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


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.


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 respond 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:

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

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:

  1. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 1992; 82(7):1020-3.
  2. Pointer S. Harrison J, Bradley C. National injury prevention plan. Priorities for 2004 and beyond: discussion paper. Injury Research and Statistics Series 2003; July; 18.
  3. Kurschinski C, Sheehy O, Hummers-Pradier E, Lelorier J. Fracture risk of patients suffering from dizziness: a retrospective cohort study. Euro J General Practice. 2010; 16(4): 229-35.
  4. Sibley KM, Voth J, Munce Se, et al. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatrics 2014; 14:22.
  5. Heinrich S. Rapp K, Rismann U, et al. Cost of falls in old age: a systematic review. Osteoporosis International: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2010; 21(6): 891-902.
  6. Colledge NR, Wilson JA, Macintyre CC, MacLennan WJ. The prevalence and characteristics of dizziness in an elderly community. Age and Ageing 1994; 23(2): 117-20.
  7. de Moraes SA, Soares WJ, Ferriolli E, Perracini MR. Prevalence and correlates of dizziness in community-dwelling older people: a cross-sectional population based study. BMC Geriatrics 2013; 13:4.
  8. Jung JY, Kim JS, Chung PS, et al. Effect of vestibular rehabilitation on dizziness in the elderly. Am J Otolaryngology 2009; 30(5): 295-9.
  9. Perez-Jara J, Olmos P, Abad MA, et al. Differences in fear of falling in the elderly with or without dizziness. Maturitas 2012; 73(3): 261-4.
  10. Deandrea S, Lucenteforte E, Bravi F, et al. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiol 2010; 21(5): 658-68.
  11. Kao AC, Nanda A, Williams CS, Tinetti ME. Validation of dizziness as a possible geriatric syndrome. J Am Geriatrics Society 2001; 49(1): 72-5.
  12. Hikosaka O Maeda M. Cervical effects on the abducens motoneurons and their interaction with vestibulo-ocular reflex. Exp Brain Res Experimentelle Hirnforschung Experimentation Cerebrale 1973; 18(5): 512-30.
  13. Corneil BD, Olivier E, Munoz DP. Neck muscle responses to stimulation of monkey superior colliculus. I. Topography and manipulation of stimulation parameters. J Neurophysiology 2002; 88(4): 1980-99.
  14. Shinoda Y, Sugiuchi Y, Futami T, et al. Synaptic organization of the vestibulo-collic pathways from six semicircular canals to motoneurons of different neck muscles. Progress Brain Res 1993; 97: 201-9.
  15. March LM, Brnabic AJ, Skinner JC, et al. Musculoskeletal disability among elderly people in the community. Med J Austr 1998; 168(9): 439-42.
  16. Yacovino DA. Cervical vertigo: myths, facts, and scientific evidence. Neurologia 2012; Sep 13. pii: S0213-4853(12)00211-3. doi: 10.1016/j.nrl.2012.06.013.
  17. Morinaka S. Musculoskeletal diseases as a causal factor of cervical vertigo. Auris, Nasus, Larynx 2009; 36(6): 649-54.
  18. Michaelson P, Michaelson M, Jaric S, et al. Vertical posture and head stability in patients with chronic neck pain. J Rehabil Med 2003; 35(5): 229-35.
  19. Karlberg M, Persson L, Magnusson M. Impaired postural control in patients with cervico-brachial pain. Acta otolaryngologica Supplementum 1995; 520 Pt 2: 440-2.
  20. Menant JC, Wong A, Sturnieks DL, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatric Soc 2013; 61(3): 423-8.
  21. Gross A, Miller J, D’Sylva J, et al. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther 2010; 15(4): 315-33.
  22. Walker BF, Losco B, Clarke BR, et al. Outcomes of usual chiropractic, harm & efficacy, the ouch study: study protocol for a randomized controlled trial. Trials 2011; 12: 235.
  23. Vernon H, Triano JT, Soave D, et al. Retention of blinding at follow-up in a randomized clinical study using a sham-control cervical manipulation procedure for neck pain: secondary analyses from a randomized clinical study. J Manip Physiol Ther 2013; 36(8): 522-6.
  24. Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine 2009; 34(11): E405-13.
  25. Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine 2007; 32(21): 2375-8; discussion 9.
  26. Malmstrom EM, Karlberg M, Melander A, et al. Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome. Disabil Rehabil 2007; 29(15): 1193-205.
  27. Matsui T, Ii K, Hojo S, Sano K. Cervical neuro-muscular syndrome: discovery of a new disease group caused by abnormalities in the cervical muscles. Neurologia medico-chirurgica 2012; 52(2): 75-80.
  28. Fraix M. Osteopathic manipulative treatment and vertigo: a pilot study. PM R 2010; 2(7): 612-8.
  29. Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizziness: a systematic review. Man Ther 2005; 10(1): 4-13.
  30. Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV. Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiro Man Ther 2011; 19(1):21.