vértigo postural e inestabilidad de la marcha, quien fue intervenida con maniobras de reposición y rehabilitación vestibular con ejercicios de adaptación y sustitución, ejercicios de habituación del equilibrio vestibular y de control postural. Se obtuvo una respuesta favorable, con desaparición del vértigo posicional, disminución significativa de la inestabilidad y gran mejoría en su calidad de vida. No se puede llegar a conclusiones con un solo caso, sin embargo, es importante el abordaje integral en el tratamiento de pacientes con EM. (AU)

Meniere's disease presents fluctuating attacks of dizziness, hearing loss and tinnitus. Once acute symptoms are controlled, vestibular rehabilitation is an effective treatment alternative. We present the case of a 46-year-old woman with Meniere's disease in the chronic phase, who presented persistent postural vertigo and gait instability and who was treated with repositioning maneuvers, along with vestibular rehabilitation with adaptation, substitution and habituation exercises, vestibular balance and postural control. A favorable response is achieved, with the disappearance of positional vertigo, a significant decrease in instability and a great improvement in her quality of life. No conclusions can be drawn from a single case; however, a comprehensive approach is important in the treatment of patients with MS. (AU)

Internet-Based Self-Help for Ménière's Disease: Details and Outcome of a Single-Group Open Trial.

PURPOSE: In this article, we present the details and the pilot outcome of an Internet-based self-help program for Ménière's disease (MD). METHOD: The Norton-Kaplan model is applied to construct a strategic, person-focused approach in the enablement process. The program assesses the disorder profile and diagnosis. In the therapeutic component of the program, the participant defines vision and time frame, inspects confounding factors, determines goals, establishes a strategy, and starts to work on the important problems caused by the disorder. The program works interactively, utilizes collaboration with significant others, and enhances positive thinking. Participants took part in an Internet-based self-help program. Data were collected interactively using open-ended and structured questionnaires on various disease-specific and general health aspects. The pilot outcome of 41 patients with MD was evaluated. RESULTS: The analysis of the pilot data showed statistically significant improvement in their general health-related quality of life (p < .001). Also, the outcome of the Posttraumatic Growth Inventory (Cann et al., 2010) showed small to moderate change as a result of the intervention. CONCLUSIONS: The Internet-based self-help program can be helpful in the rehabilitation of patients with MD to supplement medical therapy.

Intralabyrinthine schwannomas : Surgical management and hearing rehabilitation with cochlear implants.

Intralabyrinthine schwannomas (ILS) are a rare differential diagnosis of sudden hearing loss and vertigo. In an own case series of 12 patients, 6 tumors showed an intracochlear, 3 an intravestibular, 1 a transmodiolar including the cerebellopontine angle (CPA), 1a transotic including the CPA, and 1 a multilocular location. The tumors were removed surgically in 9 patients, whereas 3 patients decided for a "wait-and-test-and-scan" strategy. Of the surgical patients, 3 underwent labyrinthectomy and cochlear implant (CI) surgery in a single-stage procedure; 1 patient had extended cochleostomy with CI surgery; 3 underwent partial or subtotal cochleoectomy, with partial cochlear reconstruction and CI surgery (n = 1) or implantation of electrode dummies for possible later CI after repeated MRI follow-up (n = 2); and in 2 patients, the tumors of the internal auditory canal and cerebellopontine angle exhibiting transmodiolar or transmacular growth were removed by combined translabyrinthine-transotic resection. For the intracochlear tumors, vestibular function could mostly be preserved after surgery. In all cases with CI surgery, hearing rehabilitation was successful, although speech discrimination was limited for the case with subtotal cochleoectomy. Surgical removal of intracochlear schwannomas via partial or subtotal cochleoectomy is, in principle, possible with preservation of vestibular function. In the authors' opinion, radiotherapy of ILS is only indicated in isolated cases. Cochlear implantation during or after tumor resection (i. e., as synchronous or staged surgeries) is an option for hearing rehabilitation in cartain cases and represents a therapeutic approach in contrast to a "wait-and-test-and-scan" strategy.

Acute vestibular syndrome in cerebellar stroke : A case report and review of the literature.

The current paper reports on a patient with recurrent rotational vertigo and persistent dizziness and imbalance lasting several weeks, who underwent extensive neuro-otological and radiological examinations. Pathological findings initially included right-sided benign paroxysmal positional vertigo (BPPV), persistent horizontal spontaneous nystagmus (SPN) to the left, and a pathological bedside and video head impulse test (HIT) on the left. The pathological HIT on the left and the SPN to the left indicated a central origin. Therefore, cranial magnetic resonance imaging was performed which revealed a left-sided ischemic stroke in the territory of the medial branch of the posterior inferior cerebellar artery (mPICA).

The Effect of Vestibular Rehabilitation in Patients with Ménière's Disease.

