Long-Term Survival in 1,931 Patients With Dizziness: Disease- and Symptom-Specific Mortality

Objective: To evaluate mortality among patients referred for suspected vestibular disorder and to examine whether specific symptoms or disorders predict long-term survival among patients with dizziness or vertigo. Study Design: Retrospective cohort study. Methods: This retrospective cohort study analyzed long-term survival data. Consecutive patients examined for suspected vestibular disease at an otolaryngology clinic completed a detailed questionnaire regarding symptoms and comorbidities. Results: The study included 1,931 patients. Their mean age (standard deviation) was 50.5 (16.5) years, and 60% were women. The mean follow-up period was 20.6 years (range, 15.3–27.5 years). The standardized mortality ratio for the entire cohort compared with the Norwegian age- and sex-matched population was 1.03 (95% confidence interval [CI]: 0.94–1.12), illustrating no difference in overall survival. Patients with a cerebrovascular cause of dizziness had higher mortality in adjusted Cox regression analyses (hazard ratio [HR] 1.56, 95% CI: 1.11–2.19), whereas patients reporting periodic or short attacks of dizziness had lower mortality (HR 0.62 [0.50–0.77] and 0.76 [0.63–0.93], respectively). Reported unsteadiness between dizziness attacks was associated with higher mortality with an HR of 1.30 (95% CI: 1.08–1.57). Conclusion: This long-term study found comparable mortality rates between patients evaluated for suspected vestibular disorder and that of the general population. However, subgroup analyses showed reduced mortality in patients with periodic or short attacks of dizziness and increased mortality in patients with unsteadiness between attacks or cerebrovascular causes of dizziness. The time course of vestibular symptoms should be determined, and thorough evaluation including fall risk and comorbidities must be considered in patients with nonepisodic symptoms.publishedVersio

Vestibular Tests Related to Tumor Volume in 137 Patients With Small to Medium-Sized Vestibular Schwannoma

Objective: The video head impulse test (vHIT) and cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP) are new methods for measuring peripheral vestibular function. The objectives of this study were to compare these tests and the traditionally used caloric test in patients with small and medium-sized untreated vestibular schwannoma (VS) and to measure the correlation between the tests' results and tumor volume. Study Design: National cross-sectional study. Setting: Tertiary university clinic. Methods: Prevalence of abnormal cVEMP, oVEMP, caloric test, and 6-canal vHIT results on the tumor side and the nontumor side were compared and related to tumor volume with regression analyses in 137 consecutive VS patients assigned to a wait-and-scan protocol in the period 2017 to 2019. Results: The sensitivity of 6-canal vHIT, caloric test, cVEMP, and oVEMP to detect vestibulopathy in VS patients was 51%, 47%, 39%, and 25%, respectively. Normal tests were found in 21% of the patients. The results of vHIT and caloric test were related to tumor volume, but this was not found for cVEMP and oVEMP. Conclusion: The caloric test and 6-canal vHIT showed the highest sensitivity in detecting vestibulopathy in untreated VS patients. vHIT, and particularly the posterior canal, was limited with a high prevalence of abnormal results on the nontumor side. A combination of cVEMP and caloric test was favorable in terms of a relatively high sensitivity and low prevalence of abnormal results on the nontumor side. Larger tumors had a higher rate of pathology on caloric testing and vHIT.publishedVersio

The Romberg sign, unilateral vestibulopathy, cerebrovascular risk factors, and long-term mortality in dizzy patients

