어지럼증

Background: Dizziness is a common reason for consulting a general practitioner and there is a broad range of possible underlying aetiologies. There are few evidence-based data about prevalence, aetiology and prognosis in primary care. We aimed to conduct a systematic review of symptom-evaluating studies on prevalence, aetiology or prognosis of dizziness in primary care.

Methods: We systematically searched MEDLINE and EMBASE. Two independent researchers screened titles and abstracts according to predefined criteria. We included all studies evaluating the symptoms ‘dizziness’ or ‘vertigo’ as a reason for consultation in primary care. We extracted data about study population and methodology and prevalence, aetiology and prognosis. Two raters independently judged study quality and risk of bias. We investigated the variation across studies using forest plots, I2 and prediction intervals. Since we anticipated a great amount of clinical and unexplained statistical heterogeneity, we provided qualitative syntheses instead of pooled estimates.

Results: We identified 31 studies (22 on prevalence, 14 on aetiology and 8 on prognosis). Consultation prevalence differs between 1,0 and 15,5%. The most common aetiologies are vestibular/peripheral (5,4-42,1%), benign peripheral positional vertigo (4,3-39,5%), vestibular neuritis (0,6-24,0%), Menière’s disease (1,4-2,7%), cardiovascular disease (3,8-56,8%), neurological disease (1,4-11,4%), psychogenic (1,8-21,6%), no clear diagnosis (0,0-80,2%). While studies based on subjective patient assessment reported improvement rates from 37 to 77%, these findings could not be confirmed when applying instruments that measure symptom severity or quality of life.

Conclusion: There is a broad variety of possible underlying diseases for the symptom dizziness. There exist only few methodologically sound studies concerning aetiology and prognosis of dizziness.

Electronic supplementary material: The online version of this article (10.1186/s12875-017-0695-0) contains supplementary material, which is available to authorized users.

Search result and study selection: Our initial search identified 1598 references in EMBASE and 903 in PUBMED. The snowball search identified eleven references. After extraction of 332 duplicates, 2501 unique references remained. The title and abstract screening of these references detected 120 studies as potential appropriate. Finally, the full text analysis of these trials produced 31 studies, which met the inclusion criteria. Further details are given in a flow chart (Fig. 1).Fig. 1Flow chart

