A Role for Neck Manipulation in Elderly – Falls Prevention
Written by Editor   
Friday, April 24, 2015 12:00 AM

Falls in the elderly can be due to many causes. Dizziness is an important risk factor for these falls. In this overview of the literature, we examine the relationship between non-specific dizziness, an important form of dizziness in the elderly, and neck pain and dysfunction. 

Many elderly patients with chronic neck pain and concomitant non-specific dizziness or unsteadiness consult chiropractors and other practitioners who perform spinal manipulative therapy (SMT). It has also been shown that at least the elderly patients who present to chiropractors in Auckland New Zealand and Melbourne Australia have risk factors for falls, including dizziness, that are comparable to the community dwelling elderly in general.  It is well established that falls in the elderly constitute an important global health problem. Every year in the US and Australia, approximately one in three elderly people fall, with 10-20% experiencing serious injury including fractures. Similarly, a large population study has found the incidence of falls over a twelve month-period in Canadian elderly to be as high as 19.8%. 

Falls in the elderly are associated with increased morbidity, disability, loss of independence and even death. Hence, they constitute a serious health problem with substantial human costs. They account for 75% of all casualty visits in the elderly, and result in significant hospital stays. The frequency of falls in the elderly increases sharply with age making this health problem particularly significant in aging populations of the industrialized world. These falls also result in substantial economic costs to the individuals concerned and the health care system, with the estimated cost per fall between $2,000 to $42,000 and the total economic burden for falls $23.3 billion in the USA, with comparable substantial costs in the UK and Canada. In addition, falls in the elderly are an increasingly important global health problem. 

Dizziness, which predisposes the elderly to falls, is also very common in the elderly population. For instance, a study from Scotland found the point prevalence for dizziness to be 30% in 893 elderly people, and the comparable proportion in Brazil has been reported as high as 45% in a cohort of 391 community dwelling elderly adults. Moreover, the proportion of those above the age of 70 presenting with non-specific dizziness was recently reported as 63% in South Korea.  Moreover, dizziness becomes more prevalent with age. There is a strong association between dizziness and falls in the elderly.  In short, falls, falls-related injuries, and dizziness are common and closely associated in the elderly.

Vestibular disorders are widely believed to constitute the most common cause of dizziness. However, there is evidence in the primary care setting that cardiovascular disease and related medications may be the most common cause in the elderly. Consistent with this notion, vestibular disorders have been found to be much less prevalent in the general population than the symptoms of vertigo dizziness and unsteadiness. It is generally accepted that the second most common cause of dizziness in the elderly (after benign positional paroxysmal vertigo) is what is termed “multi sensory dizziness.” This condition is attributed to aging and deterioration of multiple sensory systems, namely the vestibular, optic and proprioceptive. The prevalence of dizziness in the elderly that can be attributed to pain and dysfunction of the cervical spine (cervicogenic dizziness) is not known. At least some patients diagnosed with multisensory dizziness may suffer from cervicogenic dizziness. 

It is established that somatic afferent information from the neck, particularly the upper cervical spine, converges with vestibular and visual inputs on central nervous system (CNS) nuclei involved in processing and integration of postural balance inputs. Data presented in this source report convincingly demonstrates integration of vestibular, visual and proprioceptive (particularly from the neck) inputs to maintain postural balance. Given this integration, it is probable that abnormal cervical proprioceptive input to the CNS (as a result of injury, pain, or musculoskeletal dysfunction of the neck) may create a mismatch with the other inputs thereby causing dizziness. This can be particularly so in the context of the elderly who suffer deterioration of multiple sensory systems.

In agreement with this premise, a recent study has found greater levels of sensorimotor dysfunction (particularly in terms of joint position error in the neck) in association with upper cervical pain than lower cervical pain correlating with the higher density of proprioceptors in the upper cervical region. We also know that anaesthetising the deep structures of the neck, or unilateral sectioning of the cervical dorsal roots induce severe ataxia and disturbance of balance. Equally importantly, stimulation of the abundant neck muscle spindle afferents, by the use of vibration, increases body sway and influences the velocity and direction of gait and running. Additionally, there is evidence that the elderly may be more reliant on proprioceptive input for maintenance of postural balance than younger people. For instance, afferent input from the legs is important for postural control in healthy elderly people.  Furthermore, the elderly with polyneuropathy suffer from a higher risk of falls. In addition, the inability to stand in tandem stance is associated with double the risk of falls in the elderly. These data together demonstrate the importance of proprioception to postural balance, particularly in the elderly. They also support the notion that neck pain and/or disturbed proprioception may contribute, or act as a predisposing factor, to dizziness and falls.

Neck pain is common in the general population; a large population study in 1997 identified prevalence of neck pain in Saskatchewan adults at 22.2%. This study also reported six month prevalence of: low intensity and low disability neck pain; high intensity low disability neck pain; and high intensity and moderately or severely disabling neck pain were found to be 39.7%, 10.1%, and 4.6% respectively. In addition, neck pain is common in the elderly. Its prevalence has been estimated at 36.1% and 40.5% for men and women respectively in community dwelling elderly people in Australia. 

