This cohort study examines the association between the receipt of physical therapy to treat dizziness and the risk of falls requiring medical care in the subsequent year.
Key Points
Question
Is receipt of physical therapy by patients with dizziness associated with a subsequent risk of a fall requiring medical care?
Findings
In this cross-sectional study of 805 454 patients aged 18 years or older evaluated for dizziness, 7% had a fall resulting in a medical encounter within 12 months of presentation for dizziness. Receipt of physical therapy within 3 months of presentation for dizziness was associated with an 86% reduction in the odds of falling by 12 months.
Meaning
Findings of this study suggest that timely physical therapy referral for dizziness is associated with a reduction in the risk of injurious falls.
Abstract
Importance
Among adults who present for clinical evaluation of dizziness, there is a critical need to identify interventions, such as physical therapy (PT), to mitigate the risk of falls over time.
Objective
The primary objective was to examine the association between receipt of PT and falls requiring medical care within 12 months of presentation for dizziness. Secondary objectives included identification of factors associated with falls requiring medical care and factors associated with receipt of PT after presentation for dizziness.
Design, Setting, and Participants
This cross-sectional study examined US commercial insurance and Medicare Advantage claims from January 1, 2006, through December 31, 2015. In all, 805 454 patients 18 years or older with a new diagnosis of symptomatic dizziness or vestibular disorders were identified. Data were analyzed from October 1, 2021, to February 1, 2023.
Main Outcomes and Measures
Receipt of PT services and the incidence of falls requiring medical care were measured. The association between receipt of PT and falls that occurred 12 months after presentation for dizziness was estimated after accounting for presentation setting (outpatient clinic or emergency department), Charlson Comorbidity Index (CCI; with higher scores indicating greater morbidity), diagnosis code, and sociodemographic characteristics.
Results
A total of 805 454 patients presented for dizziness from 2006 through 2015 (median [range] age, 52 [18-87] years; 502 055 females [62%]). Of these patients, 45 771 (6%) received PT within 3 months of presentation for dizziness and 60 060 (7%) experienced a fall resulting in a medical encounter within 12 months after presentation for dizziness. In adjusted models, patients least likely to receive PT were female (adjusted odds ratio [AOR], 0.80; 95% CI, 0.78-0.81), those aged 50 to 59 years (AOR, 0.67 [95% CI, 0.65-0.70] compared with patients aged 18-39 years), and those with more comorbidities (AOR, 0.71 [95% CI, 0.70-0.73] for CCI ≥ 2 vs 0). Receipt of PT services within 3 months of presentation for dizziness was associated with a reduced risk of falls over the subsequent 12 months, with the greatest risk reduction found within 3 months after PT (AOR, 0.14 [95% CI, 0.14-0.15] at 3-12 months vs 0.18 [95% CI, 0.18-0.19] at 6-12 months and 0.23 [95% CI, 0.23-0.24] at 9-12 months).
Conclusions and Relevance
Results of this cohort study suggest that receipt of PT after presentation for dizziness was associated with a reduction in fall risk during the subsequent 12 months; thus, timely PT referral for dizziness may be beneficial for these patients. Future research, ideally with a clinical trial design, is needed to explore the independent impact of PT on subsequent falls for adults with dizziness.
Introduction
Dizziness and balance disorders are associated with falls, particularly falls resulting in fractures and other injuries with attendant disability and risk of death.1,2 Studies among adults aged 40 years or older in the US have shown that dizziness is associated with an up to 12-fold increase in the risk of self-reported falls.3 Furthermore, in a study from South Korea, the risk of injurious trauma was found to be substantially increased for 1 year after patients presented to an emergency department (ED) for vertigo.4 Despite the association between dizziness and falls, there is limited information on fall rates among individuals with dizziness who seek care in outpatient clinics, where the majority of people with dizziness initiate and receive care.5
Preventive measures taken at the time of presentation for dizziness may have implications for the burden of fall-related injuries and deaths. While there is growing interest in wearable technological innovations to monitor fall risk and occurrence,6 established exercise programs that are not dependent on technology have been associated with reductions in fall rates and the number of falls among adults aged 60 years or older who live in community settings.7 Among patients with dizziness or balance disorders specifically, physical therapy (PT) interventions have been associated with improved balance and reduced surrogate measures of fall risk.8 However, direct evidence of actual fall rate reduction associated with vestibular PT is lacking.