Included studies: Data accrue mainly from Europe (21 studies) and USA (five studies). Time of publications varied between 1972 and 2014. Twenty three studies took place in general practice, five in primary health care centres and the remaining three in hospital based primary care centres. Studies varied widely concerning the number on included patients with dizziness ranging from 30 to 10,871. The percentage of women included was mentioned in 16 studies ranging from 58 to 80%. Nineteen of the included studies recruited patients prospectively during the consultations; the other studies were based on chart review and routine data. Further details of the included studies are shown in Table 1.Table 1Brief description of the included studiesStudiesTime of recruitmentCountrySettingNumber of dizzy patientsMean Age of study sample (range)Female (%)Data collectionInclusion criteriaExclusion criteriaAnswered research questionsbBEACH 2014 04/2013 - 03/2014Australia959 general practitioners993n.r.n.r.prospectiveall patients contacts ICPC: Reason for encounter vertigo/ dizziness1Bird 1998 08/1993 - 071995Great Britain3 general practices503median 58 (3-99)n.r.retrospectivecomplaining of symptoms allied to dizziness ➔ stratified sample was studied in more detailpatients had seen their GP about the same problem within the past 12 months1,2CONTENT 2007 04/2005 - 12/2006Germany17 general practices607n.r.70.8aprospectiveall patients contacts ICPC: Reason for encounter N17 – vertigo/ dizziness1DNSGP-2 2010 01/2001 - 12/2001Netherlands96 family practices399076.1 (SEM 0.11) (65+)65.9prospectivedatabase with presented symptoms recorded as freetext: Dutch synonyms for dizziness1,2Ekvall 2004 1998 and 2000Sweden2 health care centres (14 GPs)311range 12-9474.9aretrospectiveICD9/10: 780.4 / R 42 and 386 / H811Ekvall 2005 01/2003 - 12/2003Sweden6 primary health care centresprev: 197 aet: 38prev: range 65-99 aet: Median 83 (65-94)prev: 70.1a aet: 65.8aprev: retrospective aet: prospectiveprev: 65 years or older diagnosis R42 (ICD 10) aet: study participants; ICD 10 Code R 421,2Fink 2007 10/1989 - 09/1999Austria1 general practitioner408an.r.n.r.prospectiveall Episodes of Cares: dizziness as reason for encounter1Garrigues 2008 11/2003 - 11/2004Spain6 primary care centres19155.8 (SD 17.6) (range 10+)68.6prospectivevertigo crisis (illusion of unequivocal rotary movement)under 10 years1Gerber 1992 15 monthsUSAgeneral internal medicine group practice (4 general internists)46range 18+n.r.prospectiveall physical complaints reported complaint of dizziness1Hanley 2002 10/1999 - 03/2000Ireland13 general practitioners70n.r.n.r.prospectivevertigo (do you see the world spin around you as if you had got off a playground roundabout)2Harding 1980 n.r.Colombia, India, Sudan, Philippinesprimary health facilities90range 16+n.r.prospectivereason for encounter of all patients aged 16 or older: dizzinessso seriously ill or required such urgent medical care that it would be unreasonable to administer the research questionnaires pat. Who refused to take part pat. Who had already attended once1Hopkins 1989 1981 - 1982Great Britain48 general practices (143 doctors)n.r.n.r.n.r.unclearpatients consulting for ICD 9: 780.4 and 3861Jayarajan 2003 08/2000 - 07/2001Great Britain53 general practitioners62,6 average (3318)range 5+ 5-20: 1.3% 20-40: 13.5% 40-60: 24.7% 60-80: 40.5% > 80: 20%n.r.retrospectivedizziness1Kroenke 1989 08/1984 – 07/1987USAInternal Medicine clinic at Brooke Army Medical Center (primary care)55n.r.n.r.retrospectivedizziness (new complaint or recurrent complaint that prompted a new diagnostic workup)chronic dizziness1,2,3Kroenke 1998 n.r.USAWalter Reed Army Medical Center general medicine walk-in clinic30adultsn.r.prospectiveadult outpatients presenting with physical complaints (excl. Upper respiratory infection) dizziness3Kwong 2005 02/2001 – 01/2003Canada1 family practice center50range 65-91 < 80: 38% > = 80 62%58retrospectiveICD 9 code of “780” (dizziness) 65 years of age or older random sample of eligible chartsPatients who are discharged from service or died2Lawson 1999 a 3 month periodGreat Britaingeneral practitioners from 4 practices5074 (61-78)74aprospectivepatients presenting with dizziness more than 60 years of age1,2Maarsingh 2010 06/2006 - 01/2008Netherlands45 family physicians in 24 family practices41778.5 (65-95)74prospectivedizziness being present for at least 2 weeks main reason for consultation 65 years or olderinability to speak Dutch or English, severe cognitive impairment, severe visual impairment (i.e. corrected visual acuity of less than 3/60 for the best eye), severe hearing impairment (i.e. verbal communication impossible), wheelchair dependency2,3Mash 2012 n.r.South Africa240 health workers (nurses saw 86,1% of the patients) in mobile clinics, fixed clinics and community health centres299n.r.n.r.prospectiveall patients contacts ICPC: Reason for encounter N17 – vertigo/ dizziness1MedViP 2008 04/2001 - 12/2002Germany138 primary care practices10,8715967.2retrospectiveICD 10 Codes (H81, H82, A88, R42) dizziness medication synonyms for dizziness diagnoses1,2Morrell 1972 1 yearGreat Britain1 general practice (3 doctors)740-4: 1.4a % 5-14: 10.8a % 15-24: 17.6a % 25-44: 21.6a % 45-64: 25.7a % > 65: 23.0a %70.3aprospectivepatients with a new symptom (which had not been presented to any doctor in the previous 12 months) disturbance of balance1,2NAMCS 1989 1981 and 1985USAfamily physicians, general practitioners and general internists53161.3 (25+)66.7prospectiveall patients contacts Reason for encounter: S225.0 vertigo – dizziness1PCD 1994 01-06 and 08-10 1991USA4 family group practices, 1 internal medicine group practice, 1 university family practice center, 1 solo general internist, 1 solo family physician, 1 county hospital emergency department14258.6 (17-90) > 60: 59.2% < 60: 40.8%71.8prospectivedizziness as chief complaint or part of a symptom complex that represented the principal reason for visit at least 18 years2,3Rieger 2014 01/2008 - 12/2008Germanygeneral practitioners489598arange 18-74n.r.retrospectiveICD H81, H82, R42, A88.1, E53.8, F45.8, G11.8, G43.1, G45.0-, G62, G63, G90.3, H55, H83.0– 2, I95.1, N95.1 and R26 without R26.11Sicras 2007 2006Spain5 primary health care centers6504n.r.n.r.retrospectiveICPC diagnosis N17 vertigo/ dizziness1Sczepanek 2011 n.r.Germany21 primary care practices6976.19 (SD 6.64) (range 65-95)69.6prospectiveincident dizziness (less than six months) as main reason for encounter age at least 65 yearsinsufficient command of the German language, dementia, terminal diseases2,3Transition Project 2012 1995 - 2005Netherlands, Malta, Serbia59 general practices (69 doctors)n.r.n.r.n.r.prospectiveall patients contacts ICPC: Reason for encounter N17 – vertigo/ dizziness1Wun 2000 12/1997 - 03/1998China28 commune clinics = general practice clinics (42 primary care doctors)133160.8 (SD 13.5)n.r.prospectiveall patients contacts ICPC: Reason for encounter N17 – vertigo/ dizziness1Yardley 1998 n.r.Great Britain10 general practicesaet: 143 prog: 76aet: 59.8a(18+) prog: 59.6aaet: 80.4a prog: 82.9aaet: retrospective prog: prospectivestudy participants 18 years and older with a complaint of dizziness patient still symptomaticnon-vestibular cause for dizziness performance of vigorous head or body movements during exercise therapy was contraindicated multiple, life-threatening or progessive central disorders2,3Yardley 2004 2001 - 2002Great Britain20 general practicesaet: 170 prog: 87aet: 61.9a(18+) prog: 61.0 SD 14.42aet: 71 prog: 71aet: retrospective prog: prospectivestudy participants 18 years and older with a complaint of dizzinessPatients no longer found to be dizzy duration of dizziness less than 2 months during the past 2 years nonlabyrinthine cause of dizziness in patient records, none of the rehabilitation exercises provoked dizziness, medical contraindications for making required head movements serious comorbid conditions2,3Yardley 2012 10/2008 - 07/2009Great Britain35 general practices11258.2 (18 +)75prospectivestudy participants 18 years and older with a complaint of dizziness during the past two yearspatients who were no longer dizzy, non vestibular causes of dizziness, dizziness was not aggravated by rapid head movements, contraindications to treatment by vestiublar rehabilitation inability to speak English3aData not directly available in publication, but could be calculatedbFirst research question: Prevalence of the consulting reason dizziness at general practiceSecond research question: Aetiology of the consulting reason dizziness at general practiceThird research question: Prognosis of the consulting reason dizziness at general practicen.r Not reported, prev Prevalence, aet Aetiology, prog Prognosis, BEACH Bettering the Evaluation and Care of Health, CONTENT CONTinuous morbidity registration Epidemiologic NeTwork, DNSGP-2 Second Dutch National Survey of General Practice, MedViP Medizinische Versorgung in der Praxis, NAMCS National Ambulatory Medical Care Survey, PCD Primary Care Dizziness Study