Objective To systematically review the evidence on the effect of vestibular rehabilitation in patients with Ménière's disease (MD) on balance and dizziness-related quality of life. Data Sources A literature search was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Web of Science, and CINAHL databases. Review Methods Articles were reviewed by 2 independent authors and data were compiled in tables for analysis regarding balance (ie, posturography) and dizziness-specific quality of life in patients with MD. A comprehensive search was performed up to November 2015. Studies on relevance and methodological quality were assessed by means of the Cochrane risk of bias tool. For outcome on balance and quality of life, we calculated mean differences and their 95% confidence intervals. Results A total of 986 unique studies were retrieved. Five studies, including a total of 498 patients, fulfilled the eligibility criteria, including 2 randomized controlled trials and 3 prospective cohort studies. There was no study with a low risk of bias. We found inconsistent evidence for the effect of vestibular rehabilitation on balance and dizziness-related quality of life. Conclusion Based on the low quality of the selected studies, it is inconclusive whether there is a positive effect of vestibular rehabilitation in patients with MD on balance and dizziness-related quality of life.

Three-dimensional, virtual reality vestibular rehabilitation for chronic imbalance problem caused by Ménière's disease: a pilot study.

PURPOSES: The purpose of this study was to evaluate a three-dimensional, virtual reality system for vestibular rehabilitation in patients with intractable Ménière's disease and chronic vestibular dysfunction. METHODS: We included 70 patients (36 for study, 34 as control) with a chronic imbalance problem caused by uncompensated Ménière's disease. The virtual reality vestibular rehabilitation comprised four training tasks (modified Cawthorne-Cooksey exercises: eye, head, extension, and coordination exercises) performed in six training sessions (in 4 weeks). Measurements of the task scores and balance parameters obtained at the baseline and after final training sessions were compared. RESULTS: A significant improvement was observed in extension and coordination scores. Patients in the early stages of Ménière's disease had a significantly greater improvement in the center of gravity sway and trajectory excursion in the mediolateral direction than did patients in the late stages of Ménière's disease. Mild functional disability attributable to Ménière's disease was a predictor of improvement in the statokinesigram and maximum trajectory excursion in the anteroposterior direction after rehabilitation. The control group showed no significant improvement in almost all parameters. CONCLUSION: Virtual reality vestibular rehabilitation may be useful in patients with Ménière's disease, particular those in the early stages or having mild functional disability. Implication for rehabilitation Chronic imbalance caused by uncompensated Ménière's disease is an indication for vestibular rehabilitation. The interactive virtual reality video game, when integrated into vestibular rehabilitation exercise protocol, may assist patients who have mild disability Ménière's disease and who cannot benefit from treatment with drugs or surgery. The initial data from this study support the applicability of three-dimensional virtual reality technology in vestibular rehabilitation programs. The technology gives professionals a new tool to guide patients for vestibular rehabilitation exercises through three-dimensional virtual reality video game playing. The virtual reality vestibular exercise game can provide patients a step-wise, interactive, dynamic, three-dimensional, and interesting rehabilitation environment.

Disability perception in Menière's disease: when, how much and why?

The purpose of the study was to evaluate self-perceived handicap in patients with definite Menière's disease (MD). A cross-sectional study was conducted. To examine the self-perception of disability, participants completed a DHI (Dizziness Handicap Inventory). Parameters compared with DHI scores: sex, age, unilateral/bilateral affectation, time elapsed since the onset of symptoms, pure-tone average (PTA), stages of MD, audiometric change (last 6 months), PTA in low frequencies (PTAl) and audiometric change in PTAl, subjective perception of fluctuating hearing threshold, tinnitus between attacks, number of vertiginous episodes (last 6 months), time elapsed since last attack, subjective perception of instability intercrises and Tumarkin attacks. 90 patients were included; they completed a total of 104 questionnaires. DHI scores ranged from 2 to 100 (average: 47.08, SD 24.45). In 29 cases (27.9 %) the disability perception was mild, in 43 (41.3 %) moderate, and in 32 (30.8 %) severe. Correlation between disability perception and some vestibular symptoms was found: number of typical attacks (last 6 months), time elapsed since last attack, instability intercrises and Tumarkin attacks. No relationship was found with the rest of variables. Disability perception in patients with MD depends primarily on vestibular symptoms (particularly, instability and frequency of attacks). So, we suggest to design a new staging system of MD taking into account both auditory criteria and also vestibular symptoms.

Home-Based Computer Gaming in Vestibular Rehabilitation of Gaze and Balance Impairment.