There is a critical need to examine fall rates and risk mediators in both young and older adults with dizziness. Claims-based identification methods developed for falls facilitate large-scale examination of longitudinal risk of documented falls with injury after health care encounters for dizziness. This study evaluated a large cohort to address 3 objectives. The primary objective was to examine the association between receipt of PT and falls requiring medical care within 12 months of presentation for dizziness. Secondary objectives included identification of factors associated with falls requiring medical care and factors associated with receipt of PT after presentation for dizziness.
Methods
Data Source
This cohort study used deidentified administrative claims data with linked socioeconomic status information from the OptumLabs Data Warehouse, which includes medical and pharmacy claims, laboratory results, and enrollment records for commercially insured and Medicare Advantage enrollees. The database represents a diverse mixture of patient ages and geographical regions across the US.9 Beneficiaries with commercial insurance who are included in the OptumLabs Data Warehouse have been shown to be similar to the broader US commercially insured population in terms of age, race and ethnicity, and sex.10 Since this study involved analysis of preexisting deidentified data, the Institutional Review Board at the University of Minnesota deemed it exempt from review and waived the informed consent requirement. The study followed the STROBE reporting guideline.
Population
The study population comprised patients aged 18 years or older with a new International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of dizziness and giddiness (code 780.4) or a vestibular disorder (code 386.x) between January 1, 2006, and December 31, 2015. Diagnosis codes were associated with evaluation and management codes to indicate a visit in the ED or outpatient clinic and provider specialty type was assigned, as previously described.5,11 The index date was the date of the initial encounter for evaluation of dizziness. To select new presentations with consistent follow-up, patients were required to have at least 365 days of continuous enrollment before and after the index date and no dizziness or vestibular diagnoses prior to the index date. Patient characteristic included age group (18-39, 40-49, 50-59, 60-64, 65-74, or ≥75 years); commercial or Medicare Advantage insurance; sex (female or male); race and ethnicity (Asian, Black, Hispanic, White, or unknown); Charlson Comorbidity Index (CCI) of 0, 1, or 2 or greater, with higher scores indicating greater morbidity; presentation setting (ED or outpatient clinic); and the category of the first diagnosis (any vestibular disorder [ICD-9 code 386.x] or dizziness and giddiness [ICD-9 code 780.4]). Race and ethnicity were analyzed to assess the potential generalizability of the results of this study and to identify disparities and inequities in care for dizziness. We previously published a description of this cohort.5
Definitions of Physical Therapy and Falls
Physical therapy was defined as the occurrence of a PT visit within 3 months of presentation for dizziness with Current Procedural Terminology codes of 97112, 97116, 97110, 95992, 97530, or 97750 (eTable in Supplement 1). We assessed the occurrence of overall fall patterns over quarterly time periods within 12 months after presentation for dizziness (3-12, 6-12, and 9-12 months) using an established fall identification algorithm comprised of E-codes (external site of injury codes for accidental falls) plus diagnosis codes for fractures, dislocations, sprains, intracranial injuries, and contusions (eTable in Supplement 1).12,13 Quarterly periods were assessed to capture and account for sufficient time for the potential benefits of PT.
Statistical Analysis
The magnitude of differences in cohort characteristic between groups was reported as crude odds ratios (ORs) with 95% CIs. Multivariable regression was used to assess the factors associated with receipt of PT. A separate multivariable model was used to assess the factors associated with falls, controlling for patient characteristics. For multivariable analyses, the time frame for capturing falls was between 3 and 12 months from presentation for dizziness to avoid overlapping with the PT intervention. A significance level of α = .05 was used for all analyses. Sensitivity analyses were also performed that excluded patients with multiple falls from the models. Data were analyzed from October 1, 2021, to February 1, 2023, using SAS, version 9.4 (SAS Institute, Inc).