Quality of included studies: Quality assessment happened for four distinctive domains. For domain A (selection of patients and GPs), 14 studies had a low, three an unclear and 12 a high risk of bias. For domain B (data collection and patient flow), 19 studies had a low, one an unclear and ten a high risk of bias. For domain C (assessment of aetiology), two studies had a low, two an unclear and ten a high risk of bias. For domain D (assessment of prognosis), five studies had a low, two an unclear and one a high risk of bias. Table 2 summarizes the quality assessment of all included studies.Table 2Risk of biasStudyDomain A: selection of patients and GPsDomain B: Data collection and patient flowDomain C. diagnostic work-upDomain D: prognostic work-upBEACHlowlown.r.n.r.Bird 1998??highn.r.CONTENTlowlown.r.n.r.DNSGP-2lowlowhighn.r.Ekvall 2004highhighn.r.n.r.Ekvall 2005highhighhighn.r.Fink 2007highlown.r.n.r.Garrigues 2008lowlown.r.n.r.Gerber 1992highlown.r.n.r.Hanley 2002lowlow?n.r.Harding 1980lowlown.r.n.r.Hopkins 1989highhighn.r.n.r.Jayarajan 2003highhighn.r.n.r.Kroenke 1989highhighhighhighKroenke 1998lowlown.r.?Kwong 2005?highhighn.r.Lawson 1999 – prev.?lown.r.n.r. Lawson 1999 – aet. lowlowlown.r.Maarsingh 2010lowlowlowlowMash 2012lowlown.r.n.r.MedViP –prev.lowhighn.r.n.r. MedViP –aet. highhighhighn.r.Morrell 1972?lowhighn.r.NAMCSlowlown.r.n.r.PCDlowlow??Rieger 2014highhighn.r.n.r.Sczepanek 2011lowlowhighlowSicras 2007highhighn.r.n.r.Transition Projectlowlown.r.n.r.Wun 2000lowlown.r.n.r.Yardley 1998highhighhighlowYardley 2004 – aet.highhighhighn.r. Yardley 2004 – prog. highlown.r.lowYardley 2012highlown.r.lowRisk of bias was rated as low, high or unclear (?)n.r Not relevant, because the respective study provided no data in regard to aetiologies and/ or prognosisprevalence, aet Aetiology, prog Prognosis

