Research Review By Dr. Brynne Stainsby©


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Date Posted:

October 2016

Study Title:

Effects of nonpharmacological interventions for dizziness in older people: A systematic review


Kendall JC, Hartvigsen J, Azari MF & French SD

Author's Affiliations:

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

Publication Information:

Physical Therapy 2016; 96: 641-649.

Background Information:

Dizziness has been reported in up to 58% of women and 30% of men over 65, with prevalence increasing with age (1-3). Unfortunately, dizziness is associated with an increased risk of falls, leading to an increase in disability, morbidity and mortality and a decrease in independence (5-7). Typically, older people are under-referred and under-treated for dizziness; despite this, dizziness in those over 65 remains a significant economic burden on the health care system (4, 8, 10).

Dizziness can often be multifactorial in nature, but it has been categorized as being caused by: frailty, psychological disorders, cardiovascular disorders, presyncope (lightheadedness, weakness, blurred vision and feeling faint) and nonspecific disorders or disorders of the ear, nose and throat (3, 9, 11). It can also be associated with anxiety, spinal pain and increased medication use, including inappropriate prescriptions and polypharmacy (3, 11, 12, 13).

Given the increased risk of falls associated with polypharmacy, it is important to examine the effectiveness of nonpharmacological therapies for dizziness in older people.

Pertinent Results:

  • A total of 1966 records were identified, 1435 titles and abstracts were screened and 51 records were identified for full-text analysis. 40 were eventually reviewed (11 could not be translated).
  • Seven studies met the inclusion criteria (14-16, 19-22).
  • All included studies contained some form of exercise (vestibular rehabilitation [14, 16, 19, 21], balance exercise [20, 22] or tai chi [15]) as the main intervention.
  • Self-reported dizziness and balance were the most commonly used outcome measures (14, 15, 19-22).
  • With respect to studies showing significant differences, two studies favoured the interventions for self-reported dizziness and four studies favoured the intervention with respect to balance (15, 16, 19-21).

Clinical Application & Conclusions:

This review highlights the significant methodological flaws in the body of evidence studying nonpharmacological therapies for dizziness in those over 65 and the critical need for more clinically relevant studies.

The studies included in this review do suggest the following may be beneficial:
  • Individual or group vestibular rehabilitation
  • Individualized or group strength and balance training
  • Tai chi
  • Head-neck balance exercises based on the Cawthorne-Cooksey protocol
Importantly, the limited findings of this study will hopefully highlight the need for high quality research regarding of effectiveness of individual and combined therapies, and the optimal dose for prescribing them.

Study Methods:

This was a systematic review that searched nine databases from inception to May 2014 using appropriate search terms for each database. Reference lists of included articles and relevant systematic reviews were screened for additional resources. Two authors independently screened titles and abstracts for inclusion. Two authors then independently applied the inclusion criteria to the full texts of the articles that remained following screening to determine which studies to include in the review.

Inclusion Criteria:
  • Controlled trials published in English.
  • Study participants had to be over 60 years of age and have dizziness related to presbyastasis (age-related vestibular dysfunction), cervicogenic dizziness associated with osteoarthritis, nonspecific dizziness or dizziness with unspecified origin (other specific causes were excluded).
  • Interventions consisting of exercise, manual therapy, CBT and/or acupuncture. Comparisons could include placebo, sham therapy, no treatment or another active intervention.
  • Primary outcome measures could be any self-reported measures of dizziness. Objective measures (such as balance, number of falls, or quality of life) could also be included.
Two authors independently extracted data from the included studies related to participant characteristics, interventions and outcomes. Two authors then independently assessed each included article for risk of bias according to the Cochrane 12-item criteria (17). In addition to evaluating the methodology, two authors assessed the clinical relevance of each included study using the 5-item clinical relevance assessment of the Cochrane Back Review Group (18). Due to the heterogeneity of the included studies, meta-analysis of the data could not be performed and thus a narrative synthesis was completed.

Study Strengths / Weaknesses:

  • The authors had a clearly defined researched question with a thorough and systematic search.
  • Independent screening of titles and abstracts, and full texts.
  • Only those trials assessed as being of high quality were included.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • In addition to methodological quality, clinical relevance was also assessed.
  • Two authors independently extracted the data from the included articles.
  • The primary limitation of this study relates more to the quality of the body of evidence than the methodology of the review itself.
  • Although the authors used a validated tool to assess risk of bias, the high risk of bias in all included studies mean the findings of this review must be interpreted with a great degree of caution.
  • The sample sizes of the included studies were small, and only one reported performing a sample size calculation.
  • All included studies had a high risk of bias due to: lack of adequate randomization and allocation concealment, lack of reporting of co-intervention and reasons for dropout, selective reporting of results, and lack of reporting on adherence.
  • The included studies did not adequately describe the participants or the clinical setting which limits the external validity of the review findings.
  • Given the high risk of bias combined with the lack of high quality findings, it is not possible to determine the most effective interventions or doses.