Musculoskeletal problems of the neck can cause disturbance of balance, which is termed “cervicogenic dizziness” “cervical dizziness” or “cervical vertigo”. Patients who have suffered whiplash neck injuries as a result of motor vehicle accidents often complain of dizziness and exhibit motor co-ordination deficits. Persistent neck pain following whiplash injury has also been recently associated, in a small cohort, with impairments of a variety of dynamic and functional balance tasks.  These signs and symptoms are not surprising, due to the stretch and sheer forces involved in whiplash injury, which can damage vestibular and neck receptors. Furthermore, in cases of whiplash that warrant the diagnosis of mild traumatic brain injury (or concussion), it may be the damage to the brain itself that causes the common post-injury symptom of dizziness. Nevertheless, it is important to note that dizziness balance deficits and joint position errors are also common in patients with non-traumatic neck pain.  It is likely then that pain originating from the neck may in itself be responsible for, or at least associated with, dizziness in these cases.

As expected, participants with dizziness, anxiety, depression and history of transient ischemic attacks were more likely to experience multiple falls (more than 2 falls). However, the strongest predictors of multiple falls were found to be neck and back pain as well as anxiety in this population. Therefore, there may be a strong causal relationship between neck pain, dizziness, and multiple falls in at least a subpopulation of the elderly.

A recent study has found that in middle-aged chronic neck pain patients, the presence of vertigo is highly correlated with neck stiffness. In addition, fatigue of the neck muscles disturbs standing balance.  Additionally, neck tenderness is associated with cervical vertigo in the elderly. Taken together these data suggest that neck pain, and associated joint stiffness and muscular hypertonicity and tenderness, may cause postural imbalance possibly by altering the proprioceptive input to the CNS, or its processing by the CNS, leading to dizziness. This in turn, could predispose the individual, particularly the elderly, to falls.

SMT, including joint manipulation and mobilisation, has been used clinically for neck pain by chiropractors and other health care practitioners for many years. Several studies have shown that SMT and spinal exercise regimes are significantly more effective than usual medical care in reducing neck pain. A recent systematic review has found high quality evidence for greater short term pain relief with manual therapy and exercise over exercise alone. The same review also found evidence, although of low quality, for clinically important long term improvement in pain and functional status with manual therapy and exercise compared to no treatment. Similarly, a recently reported short term effectiveness of SMT in the elderly was the first randomised controlled trial (RCT) of cervical SMT in community dwelling elderly comparing its effectiveness for chronic mechanical neck pain with home and supervised exercises; it found that the SMT and home exercise group had a statistically significant reduction in pain at the conclusion of the treatment period compared to either the home exercise alone or home exercise and supervised exercise groups.

Usual treatment of non-specific dizziness in the elderly comprises mainly of vestibular rehabilitation.  According to a recent Cochrane systematic review, there is moderate evidence to support the use of vestibular rehabilitation for vertigo and dizziness of vestibular origin, such as benign paroxysmal positional vertigo (BPPV) and Ménière’s disease.  However, non-specific dizziness is a diagnosis by exclusion, and it has no established satisfactory treatment at present. In the elderly, patients with non-specific dizziness are often diagnosed with multisensory dizziness or presbyastasis (age related decreased vestibular function) and are often inadequately treated. Nonetheless, their treatment often involves vestibular manoeuvres and vestibular rehabilitation exercises.  Vestibular rehabilitation neck exercises alone have been shown to be moderately effective for non-specific dizziness in a retrospective study of 153 elderly cases. These studies are limited by small sample sizes and variability in treatment protocols, but they do show promise for the use of neck rehabilitation exercises in treatment of non-specific dizziness, particularly in the elderly population. 

There is, in fact, a growing body of preliminary evidence for physical and manual treatment of the neck for non-specific dizziness. These observations are consistent with anecdotal evidence from practitioners of SMT that some patients presenting with neck pain also report an improvement with their sense of balance. 

At present there is no satisfactory treatment for non-specific or age related dizziness. However, there is preliminary evidence that physical treatment of the neck may improve balance in neck pain patients. Therefore, it is important to examine the possible therapeutic effect of chiropractic interventions (particularly SMT) directed at the neck in treatment of this condition and prevention of falls in this subpopulation of the elderly.  

Neck pain is widely believed to be capable of compromising mechanisms of postural balance by distorting the proprioceptive input from the neck to the CNS. It is possible that integration of incongruous inputs by CNS balance centers becomes more challenging as proprioceptive visual and vestibular sensory mechanisms age. Whilst neck manipulation, a commonly practiced treatment by chiropractors, has shown effectiveness for neck pain, it has not been adequately evaluated for non-specific dizziness. However, there is encouraging preliminary data that seems to support the use of neck manipulation in treating this condition. 

Source:  http://chiro.org/wordpress/2015/03/03/is-there-a-role-for-neck-manipulationin-elderly-falls-prevention-an-overview/