Prevalence of the symptoms “dizziness” and “vertigo” in primary care: Twentry two studies commented on prevalence data, nine of them had a low risk of bias. Depending on numerator and denominator, results for prevalence can be grouped in four categories. Four studies describe the number of patients who have contacted a physician at least once because of dizziness/vertigo in relation to all listed patients. Prevalence ranges from 0,8% to 7,9% (DNSGP-2). Seven studies describe the number of patients with dizziness in relation to all patients seen in consultation. Prevalence ranges from 1,2% to 8,1%. Five studies describe the number of consultations due to the symptom dizziness in relation to all consultations (e.g. if the same patient has more than one consultation he is here counted more than one time). Prevalence ranges from 1,0% (BEACH) to 15,5%. In four of the five studies results are below 2%, only the study done by Wun et al. represents with 15,5% an outlier. 50% of the patients seen in this study suffered from hypertension. The authors assume that patients utilized the symptom “dizziness” as a kind of entrance card to get their blood pressure monitored. Finally, four studies describe the number of consultations due to the symptom dizziness in relation to all reasons for encounter. Prevalence ranges from 0,7% (BEACH) to 9,9%. Forest plots and measures of heterogeneity are presented in Additional file 3.

Aetiologies of the symptoms “dizziness” and “vertigo” in primary care: We identified 14 studies assessing data on the aetiology of dizziness and/or vertigo. The most common categories for dizziness were cardiovascular (3,8-56,8%) and otologic peripheral (5,4-42,1%) problems including Benign Positional Paroxysmal Vertigo (BPPV) and vestibular neuritis. Frequent reasons for vertigo were as well otologic peripheral causes, BPPV and vestibular neuritis, whereas cardiovascular disease did not play any role. It is noteworthy that 13 out of 14 studies used a category like “no specific diagnosis possible” and that up to 80% of cases were assigned to that category. Table 3 summarizes the results for several differential diagnoses separated for the symptoms dizziness and vertigo. Forest plots and measures of heterogeneity are presented in Additional file 4.Table 3Aetiologies of dizziness and vertigo (all studies)DizzinessAetiologyNumber of studiesNumber of patientsResults (range)Heterogeneity I2 (95% CI)/prediction intervalOtologic peripher1010,6585,4-42,1%95.5% (93.4-96.9%)7.7-51.6%BPPV (subcategory)679564,3-39,5%93.2% (88.0-96.2%)0.5-73.8%Vestibular neuritis (subcategory)679560,6-24,0%98.4% (97.6-98.9%)0.0-98.6%Ménière’s disease (subcategory)478021,4-2,7%0.0% (0.0-0.0%)1.4-2.8%Cardiovascular830113,8-56,8%98.5% (98.0-98.9%)0.4-89.1%Neurological central910,6201,4-11,4%78.7% (60.0-88.7%)2.1-12.7%Psychogenic830161,8-21,6%88.5% (79.7-93.5%)1.1-31.2%No specific diagnosis1110,7130,0-80,2%99.4% (99.3-99.5%)1.6-90.5%VertigoAetiologyNumber of studiesNumber of patientsResults (range)Heterogeneity I2 /prediction intervalOtologic peripher338327.3-92.9%96.2% (91.8-98.2%)0.0-100.0%BPPV (subcategory)33834.9-42.9%96.4% (92.5-98.3%)0.0-100.0%Vestibular neuritis (subcategory)33838.4-40.0%94.3% (86.8-97.6%)0.0-100.0%Ménière’s disease(subcategory)33834.2-10.0%43.5% (0.0-83.1%)0.0-94.1%Cardiovascular0Neurological central1704.3%n/aPsychogenic1701.4%n/aNo specific diagnosis33831.4-72.7%92.3% (80.7-96.9%)0.0-100.0%

We could identify only two studies with a low risk of bias. Both looked at older patients with the symptom dizziness and identified cardiovascular disease as main aetiology followed by peripheral vestibular disease (see Table 4).Table 4Aetiology of dizziness (only studies with low risk of bias)Maarsingh 2010Lawson 1999Peripheral vestibular14.4% [11.2; 18.2]34.0% [21.6; 48.9]BPPV8.0% [2.6; 20.1]Vestibular neuritis24.0% [13.5; 38.5]Morbus Meniere–2.0% [0.1-12.0]Cardiovascular56.8% [51.9; 61.6]a48.0% [33.9; 62.4]Neurological central2.9% [1.6; 5.1]b10.0% [3.7; 22.6]Cerebrovascular–4.0% [0.7; 14.9]Psychogenic9.8% [7.2; 13.2]–Musculosceletal3.6% [2.1; 6.0]4.0% [0.7; 14.9]Other internistic diseases0.7% [0.2; 2.3]–Drug effects2.4% [1.2; 4.5]–Other1.2% [0.4; 2.9]–No specific diagnosis8.2% [5.8; 11.3]22.0% [12.0; 36.3]aincl. Cerebrovascular; bexcl. cerebrovascular

Prognosis of the symptoms “dizziness” and “vertigo” in primary care: Prognostic parameters were assessed in eight studies (two of them with a low risk of bias) using different end-points. Three studies all conducted by Yardley et al. used the short form of the vertigo symptom scale (ranging from 0 to 60 points). All studies were intervention studies in the field of vestibular rehabilitation. In none of the studies, the respective control groups showed a significant change of 3 points (5%) at the end of the one-year follow up period.