Results
Population Characteristics
Of 805 454 patients (median [range] age, 52 [18-87] years) who presented with dizziness from 2006 through 2015, 502 055 were females (62%) and 303 399 males (38%). Of these patients, 60 060 (7%) experienced a fall that resulted in a medical encounter within 12 months after presentation for dizziness, including 18 681 patients (2%) who fell 3 to 12 months after presentation for dizziness. A subgroup of 4702 patients who fell within the first 3 months after presentation for dizziness fell again in the subsequent 3 to 12 months. Table 1 presents the characteristics of patients who did and did not fall within 12 months from presentation for dizziness. There were no clinically meaningful differences in characteristics between patients who fell within 12 months after presentation for dizziness and those who fell from 3 to 12 months after presentation for dizziness. For 6% of patients (45 771 of 805 454) with dizziness, PT was initiated within 3 months after presentation for dizziness. Characteristics of patients who did and did not receive PT are presented in Table 2. Patients who were treated by a specialist clinician received PT more often than those who were first treated by or treated by only primary care clinicians. For example, 6% (10 926 of 176 236) of patients who were treated by only primary care clinicians for dizziness received PT compared with 10% (7160 of 74 954) of patients treated by a cardiologist, 11% (7660 of 68 720) treated by an otolaryngologist, and 13% (8051 of 61 461) treated by a neurologist.
Table 1. Characteristics of Patients With and Without Subsequent Falls in the 12 Months After Presentation for Dizziness.
| Characteristic | Patients, No. (%)a | Crude OR (95% CI) | |
|---|---|---|---|
| No fall (n = 745 394) | Fall (n = 60 060) | ||
| Age group, y | |||
| 18-39 | 169 243 (23) | 11 552 (19) | 1 [Reference] |
| 40-49 | 145 363 (20) | 11 675 (19) | 1.17 (1.12-1.23) |
| 50-59 | 66 498 (22) | 13 756 (23) | 1.27 (1.21-1.33) |
| 60-64 | 53 516 (9) | 5613 (9) | 1.20 (1.13-1.27) |
| 65-74 | 149 509 (7) | 3844 (6) | 1.06 (0.99-1.13) |
| ≥75 | 161 265 (20) | 13 620 (23) | 1.35 (1.29-1.42) |
| Sex | |||
| Female | 462 923 (62) | 39 132 (65) | 1 [Reference] |
| Male | 282 471 (38) | 20 928 (35) | 1.18 (1.08-1.15) |
| Race and ethnicity | |||
| Asian | 31 447 (4) | 1268 (2) | 0.47 (0.42-0.52) |
| Black | 106 294 (14) | 8736 (15) | 0.94 (0.90-0.98) |
| Hispanic | 83 268 (11) | 4580 (8) | 0.68 (0.64-0.72) |
| White | 416 048 (56) | 36 446 (61) | 1 [Reference] |
| Unknown | 108 337 (15) | 9030 (15) | 0.96 (0.92-1.00) |
| Insurance type | |||
| Commercial | 587 100 (79) | 47 607 (79) | 1 [Reference] |
| Medicare Advantage | 158 294 (21) | 12 453 (21) | 0.98 (0.94-1.02) |
| Charlson Comorbidity Index score | |||
| 0 | 376 208 (50) | 25 866 (43) | 1 [Reference] |
| 1 | 167 147 (22) | 14 187 (24) | 1.19 (1.15-1.24) |
| ≥2 | 202 039 (27) | 20 007 (33) | 1.39 (1.34-1.44) |
| Setting of presentation for dizziness | |||
| Emergency department | 171 389 (23) | 13 949 (23) | 1 [Reference] |
| Outpatient clinic | 574 005 (77) | 46 111 (77) | 1.05 (1.02-1.09) |
| Diagnostic category of first diagnosis | |||
| Any vestibular disorder (ICD-9 code 386.x) | 121 241 (17) | 10 031 (17) | 1 [Reference] |
| Dizziness and giddiness (ICD-9 code 780.4) | 624 153 (83) | 50 029 (83) | 1.03 (0.98-1.06) |
| Physical therapy within 3 mo of presentation for dizziness | |||
| No | 704 297 (94) | 55 386 (92) | 1 [Reference] |
| Yes | 41 097 (6) | 4674 (8) | 0.15 (0.15-0.16) |
Abbreviations: ICD-9, International Classification of Disease, 9th Revision; OR, odds ratio.