Objectives: Describe the relationship between unsteadiness, canal paresis, cerebrovascular risk factors, and long-term mortality in patients examined for dizziness of suspected vestibular origin. Study design: Observational cohort with prospective collection of survival data. Setting: University clinic neurotological unit. Patients: Consecutive patients aged 18–75 years examined in the period 1992–2004 for dizziness of suspected vestibular origin. Outcome measures: Overall survival. Standardized mortality ratio (SMR). Factors: Unsteadiness, canal paresis, age, sex, patient-reported diabetes, hypertension, heart disease, stroke, or TIA/minor stroke. Patients were classified as steady or unsteady based on static posturography at baseline compared to normative values. Results: The study included 1,561 patients with mean age 48 years and 60 % females. Mean follow-up was 22 years. Unsteadiness was associated with higher age, heart disease, diabetes, hypertension, and cerebrovascular dizziness. There were 336 deaths over 31,335 person-years (SMR 0.96; 95 % confidence interval: 0.86–1.07). Canal paresis was not related to unsteadiness (chi square: p = 0.46) or to mortality (unadjusted Cox hazard ratio: 1.04, 95% CI: 0.80–1.34). Unsteadiness was an independent predictor of mortality (adjusted Cox hazard ratio: 1.44, 95% CI: 1.14–1.82). Conclusions: Unsteadiness measured by static posturography is associated with higher age, known cerebrovascular risk factors, and with increased long-term mortality, but not with canal paresis in patients evaluated for dizziness. The study highlights the importance of evaluating patients with conspicuous postural instability for non-vestibular causes.publishedVersio

Prevalence and distribution of musculoskeletal pain in patients with dizziness—A systematic review

Background and purpose Musculoskeletal disorders are among the leading causes of disability globally, but their role in patients with dizziness and imbalance is not well understood or explored. Such knowledge may be important as musculoskeletal pain and dizziness can mutually influence each other, leading to a complex condition requiring more comprehensive approaches to promote successful recovery. We conducted a systematic review to examine the extent and characteristic of reported musculoskeletal pain in patients with dizziness. Methods A comprehensive literature search in Medline, Embase, Cochrane, Scopus, Amed, Google Scholar, SveMed+, and Web of Science was conducted in March 2021. Inclusion criteria were studies examining patients with a vestibular diagnosis, patients with cervicogenic dizziness and patients included based on having dizziness as a symptom; and reported musculoskeletal pain. Data regarding age, sex, sample size, diagnosis and musculoskeletal pain was extracted. The Crowe Critical Appraisal Tool was used for assessing methodical quality of the included studies. Results Out of 1507 screened studies, 16 studies met the inclusion criteria. The total sample consisted of 1144 individuals with dizziness. The frequency of patients reporting pain ranged between 43% and 100% in the included studies. Pain intensity were scored between 5 and 7 on a 0–10 scale. Pain in the neck and shoulder girdle was most often reported, but musculoskeletal pain in other parts of the body was also evident. Discussion In the included studies, musculoskeletal pain was highly prevalent in patients with dizziness, with pain intensity that may have a moderate to severe interference with daily functioning. Pain in the neck and shoulder is well documented, but there are few studies addressing musculoskeletal pain in additional parts of the body. More research is needed to understand the relations between dizziness and musculoskeletal pain.publishedVersio

Self-Reported Measures Have a Stronger Association With Dizziness-Related Handicap Compared With Physical Tests in Persons With Persistent Dizziness