Five studies looked with the help of different instruments like the dizziness handicap inventory, the vertigo handicap questionnaire or the SF 36 (short version) at changes in quality of life. All studies only showed slight improvement, which was in most instances regarded as clinically non-significant.

Five studies measured subjective patient assessment. Patients reported subjective improvement in al studies ranging from 37% to 77%.

Vertigo, dizziness, and unsteadiness (VDU) are common symptoms traditionally considered to result from different kinds of vestibular and non-vestibular dysfunctions. The epidemiology of each symptom and how they relate to each other and to migraine, agoraphobia, motion sickness susceptibility (MSS), vaso-vagal episodes (VVE), and anxiety-depression was the object of this population-based study in north-eastern France. A self-administered questionnaire was returned by 2987 adults (age span 18–86 years, 1471 women). The 1-year prevalence for vertigo was 48.3%, for unsteadiness 39.1%, and for dizziness 35.6%. The three symptoms were correlated with each other, occurred mostly (69.4%) in various combinations rather than in isolation, less than once per month, and 90% of episodes lasted ≤2 min. The three symptoms were similar in terms of female predominance, temporary profile of the episodes, and their link to falls and nausea. Symptom episodes of >1 h increase the risk of falls. VDU are much more common than the known prevalence of vestibular disorders. The number of drugs taken increase VDU even when controlling for age. Each VDU symptom was correlated with each co-morbidity in Chi-squared tests. The data suggest that the three symptoms are more likely to represent a spectrum resulting from a range of similar – rather than from different, unrelated – mechanisms or disorders. Logistic regressions controlling for each vestibular symptom showed that vertigo correlated with each co-morbidity but dizziness and unsteadiness did not, suggesting that vertigo is certainly not a more specific symptom than the other two. A logistic regression using a composite score of VDU, controlling for each co-morbidity showed a correlation of VDU to migraine and VVE but not to MSS and not to agoraphobia in men, only in women.

Of the 3035 questionnaires returned 2987 (1471 women) were included, after rejecting those with too many missing or unusable data. The average age (y) was 45.6 for men and 46.2 for women with a similar distribution.

Global prevalence of vestibular symptoms: At least one VDU symptom had occurred at least once in the last 12 months in 59.2% of participants, vertigo (48.3%) was followed by unsteadiness (39.1%) and dizziness (35.6%). About 90% of each symptom episodes were of short (≤2 min) duration and occurred less than once per month (Table 1). The histogram according to frequency and duration for the three symptoms are similar (Figure 1 displays the example of vertigo).

Most participants (69.4%) with symptoms experienced more than one type in various combinations (Table 2). The three symptoms were significantly correlated, as were those with short and long durations.

The risk for falls and severe unsteadiness was significantly increased if symptoms came in combinations rather than in isolation, particularly if the combination included unsteadiness.

The risk of nausea was similarly increased for each VDU symptom – and still further in case of symptom combinations.

Balance-related falls and severe unsteadiness were about three times more frequent if the symptoms lasted >1 h rather than ≤1 h, and this was true for all three symptoms.

Gender and age effect: In women the symptoms were more frequent than in men in most age groups except for ≥70 years. The prevalence was similar across the various age groups except that in women VDUacute was lower for age group 40–49 years (Table 3).

Medication and VDU: Leaving aside contraception, 55.4% took no medication and 4.4% more than six drugs. The number of drugs increased with age. The prevalence of VDUshort and VDUacute increased significantly with the number of drugs, independently of age and gender (Table 4). The risk for VDUshort and VDUacute decreased with age when controlling for drug intake. Balance-related falls increased strongly with five or more drugs but were also mildly increased with exactly one drug. Each VDU symptom was significantly correlated to drug intake in Chi-squared tests, but in a logistic regression controlling age and gender and for each VDU symptom, unsteadiness was the best explanatory factor.

VDU and co-morbidities: The global prevalence of migraine was 17.90% with the typical female predominance and decrease over age 50 years, which is similar to European figures (Stovner and Andree, ).

The average agoraphobia score was 4.1 which is comparable with data from the literature (Mizes and Crawford, ). Prevalence of moderate or severe MSS in men was 3.9% and in women 11.2%, in a study using the same tool (Bosser et al., ) in a population of students <30 years, the prevalence were 6.0% for men and 15.7% for women, which is also comparable considering that MSS tends to decrease with age.

Each VDU symptom was highly correlated with every co-morbidity in Chi-squared tests (p < 0.001). Table 5 sets out the results of the logistic regression analysis testing the correlation of the co-morbidities with each VDU symptom, controlling for age, gender, and the other VDU symptoms. In this model migraine is correlated with each VDU symptom, VVE and AD with vertigo and dizziness, MSS and agoraphobia only with vertigo.