Additional References:

  1. Colledge NR, Wilson JA, Macintyre CC, et al. The prevalence and characteristics of dizziness in an elderly community. Age Ageing. 1994; 23: 117–120.
  2. Jonsson R, Sixt E, Landahl S, et al. Prevalence of dizziness and vertigo in an urban elderly population. J Vestib Res 2004; 14: 47–52.
  3. Gassmann KG, Rupprecht R. Dizziness in an older community dwelling population: a multifactorial syndrome. J Nutr Health Aging 2009; 13: 278–282.
  4. Saber Tehrani AS, Coughlan D, Hsieh YH, et al. Rising annual costs of dizziness presentations to U.S. emergency departments. Acad Emerg Med 2013; 20: 689–696.
  5. Deandrea S, Lucenteforte E, Bravi F, et al. Risk factors for falls in community dwelling older people: a systematic review and meta-analysis. Epidemiology 2010; 21: 658–668.
  6. Campbell AJ, Borrie MJ, Spears GF, et al. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19: 136–141.
  7. Cripps R, Carman J. Falls by the elderly in Australia: trends and data for 1998. In: Injury Research and Statistics Series. Cat. no. INJCAT 35. Available at: 2001. Accessed October 7, 2015.
  8. Moller J. Projected costs of fall related injury to older persons due to demographic change in Australia: report to the Commonwealth Department of Health and Ageing under the National Falls Prevention for Older People Initiative. Available at: July 2003. Accessed October 7, 2015.
  9. Dros J, Maarsingh OR, van der Windt DA, et al. Profiling dizziness in older primary care patients: an empirical study. PLoS One. 2011; 6: e16481.
  10. Bird JC, Beynon GJ, Prevost AT, et al. An analysis of referral patterns for dizziness in the primary care setting. Br J Gen Pract 1998; 48: 1828–1832.
  11. Maarsingh OR, Dros J, Schellevis FG, et al. Causes of persistent dizziness in elderly patients in primary care. Ann Fam Med. 2010; 8: 196 –205.
  12. Menant JC, Wong A, Sturnieks DL, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc 2013; 61: 423–428.
  13. Maarsingh OR, Schellevis FG, van der Horst HE. Looks vestibular: irrational prescribing of antivertiginous drugs for older dizzy patients in general practice. Br J Gen Pract 2012; 62: 518–520.
  14. Hall CD, Heusel-Gillig L, Tusa RJ, et al. Efficacy of gaze stability exercises in older adults with dizziness. J Neurol Phys Ther 2010; 34: 64–69.
  15. Maciaszek J, Osinski W. Effect of Tai Chi on body balance: randomized controlled trial in elderly men with dizziness. Am J Chin Med 2012; 40: 245–253.
  16. Moreira Bittar RS, Simoceli L, Bovino Pedalini ME, et al. The treatment of diseases related to balance disorders in the elderly and the effectiveness of vestibular rehabilitation. Braz J Otorhinolaryngol. 2007; 73: 295–298.
  17. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. The Cochrane Collaboration. Available at: Updated March 2011. Accessed October 7, 2015.
  18. Furlan AD, Pennick V, Bombardier C, et al. 2009 Updated Method Guidelines for Systematic Reviews in the Cochrane Back Review Group. Spine 2009; 34: 1929–1941.
  19. Hansson EE, Månsson NO, Ringsberg KA, Håkansson A. Falls among dizzy patients in primary healthcare: an intervention study with control group. Int J Rehabil Res 2008; 31: 51–57.
  20. Kammerlind A, Hakansson J, Skogsberg M. Effects of balance training in elderly people with nonperipheral vertigo and unsteadiness. Clin Rehabil 2001; 15: 463–470.
  21. Kao CL, Tsai KL, Cheng YY, et al. Vestibular rehabilitation ameliorates chronic dizziness through the SIRT1 axis. Front Aging Neurosci 2014; 6: 27.
  22. Prasansuk S, Siriyananda C, Nakorn AN, et al. Balance disorders in the elderly and the benefit of balance exercise. J Med Assoc Thai 2004; 87:1225–1233.