Percentages may not sum to 100 due to rounding.
Table 2. Characteristics of Patients Who Did or Did Not Receive Physical Therapy Within 3 Months of Presentation for Dizziness.
| Characteristic | Patients, No. (%)a | Crude OR (95% CI) | |
|---|---|---|---|
| No PT | PT | ||
| Age group, y | |||
| 18-39 | 173 403 (23) | 7392 (16) | 1 [Reference] |
| 40-49 | 148 139 (20) | 8899 (19) | 0.71 (0.68-0.73) |
| 50-59 | 163 601 (22) | 11 420 (25) | 0.61 (059-0.63) |
| 60-64 | 67 284 (9) | 4827 (11) | 0.59 (0.57-0.62) |
| 65-74 | 54 117 (7) | 3243 (7) | 0.71 (0.68-0.74) |
| ≥75 | 153 139 (20) | 9990 (22) | 0.65 (0.63-0.67) |
| Sex | |||
| Female | 471 627 (62) | 30 428 (66) | 1 [Reference] |
| Male | 288 056 (38) | 15 343 (34) | 0.83 (0.81-0.84) |
| Race and ethnicity | |||
| Asian | 31 554 (4) | 1161 (3) | 1.83 (1.72-1.95) |
| Black | 109 198 (14) | 5832 (13) | 1.26 (1.22-1.29) |
| Hispanic | 84 719 (11) | 3129 (7) | 1.83 (1.76-1.90) |
| White | 424 073 (56) | 28 421 (62) | 1 [Reference] |
| Unknown | 110 139 (15) | 7228 (16) | 1.02 (0.99-1.05) |
| Insurance type | |||
| Commercial | 597 676 (79) | 37 031 (81) | 1 [Reference] |
| Medicare Advantage | 162 007 (21) | 8740 (19) | 1.14 (1.11-1.17) |
| Charlson Comorbidity Index | |||
| 0 | 382 377 (50) | 19 697 (43) | 1 [Reference] |
| 1 | 170 499 (22) | 10 835 (24) | 0.81 (0.79-0.83) |
| ≥2 | 206 807 (27) | 15 239 (33) | 0.69 (0.68-0.71) |
| Setting of presentation for dizziness | |||
| Emergency department | 175 606 (23) | 9732 (21) | 1 [Reference] |
| Outpatient clinic | 584 077 (77) | 36 039 (79) | 1.08 (1.06-1.10) |
| Diagnostic category of first diagnosis | |||
| Any vestibular disorder (ICD-9 code 386.x) | 123 333 (16) | 7939 (17) | 1 [Reference] |
| Dizziness and giddiness (ICD-9 code 780.4) | 624 960 (84) | 37 832 (83) | 0.94 (0.91-0.96) |
Abbreviations: ICD-9, International Classification of Disease, 9th Revision; OR, odds ratio; PT, physical therapy.
Percentages may not sum to 100 due to rounding.
Factors Associated With Receipt of PT Within 3 Months After Presentation for Dizziness
When adjusting for all other factors (Table 3), several patient characteristics were associated with a lower likelihood of receiving PT services within 3 months after presentation for dizziness. Compared with patients with a CCI of 0, receipt of PT was less likely in patients with a CCI score of 1 (adjusted OR [AOR], 0.83; 95% CI, 0.81-0.85) or 2 or greater (AOR, 0.71; 95% CI, 0.70-0.73). Females were less likely than males to receive PT (AOR, 0.80; 95%, 0.78-0.81). Patients aged 40 years or older were less likely to receive PT (AORs ranged from 0.67 [95% CI, 0.65-0.70] to 0.85 [95% CI, 0.81-0.89]) compared with patients aged 18 to 39 years, as were patients with an initial vestibular disorder diagnosis (AOR, 0.96 [95% CI, 0.94-0.99] for ICD-9 code 386.x vs ICD-9 code 780.4). Compared with White patients, receipt of PT within 3 months of presentation for dizziness was more likely for Asian (AOR, 1.74; 95% CI, 1.64-1.84), Black (AOR, 1.27; 95% CI, 1.24-1.31), and Hispanic patients (AOR, 1.77; 95% CI, 1.70-1.83).