Background: Associations between dizziness-related handicap and a variety of self-reported measures have been reported. However, research regarding associations between dizziness-related handicap and aspects of functioning that includes both physical tests and self-reported measures is scarce. Objective: The purpose of the study was to describe the variations in signs and symptoms in people with persistent dizziness using physical tests and self-reported outcomes across three severity levels of the Dizziness Handicap Inventory (DHI) and investigate their associations with the DHI. Method: Participants with persistent dizziness (n = 107) were included in this cross-sectional study. The participants underwent (1) physical tests (gait tests, grip strength, body flexibility, and movement-induced dizziness) and completed questionnaires regarding (2) psychological measures (Mobility Inventory of Agoraphobia, Body Sensation Questionnaire, Agoraphobic Cognitions Questionnaire, and Hospital Depression and Anxiety Questionnaire), and (3) fatigue, dizziness severity, and quality of life (Chalders Fatigue Scale, Vertigo Symptom Scale-Short Form, and EQ visual analog scale), in addition to the DHI. Data were presented by descriptive statistics for three DHI severity levels (mild, moderate, and severe). A multiple linear backward regression analysis was conducted for each group of measures in relation to the DHI total score, with additional analyses adjusting for age and sex. Based on these results, significant associations were tested in a final regression model. Results: With increasing severity levels of DHI, the participants demonstrated worse performance on most of the physical tests (preferred and fast gait velocity, dizziness intensity after head movements), presented with worse scores on the self-reported measures (avoidance behavior, fear of bodily sensation, fear of fear itself, psychological distress, fatigue, dizziness severity, quality of life). After adjusting for age and sex, significant associations were found between total DHI and avoidance behavior, psychological distress, dizziness severity, and quality of life, but not with any of the physical tests, explaining almost 56% of the variance of the DHI total score. Conclusion: There was a trend toward worse scores on physical tests and self-reported measurements with increasing DHI severity level. The DHI seems to be a valuable tool in relation to several self-reported outcomes; however, several signs and symptoms may not be detected by the DHI, and thus, a combination of outcomes should be utilized when examining patients with persistent dizziness.publishedVersio

Musculoskeletal pain patterns and association between dizziness symptoms and pain in patients with long term dizziness – a cross-sectional study

Background The impact of long-term dizziness is considerable both on the personal level and in society and may lead to self-imposed restrictions in daily activities and social relations due to fear of triggering the symptoms. Musculoskeletal complaints seem to be common in persons with dizziness, but studies addressing these complaints as a widespread occurrence, are scarce. This study aimed to examine the occurrence of widespread pain in patients with long-term dizziness and investigate the associations between pain and dizziness symptoms. Further, to explore whether diagnostic belonging is related to the occurrence of pain. Methods This cross-sectional study was conducted in an otorhinolaryngology clinic and included 150 patients with persistent dizziness. The patients were categorized into three groups: episodic vestibular syndromes, chronic vestibular syndromes, and non-vestibular group. The patients completed questionnaires on dizziness symptoms, catastrophic thinking, and musculoskeletal pain when entering the study. Descriptive statistics were used to describe the population, and associations between pain and dizziness were investigated by linear regression. Results Pain was reported by 94.5% of the patients. A significantly higher prevalence of pain was reported in all the ten pain sites examined compared to the general population. Number of pain sites and pain intensity were associated with the dizziness severity. Number of pain sites was also associated with dizziness-related handicap, but not with catastrophic thinking. There was no association between pain intensity and dizziness-related handicap or catastrophic thinking. Pain was equally distributed in the diagnostic groups. Conclusion Patients with long-term dizziness have a considerably higher prevalence of pain and number of pain sites than the general population. Pain co-exists with dizziness and is associated with dizziness severity. These findings may indicate that pain should be systematically assessed and treated in patients with persisting dizziness.publishedVersio

Clinical characteristics in patients with cervicogenic dizziness: A systematic review

Background and aims: Cervicogenic dizziness (CD) is a clinical syndrome of dizziness associated with neck dysfunction. CD represents a considerable diagnostic challenge since dizziness and neck pain are common symptoms with complex and multifactorial etiologies. Both research and clinical work on CD is limited by the lack of accepted diagnostic criteria. The aim of this study was to review clinical studies on CD and to assess current evidence regarding the clinical characteristics of this syndrome. Methods: A comprehensive PubMed and MEDLINE search was conducted from the date of inception of the database, with the last search conducted in September 2018. Included studies had to contain operable diagnostic criteria as well as a comparison between patients considered to have CD and a clinical comparison group. Data extracted were clinical outcomes, diagnostic criteria, age, sex, and sample size. Studies were assessed for methodological quality using the Crowe Critical Appraisal Tool. Results: Out of 2161 screened studies, eight studies comprising 225 patients met the inclusion criteria. Studies were of low to acceptable methodological quality. The most frequent and consistent clinical characteristic in patients classified as having CD, compared with other populations, was reduced posturographic stability. The most consistent diagnostic criteria were based on the concurrence of neck pain with dizziness after exclusion of other possible reasons for dizziness. Conclusion: There are few studies examining clinical characteristics in patients with cervicogenic dizziness. Altered posturography appeared to be the only consistent characteristic used when distinguishing CD from other populations. Diagnostic criteria currently used in research are likely to have low specificity, since they rest on the exclusion of other causes rather than on positive distinctive features. More studies are needed to better understand the clinical interrelations between dizziness and neck pain

