Falls risk in older adults: the impact of neck pain, dizziness and manual therapy treatment

Kendall, J 2018, Falls risk in older adults: the impact of neck pain, dizziness and manual therapy treatment, Doctor of Philosophy (PhD), Health and Biomedical Sciences, RMIT University.


Document type: Thesis
Collection: Theses

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Title Falls risk in older adults: the impact of neck pain, dizziness and manual therapy treatment
Author(s) Kendall, J
Year 2018
Abstract Falls place substantial personal and financial burdens on society, and increase in frequency with age. The proportion of older Australians is increasing, and interventions are needed to reduce the healthcare costs associated with ageing. Neck pain and dizziness are common conditions presenting in older adults. Musculoskeletal pains, and neck pain in particular, are associated with impaired performance on balance tasks, feelings of instability and dizziness. This cluster of symptoms has been proposed to increase the risk of falls in older people; however, the relationship between neck pain, dizziness and stability has predominantly been examined in younger adult populations. Therefore, this thesis seeks to explore the relationship between neck pain and instability in older adults, to determine whether this population might benefit from manual therapy interventions. The available literature examining manual therapies, including spinal manipulative therapy, suffers from: a lack of control groups; participant blinding; randomisation; clear inclusion criteria targeting older adults with falls-risk health conditions, such as musculoskeletal pain and/or dizziness; and consistent reporting on the interventions provided. Therefore, this thesis also involves designing and conducting a randomised controlled trial of spinal manipulative therapy to reduce neck pain and dizziness, and to improve instability in older adults. Specifically, this thesis answers four key questions: 1) Is neck pain associated with increased concerns of falling and decreased physical performance in an older community-based cohort? 2) Are non-pharmacological interventions effective for treating dizziness in older people? 3) Is the intensity of spinal pain increased in mobility-limited older adults who have increased concerns of falling and reduced balance performance? 4) Is it feasible to run a large trial to examine the effectiveness of spinal manipulative therapy for neck pain and non-specific dizziness in older people? To examine the relationship between neck pain and instability in older adults, a cross-sectional study of community dwelling older persons in Denmark was conducted. This study investigated whether neck pain is associated with two common falls risk factors: concerns of falling and physical performance. Neck pain was common in older adults, with one in three participants reporting neck pain in the previous four weeks. Of these people with neck pain, a third had pain that interfered with activities and daily routines (bothersome pain). Bothersome neck pain was associated with significantly greater odds of having reduced physical performance and increased concerns of falling. However, these relationships became non-significant after adjusting for confounding factors. Bothersome neck pain and concerns of falling were confounded by depression, and bothersome neck pain and decreased physical performance were confounded by concerns of falling, depression and previous history of falls. This shows that bothersome neck pain in older people is associated with increased concerns of falling and decreased physical performance, which are two known risk factors for falls in older people. However, this relationship is only evident in people with bothersome pain, and these relationships are complicated by confounders, particularly depression. A thorough examination was conducted of the literature on non-pharmacological interventions, including manual therapies, for dizziness in older adults. This systematic review found only seven controlled trials. All of these trials used exercise therapies as their main interventions. Trials were limited by their high risk of bias, and therefore, could not determine the effectiveness of these interventions for dizziness in this age group. This outcome highlights the paucity of literature on dizziness interventions in older age groups, and the need for rigorous controlled trials to assess the efficacy of manual therapies, including spinal manipulative therapy, in older adults. The relationship between musculoskeletal pain and instability was examined further in another cross-sectional study of community-dwelling older Danes. These individuals had limited mobility, defined by a normal gait speed of <0.9m/s. This study showed that increased intensity of neck pain was significantly associated with reduced balance performance, compared to mild neck pain. Furthermore, intense low back pain was significantly associated with increased concerns of falling compared to individuals without pain. This shows that intense pain, but not mild pain, is associated with a significant loss of stability in people with reduced mobility. A randomised controlled trial was conducted using spinal manipulative therapy for neck pain and dizziness in older adults. Based on the generally poor quality of previous studies of manual therapy in older adults, due to lack of randomisation, blinding and clear inclusion criteria, this trial addressed these methodological issues, and assessed the feasibility of running larger trials. This trial recruited older adults with chronic neck pain and who had experienced dizziness in at least the last three months. To determine if a large trial could be conducted using this protocol it assessed recruitment rate, compliance, study location, blinding, treatment satisfaction, costs, harms, and adequate sample size. The use of sham instrument-assisted manipulation provided acceptable blinding, compliance and treatment satisfaction, and is feasible for future trials. Mild, transient harms of increased spinal pain or headaches were reported by some participants, which is consistent with previous studies of manual therapies. A fully-powered clinical trial may require modifications to the location and recruitment strategy to increase recruitment rates, to enable the required sample size. This thesis project answered the four questions initially proposed. Neck pain is associated with increased concerns of falling and decreased physical performance in older adults; however, these relationships are confounded by a multitude of other factors. Future studies examining neck pain and instability in older adults should include measures of mood, physical performance and previous history of falling. There is currently insufficient evidence for the effectiveness of non-pharmacological interventions for treating dizziness in older people. Therefore, future rigorous controlled trials need to be conducted that target older adults. Intense neck pain, but not mild neck pain, is associated with reduced balance in mobility-limited older adults. Interventions that aim to reduce intensity of musculoskeletal pain need to be applied to older adults. Finally, it is feasible to run a large sham-controlled trial to examine the effectiveness of spinal manipulative therapy for neck pain and non-specific dizziness in older people, with modifications to increase recruitment. These trials should target older adults with bothersome or intense neck pain, to determine if alleviating these factors reduces the associated instability and falls risk.
Degree Doctor of Philosophy (PhD)
Institution RMIT University
School, Department or Centre Health and Biomedical Sciences
Subjects Geriatrics and Gerontology
Neurology and Neuromuscular Diseases
Chiropractic
Keyword(s) Chiropractic
Ageing
Falls
Neck pain
Dizziness
Randomised controlled trial
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