Table 3. Factors Associated With Receipt of Physical Therapy Within 3 Months of Presentation for Dizziness and Falls Occurring 3 to 12 Months After Presentation for Dizziness.
| Factor | AOR (95% CI) | |
|---|---|---|
| PT within 3 mo of presentation for dizziness | Falls 3-12 mo after presentation for dizziness | |
| Age, y | ||
| 18-39 | 1 [Reference] | 1 [Reference] |
| 40-49 | 0.74 (0.72-0.76) | 1.07 (1.04-1.10) |
| 50-59 | 0.67 (0.65-0.70) | 1.04 (1.02-1.07) |
| 60-64 | 0.69 (0.66-0.72) | 0.98 (0.95-1.02) |
| 65-74 | 0.85 (0.81-0.89) | 0.84 (0.80-0.87) |
| ≥75 | 0.81 (0.79-0.84) | 1.02 (0.99-1.05) |
| Sex | ||
| Male | 1 [Reference] | 1 [Reference] |
| Female | 0.80 (0.78-0.81) | 1.12 (1.10-1.14) |
| Race and ethnicity | ||
| White | 1 [Reference] | 1 [Reference] |
| Asian | 1.74 (1.64-1.84) | 0.51 (0.48-0.54) |
| Black | 1.27 (1.24-1.31) | 0.96 (0.94-0.99) |
| Hispanic | 1.77 (1.70-1.83) | 0.69 (0.66-0.71) |
| Unknown | 1.00 (0.97-1.02) | 0.96 (0.94-0.99) |
| Charlson Comorbidity Index score | ||
| 0 | 1 [Reference] | 1 [Reference] |
| 1 | 0.83 (0.81-0.85) | 1.20 (1.17-1.23) |
| ≥2 | 0.71 (0.70-0.73) | 1.39 (1.36-1.42) |
| Dizziness and giddiness (ICD-9 code 780.4) diagnosis | ||
| Yes | 1 [Reference] | 1 [Reference] |
| No | 0.96 (0.94-0.99) | 1.01 (0.99-1.03) |
| Received PT | ||
| No | NA | 1 [Reference] |
| Yes | NA | 0.14 (0.14-0.15) |
Abbreviations: AOR, adjusted odds ratio; ICD-9, International Classification of Disease, 9th Revision; NA, not applicable; PT, physical therapy.
Factors Associated With Falls 3 to 12 Months After Presentation for Dizziness
The risk of falls resulting in a medical encounter over 3 periods (3-12 months, 6-12 months, and 9-12 months from presentation for dizziness) was estimated with multivariable models (Table 3). Compared with those who did not receive PT, patients who received PT services within 3 months after presentation for dizziness were 7.1 times less likely to fall between 3 and 12 months (AOR, 0.18; 95% CI, 0.18-0.19), 5.6 times less likely to fall between 6 and 12 months (AOR, 0.23; 95% CI, 0.23-0.0.24), and 4.3 times less likely to fall between 9 and 12 months (AOR, 0.23; 95% CI, 0.23-0.24) after presentation for dizziness (Figure). Patient factors associated with increased fall risk after controlling for receipt of PT and all other model factors (Table 3) included age (for example, AOR, 1.07 [95% CI, 1.04-1.10) for patients aged 40-49 years compared with patients aged 18-39 years), female sex (AOR, 1.12; 95% CI, 1.10-1.14), and comorbidity status (CCI of 1 vs 0, AOR, 1.20 [95% CI, 1.17-1.23]; CCI of ≥2 or greater vs 0, AOR, 1.39 [95% CI, 1.36-1.42]). Compared with White patients, the risk of falls was lower among Asian (AOR, 0.51 [95% CI, 0.48-0.54]) and Hispanic (AOR, 0.69 [95% CI, 0.66-0.71]) patients compared with Black (AOR, 0.96 [95% CI, 0.94-0.99]) patients. Sensitivity analyses that excluded patients with multiple falls from the models were performed and did not change the magnitude or direction of the results. In addition, there was no meaningful association between the specificity of the dizziness diagnosis and subsequent fall risk (AOR, 1.01 [95% CI, 0.99-1.03] for ICD-9 code 386 compared with ICD-9 code 780.4).
