Research Review By Dr. Jeff Muir©

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Date Posted:

September 2015

Study Title:

Is there a role for neck manipulation in elderly falls prevention? – An overview

Authors:

Kendall JC, Hartvigsen J, French SD, et al.

Author's Affiliations:

Discipline of Chiropractic, School of Health Sciences, RMIT University, Melbourne, Australia; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark and Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark; School of Rehabilitation Therapy, Queens University, Kingston, Canada; Health Innovations Research Institute, RMIT University, Melbourne, Australia

Publication Information:

Journal of the Canadian Chiropractic Association 2015; 59(1): 53-63.

Background Information:

Falls in the elderly are a concerning and multifactorial problem, with dizziness having been identified as a potentially significant cause. In elderly patients, the most common cause of dizziness remains controversial. Vestibular disorders (such as Benign Paroxysmal Positional Vertigo, or ‘BPPV’) are widely believed to be the most common cause of dizziness. However, there is also evidence suggesting cardiovascular disease and related medications may also be the most common cause in the elderly. Despite this discrepancy, it is generally accepted that the second most common cause of dizziness in the elderly (after BPPV) is what is termed ‘multisensory dizziness’ (discussed in Summary Section below).

The relationship between this type of non-specific dizziness in the elderly – an important form of dizziness in that population – and neck pain and dysfunction has been addressed in the literature sporadically. Those in clinical practice know it is reasonable to assume that at least some patients diagnosed with multisensory dizziness may suffer from cervicogenic dizziness. For this reason, this review focuses on ‘non-specific’ rather than ‘cervicogenic’ dizziness.

In this review, the authors sought to examine the evidence supporting the relationship between dizziness and neck pain as possible causal factors for falls in the elderly. They also sought to examine whether rigorous evaluation of neck manipulation for the treatment of non-specific dizziness is warranted, with an aim to identifying and reducing the risk of falls in the elderly.

Summary:

Falls in the Elderly & Dizziness:
Falls in the elderly constitute an important health concern. Estimates regarding the prevalence of falls in this cohort range from 10-20% (1-4), with the costs associated with falls estimated at between $2000 and $42000 per patient per fall, with the total economic impact of elderly falls reaching $23 billion in the US alone (5).

Dizziness is likewise a significant concern among elderly patients, with some estimates suggesting that the point-prevalence of dizziness ranges from 30% to over 60% of this population (6-8). Additionally, the prevalence of dizziness increases with age, and recent studies have demonstrated a strong association between dizziness and falls in elderly populations (9, 10).

The Neck, Postural Balance & Dizziness:
While vestibular disorders such as BPPV are the most common causes of dizziness, ‘multisensory dizziness’ is the second most common cause of dizziness among the elderly (11). This condition can largely be attributed to aging and deterioration of the multiple sensory systems such as the vestibular, optic and proprioceptive systems. The connection between the upper cervical spine and the vestibular inputs of the central nervous system is well known (12-14), thus suggesting an association between mechanical neck pain and dizziness. When combined with the age-related deterioration associated with aging, the potential for dizziness among seniors with neck pain becomes substantial.

Neck Pain & Dizziness:
The prevalence of neck pain in the elderly has been estimated at up to 40.5% in community-dwelling elderly people (15). Neck pain and dizziness can be associated with injury (e.g. whiplash injuries [16, 17]). Yet, there is also general population evidence indicating that dizziness, balance deficits and joint position errors are also common in patients with non-traumatic neck pain (18, 19). In a recent randomized study (20), self-reported neck or back pain was far more common in patients reporting dizziness. Within this population, the strongest predictor of multiple falls were found to be neck and back pain, thus further illustrating the relationship between neck pain, dizziness and falls.

Spinal Manipulative Therapy for Mechanical Neck Pain:
Several systematic reviews (21-23) have demonstrated that, while evidence exists in support of spinal manipulation for the treatment of mechanical neck pain, this evidence supporting its use is generally of low quality. This finding likely reflects the difficulty in designing rigorous randomized, controlled trials involving spinal manipulation. Inherent in the randomized, controlled trial is the blinding of both the clinician and the patient to the treatment being received. The nature of spinal manipulation renders the blinding of either party impossible. As such, studies evaluating spinal manipulation tend to involve concomitant treatments such as exercise, in an attempt to control for the main intervention. Despite these limitations, SMT has consistently shown at least short-term benefit for mechanical neck pain, and has been found to be a safe intervention (24, 25).

Spinal Manipulative Therapy for Non-Specific Dizziness:
Non-specific dizziness is a diagnosis of exclusion, thus vestibular rehabilitation techniques that are often utilized in the treatment of BPPV or Meniere’s disease are often not successful. There is growing evidence supporting the use of physical/manual therapies in the treatment of non-specific dizziness, however (26-28). While recent systematic reviews (29, 30) have found only low quality evidence in support of manual therapies for dizziness, the overall data show promise that certainly warrants continued research.

Clinical Application & Conclusions:

Falls and their injurious potential remain a significant concern for the elderly. The role of dizziness as a causative factor is known and, as such, treatments for non-specific dizziness may help to lower the risk of falls. This review demonstrates that, while there is evidence to suggest that non-specific dizziness may response positively to manual therapies such as spinal manipulation, the need for continued research in this area is great. The authors recommend that clinicians be cognizant of the potential connection between neck pain, dizziness and falls in the elderly. They also appropriately identified the need for rigorously designed, randomized, controlled trials to determine the role of manual therapies in the management of non-specific dizziness and falls.

Study Methods:

This study focused primarily on clinical research data, regardless of study design. The authors did not focus on research data in relation to changes in laboratory-based measurements of balance (e.g. postural sway) with neck pain or manipulation. Instead, they employed a non-systematic search method utilizing PubMed searches to identify the available literature. No language restrictions were placed on the relevant literature. The authors stated that they took care to guard against inclusion or exclusion bias.

Study Strengths / Weaknesses:

Strengths:
The presentation of clinical data was comprehensive and the support provided for the link between non-specific dizziness, falls and manual therapies was logical.

Limitations:
The study’s main limitation was the lack of a systematic search and inclusion/exclusion criteria. While the search revealed a large number of trials, no statistical analysis was performed, thus potentially decreasing the overall confidence in the conclusions drawn from the evidence.

Additional References:

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