Anxiety-depression and female gender significantly increased the risk for VDUshort, VDUacute, and all co-morbidities except AD for VVE. A separate multivariate regression analysis was therefore conducted in men and women with and without AD (Table 6).

Migraine increased the risk for VDUshort in men and women and for VDUacute in women, independently of AD.

Vaso-vagal episodes increased the risk for VDUshort in men with and without AD, in women without AD, and for VDUacute in AD women.

In the global analysis the highest OR for MSS were found for female gender 2.53 (CI 1.92–3.34), followed by AD (OR 2.04; CI 1.51–2.76) and migraine (OR 1.48; CI 1.10–1.98). When controlling for AD and gender, migraine was not significant in men but still in non-AD women, MSS did not increase the risk for VDUshort or VDUacute.

In the global analysis the highest risks for agoraphobia were AD (OR 3.48; CI 2.63–4.61) and female gender OR 2.36 (CI 1.78–3.11). When the data were controlled for gender and AD, agoraphobia was found to increase the risk for VDUshort, VDUacute in non-AD women. In men the only factor was the combination of AD and MSS.

Background: Although dizziness is one of the most common symptoms of menopause, the underlying mechanism is not precisely known. Therefore, this study aimed to investigate the prevalence of, and the factors associated with, dizziness in peri- and postmenopausal women.

Methods: We conducted a cross-sectional study in which we analyzed the first-visit records of 471 Japanese women aged 40 to 65 years who enrolled in a health and nutrition education program at a menopause clinic. The prevalence of dizziness was estimated according to the participants’ responses to the Menopausal Health-Related Quality of Life Questionnaire. The background characteristics of age, menopause status, body composition, cardiovascular parameters, basal metabolism, and physical fitness; other menopausal symptoms, including vasomotor, insomnia, depression, and anxiety symptoms; and lifestyle characteristics were assessed for their associations with dizziness.

Results: The percentage of women who suffered from dizziness once a week or more frequently was 35.7%. Compared to the women without dizziness, those with the symptom were younger; had a higher body weight, body mass index, body fat percentage, muscle mass, and waist-to-hip ratio; had higher systolic pressure; were slower in reaction time; had higher physical and psychological symptom scores of menopause; exercised less regularly; and consumed less alcohol. A multivariate logistic regression analysis revealed that the anxiety symptom, which was evaluated by the Hospital Anxiety and Depression Scale, was the sole factor that was independently associated with dizziness (adjusted odds ratio 1.14; 95% confidence interval 1.08–1.20).

Conclusions: Dizziness is highly prevalent in Japanese peri- and postmenopausal women and it is associated with anxiety. The treatment of anxiety in this population might improve the symptom.

The average age of the participants was 51.2 ± 5.0 years (mean ± standard deviation). The rates (0–1 times per month, 1–2 times per week, 3–4 times per week, and almost every day) of dizziness among the 471 women screened are shown in Table 1. The percentage of women who complained of dizziness once a week or more frequently was 35.7%.

The variables that significantly differed (p < 0.20) at the univariate level between the women with (n = 168) and without (n = 303) dizziness were as follows: age (y); body weight (kg); BMI (kg/cm2); body fat (%); muscle mass (kg); waist-to-hip ratio (%); systolic pressure (mmHg); reaction time (cm); the vasomotor, insomnia, depression, and anxiety symptom scores; the habit of regular exercise; and alcohol consumption. Compared to the women without dizziness, those with the symptom were younger; had a higher body weight, BMI, body fat percentage, muscle mass, and waist-to-hip ratio; had higher systolic pressure; were slower in reaction time; had higher physical and psychological symptom scores of menopause; exercised less regularly; and consumed less alcohol (Table 2).

Of these variables, body weight and body fat had significant multicollinearity with the BMI (Pearson’s r/p: 0.906/< 0.05 and 0.917/< 0.05, respectively), and they were excluded from the following multivariate logistic regression analysis. Of the remaining factors, the HADS’ anxiety score was revealed to be the sole factor that was independently associated with dizziness (adjusted odds ratio 1.14; 95% confidence interval 1.08–1.20) (Table 3).

A multivariate logistic regression analysis using a stepwise variable selection procedure was performed to identify the independent risk factors.

Background: Persistent Postural-Perceptual Dizziness (PPPD) is a chronic disorder that significantly affects the quality of life (QoL) and daily living. Vestibular rehabilitation therapy (VRT) has emerged as a promising treatment option, yet its effectiveness, particularly in relation to symptom duration, anxiety, and depression, remains underexplored.

Methods: This cross-sectional study assessed the effect of VRT on the QoL in 188 PPPD patients, as well as the correlation between the duration of symptoms and dizziness severity and the role of anxiety and depression in the treatment response. QoL was assessed using the EuroQol-5 Dimension (EQ-5D), and dizziness-related handicap using the Dizziness Handicap Inventory (DHI) and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS).

