In a recent study published in the JAMA Otolaryngology-Head & Neck Surgery Journal, researchers investigated the association between symptomatic dizziness and vestibular disorders and the subsequent risk of falls and other injuries in the United States. The efficacy of physical therapy (PT) as an intervention for reducing dizziness-associated injury was also determined.
The study findings indicate that timely PT is associated with significant reductions in injury risk among patients, with beneficial effects that persist for up to 12 months following the PT intervention.
Study: Use of Physical Therapy and Subsequent Falls Among Patients With Dizziness in the US. Image Credit: VGstockstudio / Shutterstock.com
Dizziness and its associated risks
Dizziness is a term that describes feelings of loss of balance, faint, weak, or unsteady. Dizziness and other balance disorders can be caused by various conditions including genetic, environmental, behavioral (e.g., intoxication), and pathogenic factors. For example, labyrinthitis, an inner ear infection that affects hearing and balance, can lead to a severe form of dizziness called vertigo.
Dizziness has been associated with significant increases in the risk of falls resulting in fractures or even death, with previous research in the U.S. estimating a 12-fold risk increase in self-reported falls. A similar study in South Korea found that potentially fatal trauma risk was significantly increased 12-months following emergency department (ED) admissions for vertigo.
Despite the established association between dizziness presentation and fall/injury risk, fall rate data from outpatient clinics, which are most patients' first point of medical contact, remains lacking and unexplored. While a growing body of literature seeks to evaluate the use of technological advances, including wearable devices, in detecting fall occurrence, it is crucial to explore alternative therapeutic interventions, including PT.
About the study
The primary goal of the current study was to investigate the association between PT interventions and subsequent medical care, including ED visits, within 12 months of receiving the intervention. Secondary objectives included identifying the specific factors associated with dizziness-associated injury and factors prompting PT interventions following dizziness presentation.
Deidentified data from the OptumLabs Data Warehouse, which is a database comprising medical and pharmacy claim data for Medicare Advantage and commercially insured adults at least 18 years of age in the U.S., were used for the current study. Participants in the OptumLabs Data Warehouse cohort present a diverse mixture of geographical location and age across the U.S., with previous research verifying the database as representative of Americans with commercial medical insurance policies.
Study inclusion criteria included individuals who were continuously enrolled for at least 365 days during the study period from January 1, 2006, to December 31, 2015. Participants were excluded if they had self-reported severe balance disorders before study initiation or received prior PT interventions.
PT was defined as any professional PT intervention received within three months of dizziness symptoms. The dizziness diagnosis was made according to the International Classification of Diseases, Ninth Revision (ICD-9) for vestibular disorders (code 366.x) or dizziness and giddiness (code 780.4).
Data collection comprised anthropometric and socioeconomic characteristics including age group, Medicare Advantage or commercial insurance, race and ethnicity, presentation setting, and category of first diagnosis of dizziness or vestibular disorder.
The Charlson Comorbidity Index (CCI), a metric that predicts the ten-year mortality for a patient who may have a range of comorbid conditions, was used to evaluate dizziness severity. All data collection and presentation adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
Outcome durations were classified into quarterly time periods of three to 12 months, six to 12 months, and nine to 12 months following dizziness diagnosis. An established fall detection algorithm was used in tandem with medical reports to evaluate comorbidity risk and severity.
Crude Odds Ratios (ORs) were used to investigate the magnitude of inter-cohort differences and multivariate regression computed factors associated with PT. Sensitivity analyses were employed to find patient outliers who experienced multiple injuries during the study period, as this data could bias the results.
Study findings
A total of 805,454 patients were included in the study cohort, 62% of whom were female. Participant age varied from 18 to 87 years, with a mean age of 52. Of the included participants, 7% experienced injuries or falls requiring medical attention within the 12-month-long enrollment period.
A small subgroup of patients experienced repeated falls. PT interventions in patients were rare, with only 6% of patients receiving any form of PT intervention in the three months following diagnosis.
Analyses of data on the factors involved in PT interventions revealed that women were less likely to receive PT than men. The highest proportion of PT interventions was in patients 40 years old or younger.
Asian and Hispanic patients were more likely to receive PT than their White counterparts. Notably, a high CCI score, which reflects a more severe comorbidity risk, was associated with a reduced probability of PT therapy.
Analyses of fall and injury data revealed that despite comprising only 6% of the dataset, patients receiving PT care were up to 7.1 times less likely to experience dizziness-related injury. PT interventions were associated with long-lasting yet slowly subsiding efficacies.
As compared to controls with no PT intervention, participants who received PT exhibited 7.1-fold reductions in injury risk for the first three months following PT. This gradually reduced to 5.6-fold and 4.3-fold at six and nine months, respectively.
Fall risk was associated with age, sex, and race. Patients 40 years or older were 1.04-1.10 times more likely to fall than those between 18-39 years.
Women were also associated with a 1.12-fold increase in fall risk as ompared to men. White patients had the highest fall risk, followed by Black, Hispanic, and Asian patients.
Sensitivity analyses could not establish an association between diagnosis specificity and fall risk. The exclusion of patients with multiple falls from the model change did not change these results.
Conclusions
The present study used a large cohort to investigate the associations between dizziness and injury risk in U.S. participants with commercial or Medicare Advantage insurance. Despite anecdotal evidence for the benefits of PT interventions in mitigating dizziness comorbidities, only 6% of the study cohort received the intervention in the three months following dizziness diagnosis.
Women, patients above the age of 40, and White individuals were found to be at the highest risk of dizziness-associated falls. These patients were also the least likely to receive PT care.
Since PT care was found to mitigate fall risk by up to 7.1-fold over a 12-month period, increased awareness among clinicians regarding the benefits of PT is needed. These findings emphasize the importance of future clinical case-control trials that could establish PT as a healthy, cost-effective, and side-effect-free alternative to conventional dizziness therapies.
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