Disease or damage of the vestibular sense organs cause a range of distressing symptoms and functional problems that could include loss of balance, gaze instability, disorientation, and dizziness. A novel computer-based rehabilitation system with therapeutic gaming application has been developed. This method allows different gaze and head movement exercises to be coupled to a wide range of inexpensive, commercial computer games. It can be used in standing, and thus graded balance demands using a sponge pad can be incorporated into the program. A case series pre- and postintervention study was conducted of nine adults diagnosed with peripheral vestibular dysfunction who received a 12-week home rehabilitation program. The feasibility and usability of the home computer-based therapeutic program were established. Study findings revealed that using head rotation to interact with computer games, when coupled to demanding balance conditions, resulted in significant improvements in standing balance, dynamic visual acuity, gaze control, and walking performance. Perception of dizziness as measured by the Dizziness Handicap Inventory also decreased significantly. These preliminary findings provide support that a low-cost home game-based exercise program is well suited to train standing balance and gaze control (with active and passive head motion).

Vestibular rehabilitation with virtual reality in Ménière's disease.

UNLABELLED: Virtual reality technology can provide a wide range of sensory stimuli to generate conflicts of varying degrees of complexity in a safe environment. OBJECTIVE: To verify the effect of a virtual realitybased balance rehabilitation program for patients with Menière's disease. METHOD: This observational clinical study included 44 patients aged between 18 and 60 years diagnosed with Menière's disease submitted to a controlled randomized therapeutic intervention. The case and control groups took betahistine and followed a diet. Case group subjects underwent 12 rehabilitation sessions with virtual reality stimuli in a Balance Rehabilitation Unit (BRU TM). Patients were assessed based on DHI scores, the dizziness visual analogue scale, and underwent posturography with virtual reality before and after the intervention. RESULTS: After the intervention, the case group showed significantly lower scores in DHI (p < 0,001) and in the dizziness visual analog scale (p = 0.012), and had significantly greater limit of stability areas (p = 0.016) than controls. CONCLUSION: Virtual reality-based balance rehabilitation effectively improved dizziness, quality of life, and limit of stability of patients with Menière's disease.

Reabilitação vestibular com realidade virtual na doença de Ménière / Vestibular rehabilitation with virtual reality in Ménière's disease

A tecnologia de realidade virtual fornece uma grande variedade de estímulos que geram conflitos sensoriais em diferentes níveis de dificuldades e em ambiente seguro. OBJETIVO: Verificar o efeito de um programa de reabilitação vestibular do equilíbrio corporal com estímulos de realidade virtual em pacientes com doença de Ménière. Forma de estudo: Estudo clínico observacional. MÉTODO: Quarenta e quatro pacientes, com idade entre 18 e 60 anos e doença de Ménière definida, distribuídos em dois grupos - experimental (GE) e controle (GC) - fizeram uso de betaistina e dieta alimentar; o grupo experimental foi submetido adicionalmente a 12 sessões de reabilitação com realidade virtual da BRU TM. Os pacientes responderam ao Dizziness Handicap Inventory (DHI), à escala analógica de tontura e realizaram a posturografia com realidade virtual antes e após a intervenção. RESULTADOS: Após a intervenção, o GE apresentou valores significantemente menores do DHI (p < 0,001) e da escala analógica de tontura (p = 0,012) e valores significantemente maiores da área do limite de estabilidade (p = 0,016), em comparação com o GC. CONCLUSÃO: A reabilitação do equilíbrio corporal com estímulos de realidade virtual é eficaz na melhora da tontura, da qualidade de vida e do limite de estabilidade de pacientes com doença de Ménière.

Virtual reality technology can provide a wide range of sensory stimuli to generate conflicts of varying degrees of complexity in a safe environment. OBJECTIVE: To verify the effect of a virtual realitybased balance rehabilitation program for patients with Menière's disease. METHOD: This observational clinical study included 44 patients aged between 18 and 60 years diagnosed with Menière's disease submitted to a controlled randomized therapeutic intervention. The case and control groups took betahistine and followed a diet. Case group subjects underwent 12 rehabilitation sessions with virtual reality stimuli in a Balance Rehabilitation Unit (BRU TM). Patients were assessed based on DHI scores, the dizziness visual analogue scale, and underwent posturography with virtual reality before and after the intervention. RESULTS: After the intervention, the case group showed significantly lower scores in DHI (p < 0,001) and in the dizziness visual analog scale (p = 0.012), and had significantly greater limit of stability areas (p = 0.016) than controls. CONCLUSION: Virtual reality-based balance rehabilitation effectively improved dizziness, quality of life, and limit of stability of patients with Menière's disease.

Vestibular rehabilitation using the Nintendo® Wii Balance Board -- a user-friendly alternative for central nervous compensation.