Clinical characteristics in patients with cervicogenic dizziness: A systematic review

Background and aims: Cervicogenic dizziness (CD) is a clinical syndrome of dizziness associated with neck dysfunction. CD represents a considerable diagnostic challenge since dizziness and neck pain are common symptoms with complex and multifactorial etiologies. Both research and clinical work on CD is limited by the lack of accepted diagnostic criteria. The aim of this study was to review clinical studies on CD and to assess current evidence regarding the clinical characteristics of this syndrome. Methods: A comprehensive PubMed and MEDLINE search was conducted from the date of inception of the database, with the last search conducted in September 2018. Included studies had to contain operable diagnostic criteria as well as a comparison between patients considered to have CD and a clinical comparison group. Data extracted were clinical outcomes, diagnostic criteria, age, sex, and sample size. Studies were assessed for methodological quality using the Crowe Critical Appraisal Tool. Results: Out of 2161 screened studies, eight studies comprising 225 patients met the inclusion criteria. Studies were of low to acceptable methodological quality. The most frequent and consistent clinical characteristic in patients classified as having CD, compared with other populations, was reduced posturographic stability. The most consistent diagnostic criteria were based on the concurrence of neck pain with dizziness after exclusion of other possible reasons for dizziness. Conclusion: There are few studies examining clinical characteristics in patients with cervicogenic dizziness. Altered posturography appeared to be the only consistent characteristic used when distinguishing CD from other populations. Diagnostic criteria currently used in research are likely to have low specificity, since they rest on the exclusion of other causes rather than on positive distinctive features. More studies are needed to better understand the clinical interrelations between dizziness and neck pain

Associations between pressure pain threshold in the neck and postural control in patients with dizziness or neck pain - a cross-sectional study

Background: It is theorized that neck pain may cause reduced postural control due to the known physiological connection between the receptors in the cervical spine and the vestibular system. The purpose of this study was to examine whether the pressure pain threshold in the neck is associated with postural sway in patients with dizziness or neck pain. Methods: Consecutive patients with dizziness (n = 243) and neck pain (n = 129) were recruited from an otorhinolaryngological department and an outpatient spine clinic, respectively. All subjects underwent static posturography. Pressure pain thresholds were measured at four standardized points in the neck, and generalized pain was assessed using the American College of Rheumatology tender points. The relationship between postural sway and pressure pain threshold was analyzed by linear regression, and the covariates included age, sex, and generalized pain. Results: In the dizzy group, there was a small, inverse relationship between pressure pain thresholds and sway area with eyes closed, after adjusting for age, sex, and generalized pain (bare platform; lower neck, p = 0.002, R2 = 0.068; upper neck, p = 0.038, R2 = 0.047; foam rubber mat; lower neck, p = 0.014, R2 = 0.085). The same inverse relationship was found between pressure pain thresholds in the neck and the Romberg ratio on a bare platform after adjusting for age, sex and generalized pain (upper neck, p = 0.15, R2 = 0.053; lower neck, p = 0.002, R2 = 0.069). Neither of these relationships were present in the neck pain group. Conclusion: Our findings indicate that the pressure pain threshold in the neck is associated with postural sway in patients suffering from dizziness after adjusting for age, sex, and generalized pain, but only with closed eyes. The association was small and should be interpreted with caution