Results: Ninety three patients were included in the analysis. QoL was significantly improved post-VRT with a greater mean EQ-5D score (EQ-5D post-VRT 0.72; EQ-5D pre-VRT 0.61, p = 0.032). Age was also found to correlate with increased dizziness severity (p < 0.001), although this was not as strong as the correlation of symptom duration (longer duration correlating with increased dizziness severity; p < 0.01), anxiety (r = −0.45, p = 0.002) and depression (r = −0.51, p < 0.001) (both significantly associated with poorer outcomes especially with reference to VRT) emerging as independent correlates of reduced effectiveness of treatment.

Conclusions: This study revealed the benefit of VRT in patients with PPPD on QoL and indicates the importance of identifying and treating psychological factors to improve the success of treatment for PPPD.

The demographic and clinical characteristics of the VRT and retrospective non-VRT observational groups are presented in Table 1. The retrospective non-VRT observational group served as an observational cohort for comparison. Although they did not undergo VRT, baseline characteristics, and clinical outcomes were assessed to evaluate the relative effectiveness of VRT. The groups were comparable in terms of age and gender distribution, with no significant differences observed (p > 0.05). However, a higher proportion of participants in the VRT group had a symptom duration of < 1 year compared to the retrospective non-VRT observational group (54.26% vs. 48.94%, p = 0.023). Clinically, the VRT group showed significantly lower mean DHI, HADS Anxiety, and HADS Depression scores compared to the retrospective non-VRT observational group (p < 0.01 for all), indicating less severe dizziness-related handicap and better mental health outcomes. Additionally, the VRT group had a higher mean EQ-5D score, reflecting better QoL (p = 0.032).

The comparison of EQ-5D scores between the VRT and Retrospective non-VRT observational groups showed a statistically significant difference in favor of the VRT group (Table 2; Figure 1). Patients who underwent vestibular rehabilitation therapy had a higher mean EQ-5D score of 0.72 compared to 0.61 in the Retrospective non-VRT observational group (p = 0.032). This indicates that the VRT group experienced a better QoL, as reflected by higher EQ-5D scores. The 95% confidence intervals for the VRT group were between 0.70 and 0.74, while for the Retrospective non-VRT observational group, they ranged from 0.58 to 0.64. This further supports the effectiveness of VRT in improving QoL in patients with PPPD.

Patients with PPPD symptoms for more than 1 year had significantly higher DHI scores compared to those with symptoms lasting < 1 year (Table 3; Figure 2). Specifically, the >1 year group had a mean DHI score of 45.62, while the < 1 year group had a mean score of 30.42 (p < 0.01). This indicates that a longer symptom duration is associated with a greater dizziness-related handicap, suggesting that patients with more chronic symptoms experience more severe impairments in daily functioning. The ANOVA results showed a significant effect of symptom duration on DHI scores, with an F-value of 15.67.

The subgroup analyses revealed significant differences in DHI and EQ-5D scores based on symptom duration, anxiety, and depression levels (Table 4). Patients with symptom durations of < 1 year had lower DHI scores (mean = 30.42, SD = 7.54) and higher EQ-5D scores (mean = 0.81, SD = 0.12) compared to those with symptoms persisting for more than 1 year (mean DHI = 45.62, SD = 9.31; mean EQ-5D = 0.61, SD = 0.10). Similarly, lower levels of anxiety and depression were associated with better outcomes, as patients with low HADS Anxiety (0–7) and HADS Depression (0–7) scores demonstrated lower DHI scores (mean = 28.45, SD = 6.75; mean = 29.34, SD = 6.85) and higher EQ-5D scores (mean = 0.85, SD = 0.11; mean = 0.84, SD = 0.10) than those with high anxiety (mean DHI = 48.23, SD = 10.34; mean EQ-5D = 0.62, SD = 0.15) or high depression (mean DHI = 49.78, SD = 9.45; mean EQ-5D = 0.60, SD = 0.14). Regression analyses confirmed that higher anxiety and depression levels and longer symptom duration were significantly associated with worse DHI and EQ-5D outcomes, with regression coefficients ranging from −0.20 to −0.55 (p < 0.05).