CONCLUSION: The Nintendo® Wii Balance Board is a cost-effective and user-friendly alternative to other popular frequently used systems that aid vestibular compensation, particularly in elderly patients. In addition, further treatment in the home environment is possible. OBJECTIVE: This cohort study was designed to investigate the impact of the Nintendo® Wii Balance Board as a visual compensation device after acute vestibular neuritis. METHODS: Subjects were randomly assigned to one of two treatment groups. Group A (n = 37) performed customized exercises with the Nintendo® Wii Balance Board. Group B (n = 34) performed only two elected exercises as a control group for comparison of the results. Both groups underwent additive therapy with steroids (intravenous) in decreasing doses (250 mg decreasing to 25 mg over 10 days). The Sensory Organization Test (SOT), Dizziness Handicap Inventory (DHI), Vertigo Symptom Scale (VSS), and Tinneti questionnaire were evaluated immediately before treatment (baseline), at the end of treatment, i.e. at day 5, and after 10 weeks. RESULTS: The early use of a visual feedback system in the context of the balance training supports the central nervous vestibular compensation after peripheral labyrinthine disorders. Patients in group B (without training) required a longer in-patient stay (average 2.4 days, SD 0.4) compared with patients following early Wii rehabilitation. The absence of nystagmus under Frenzel's goggles in group A was observed 2.1 days (SD 0.5) earlier than in group B. Group A showed significantly better results in the SOT, DHI, VSS, and Tinneti questionnaire at all time points measured (p < 0.05).

Evaluation of quality of life pre- and post-vestibular rehabilitation in patients with benign paroxysmal positional vertigo associated with Meniere's disease

Introduction: Vertigo is a symptom that impacts the patients' quality of life and may force them to cease performing activities of daily living. Here, we discuss benign paroxysmal positional vertigo (BPPV) and Meniere's disease (MD), which show exacerbated symptoms when they appear in association. Vestibular rehabilitation (VR) is an effective treatment in reducing vertigo, especially in conjunction with other therapies. Aim: To evaluate the quality of life of patients with BPPV and MD before and after VR. Method: We conducted a descriptive observational qualitative and quantitative case study with 12 patients aged 35 to 86 years. All patients diagnosed with BPPV and MD received treatment in the ENT clinic. The Brazilian DHI questionnaire, which assesses the quality of life with a focus on physical, emotional, and functional aspects, was used for data collection, and was completed by patients before the first session and after the fifth session of VR. Data were tested using the Shapiro-Wilk normality test, followed by Wilcoxon, Friedman, and Spearman correlation tests (p < 0.05). Results: There were significant improvements in scores for all aspects, with median changes ranging from 12 to 0 in the physical, 6 to 1 in the emotional, and 11 to 1 in the functional aspect. There were no correlations between the scores and sample characteristics. Conclusion: VR was an effective method for the treatment of patients with BPPV and MD; it improves quality of life and shows the maximal influence on physical aspect scores, regardless of age or gender...

The effects of Ménière's disorder on the patient's significant others.

OBJECTIVE: To determine the effects of their partners' MD on the significant others of the patients. DESIGN: Open-ended questionnaire. STUDY SAMPLE: Significant others of members of the Finnish Ménière's Federation. RESULTS: The predominant responses concerned effects on their lives and lifestyle--participation restrictions (effects on personal and community life)--and on personal contextual factors (uncertainty of life). In contrast they fail to list such effects of the patients, focussing rather on the patients' symptoms. Five percent of the responses given entailed positive experiences. CONCLUSIONS: Significant others of patients with MD listed a wide range of effects of their partner's condition on them. We encourage doctors and therapists to include the significant others in the rehabilitation process to enable them to understand the patient's condition, to help the significant other, and so better support the patients concerned.

EuroQol 5D quality of life in Menière's disorder can be explained with symptoms and disabilities.

The purpose of this study was to determine the factors explaining changes in the generic quality of life among patients with Menière's disorder (MD) and to evaluate the EuroQol 5D (EQ-5D) quality-of-life measures. A questionnaire focusing on symptoms and disabilities caused by MD was collected from 726 individuals. General health-related quality of life (EQ-5D) was evaluated using the time trade-off (TTO) and visual-analogue scale (VAS). Personal traits were measured with the sense of coherence. The TTO-VAS score difference was modeled with activity limitations, participation restrictions, attitudes, and symptoms. For TTO as the outcome measure, one symptom-based, three attitude-based, one activity limitation, and one participation restriction item explained 43% of the variability. For VAS, six attitude-based, one symptom-based, three activity limitations, and one participation restriction item explained 43% of the variability of the data. The correlation between TTO and VAS (r=0.515, P<0.001) explained only 27% of the variance. The difference between TTO and VAS was reflected in attitudes towards the illness. The model explained 10% of the variability in the VAS and TTO difference. There was a disease duration effect in the TTO-VAS difference. In conclusion, a symptom-based model combined with disabilities provided a good description of general quality of life in MD. The TTO-based and VAS-based evaluation explained somewhat different aspects of MD. The difference between TTO and VAS could be described as an attitude toward the ailment. Evaluation of disabilities and the difference in TTO and VAS can be used to guide the rehabilitation to promote attitude change.