The correlation and regression analysis revealed that both anxiety and depression were significantly associated with dizziness severity and functional outcomes in patients undergoing VRT (Table 5; Figure 3). HADS Anxiety and HADS Depression scores showed moderate negative correlations with DHI scores (r = −0.45 and r = −0.51, respectively), indicating that higher anxiety and depression were associated with worse dizziness-related handicap. Similarly, these variables were negatively correlated with EQ-5D scores, reflecting poorer QoL. In the adjusted regression models, both anxiety and depression remained significant independent predictors of DHI and EQ-5D outcomes, with depression showing a slightly stronger impact (p < 0.001). These findings suggest that addressing mental health factors is crucial in improving the effectiveness of VRT for PPPD patients. At 12 weeks post-therapy, the improvements in EQ-5D and DHI scores observed immediately post-VRT were largely sustained, with mean EQ-5D scores remaining at 0.71 and mean DHI scores showing a slight decline to 39.12 (p = 0.052). The adjusted regression model showed that depression had a slightly stronger effect on DHI outcomes (B = −0.44, adjusted R2 = 0.35, p < 0.001) compared to anxiety (B = −0.38, adjusted R2 = 0.28, p = 0.002).

Background: Manual therapy is an intervention commonly advocated in the management of dizziness of a suspected cervical origin. Vestibular rehabilitation exercises have been shown to be effective in the treatment of unilateral peripheral vestibular disorders, and have also been suggested in the literature as an adjunct in the treatment of cervicogenic dizziness. The purpose of this systematic review is to evaluate the evidence for manual therapy, in conjunction with or without vestibular rehabilitation, in the management of cervicogenic dizziness.

Methods: A comprehensive search was conducted in the databases Scopus, Mantis, CINHAL and the Cochrane Library for terms related to manual therapy, vestibular rehabilitation and cervicogenic dizziness. Included studies were assessed using the Maastricht-Amsterdam criteria.

Results: A total of fifteen articles reporting findings from thirteen unique investigations, including five randomised controlled trials and eight prospective, non-controlled cohort studies were included in this review. The methodological quality of the included studies was generally poor to moderate. All but one study reported improvement in dizziness following either unimodal or multimodal manual therapy interventions. Some studies reported improvements in postural stability, joint positioning, range of motion, muscle tenderness, neck pain and vertebrobasilar artery blood flow velocity.

Discussion: Although it has been argued that manual therapy combined with vestibular rehabilitation may be superior in the treatment of cervicogenic dizziness, there are currently no observational and experimental studies demonstrating such effects. A rationale for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is presented.

Conclusion: There is moderate evidence to support the use of manual therapy, in particular spinal mobilisation and manipulation, for cervicogenic dizziness. The evidence for combining manual therapy and vestibular rehabilitation in the management of cervicogenic dizziness is lacking. Further research to elucidate potential synergistic effects of manual therapy and vestibular rehabilitation is strongly recommended.

The electronic searches returned 658 hits, which included 335 duplicate records and 323 unique citations. After removing duplicate records and screening titles and abstracts to discard obviously irrelevant citations, a total of 42 potentially eligible studies were identified. A hand search revealed four additional studies that were not captured by the electronic search. Thus, a total of 46 potentially eligible studies were evaluated for inclusion in this systematic review. Thirty-one studies did not meet the inclusion criteria and were excluded from this review. See Additional file 2 for a list of excluded studies including reasons for exclusion. Figure 1 contains a flow diagram of the study selection process. Two articles reported data from the same RCT, and the results from one cohort study were published in two separate articles Thus, this review included reports from a total of thirteen unique investigations. See Table 1 for a description of included studies.

The included studies comprised five RCTs and eight prospective, non-controlled, cohort studies, with samples sizes ranging from 12 to 168. One study did not report on the gender distribution of recruited participants, however all but one of the remaining studies included more females, ranging from 52% to 88%.

Six studies, including two RCTs, used only spinal manipulation or mobilisation, or both, as the intervention. The remaining seven investigations, including three RCTs utilised a multimodal approach consisting of several different interventions (e.g. spinal manipulation and mobilisation, soft tissue therapy, electrotherapy, and medications) and home exercise programs. However, none of the included studies used manual therapy in conjunction with vestibular rehabilitation.

Twelve studies, including all five RCTs, reported improvements in dizziness and associated symptoms (e.g. neck pain) following manual therapy intervention. The remaining study measured skull spatial offset repositioning ability, and found a significant improvement following soft tissue manipulation. In addition to reduction in dizziness and associated symptoms, two RCTs reported significant changes in vertebrobasilar artery blood flow velocity post-treatment, and a further two RCTs found improvement in balance performance measured with posturography.

The methodological quality of the included studies was generally poor to moderate. However, one study was found to be of good methodological quality. Not surprisingly, there was a trend towards more robust study designs (i.e. RCTs) and more recently published studies attaining higher quality scores. Overall, common methodological weaknesses included: lack of control group; failure to provide information allocation concealment and participant, provider, and assessor blinding; omitting performing appropriate statistical analysis; omitting reporting on patient compliance and drop-outs; and including long-term follow-up measurements. A tabulated overview of methodological quality scores is provided in Additional file 3.

Only three studies commented on adverse reactions. Two RCTs reported no adverse reactions, and one prospective cohort study found minor adverse reactions associated with the interventions in eight of nineteen participants.