Figure. Odds of Falling After Presentation for Dizziness for Patients Receiving Physical Therapy Compared With Those Who Did Not Receive Physical Therapy.
Analysis was adjusted for age, sex, race and ethnicity, Charlson Comorbidity Index, and specificity of diagnosis. AOR indicates adjusted odds ratio.
Discussion
This study evaluated a large cohort of adults of all ages who sought health care for new-onset dizziness to examine the association between dizziness and subsequent falls requiring medical evaluation, to evaluate risk factors for receipt of PT services, and to investigate if receipt of PT was associated with fewer falls. We observed that 7% of adults experienced a fall requiring medical evaluation within 12 months after presentation for dizziness to either an outpatient clinic or an ED. Physical therapy was initiated for 6% of patients within 3 months of presentation for dizziness and was more likely to be received by men, younger patients, and those with fewer comorbidities. Receipt of PT services within 3 months after presentation for dizziness was associated with an 86% reduction in fall risk over the next 9 months. The effect size of PT exposure was time-dependent, with the greatest risk reduction occurring in the 3 months after receipt of PT. Even with PT, patients with multiple comorbidities had an increased risk of falls with injury.
Prior studies among patients with dizziness have found associations between self-reported falls and sociodemographic characteristics, including increasing age, and health characteristics, such as diabetes.1,3 A National Health Interview Survey study reported that adults with dizziness had a self-reported fall rate (not restricted to falls with injury or requiring health care) of 34% compared with 9% among patients without dizziness, and dizziness was associated with a 1.5-fold increase in the odds of self-reported injury from falling.2 Among adults aged 60 years or older, falls resulting from dizziness or balance loss were more than twice as likely to result in hospitalization than those from slipping or tripping.14 The present study assessed falls requiring medical care after a presentation for dizziness using documented health care encounters rather than relying on self-report. Using encounter-based data removes the potential for recall bias while also likely selecting for more serious falls and those with injury. The present study also expands on prior investigations by including younger adults rather than restricting inclusion criteria to older patients. We observed that patients younger than 65 years comprised 71% of the patients with dizziness who underwent medical evaluation for a fall. This finding emphasizes that injurious falls are not restricted to the elderly and that there is a need to initiate fall prevention for all patients who experience dizziness.
This study captures the breadth of clinical practice for dizziness by assessing fall risk after presentations for dizziness (rather than only specific vestibular diagnoses) to outpatient clinics as well as in EDs. We previously observed that 70% of presentations for dizziness occurred in outpatient clinics, while 30% occurred in EDs, and nearly 80% of individuals receive a nonspecific symptom diagnosis at the initial encounter.5 Prior work on fall risk has largely focused on ED presentations and on specific diagnoses. For example, ED evaluation for peripheral vertigo in South Korea was found to be associated with increased risk of trauma for 1 year after presentation4 and, within the Taiwan National Health Insurance Research Database, benign paroxysmal positional vertigo (BPPV) was associated with a 1.14-fold higher risk of fracture compared with patients without BPPV.15 We found that the proportion of patients with dizziness who experienced a fall resulting in medical care was the same whether they presented to an ED or an outpatient clinic. Furthermore, patients with specific vestibular diagnoses, such as BPPV or Meniere disease, were no more likely to fall than those who had nonspecific dizziness diagnoses. Results of the present study underscore that clinicians should consider counseling and initiation of fall prevention strategies as equally important across settings and dizziness presentations.
To date, evidence for an association between a reduction in falls after PT to treat dizziness and balance disorders has been limited.16 Among people aged 60 years or older in general (not necessarily those with dizziness), exercise programs consisting of strength and balance training have been found to be effective in reducing the rate of falls and the number of people experiencing falls and have reported improvement in clinical measures of balance.7 A form of PT commonly recommended for patients with vestibular and balance disorders is vestibular rehabilitation, an approach that typically includes a combination of exercises to promote gaze stability, habituate symptoms, improve balance and gait, and improve endurance via walking.17 Vestibular PT has been associated with improved postural and gait stability for patients with vestibular hypofunction,17 and the timing of intervention appears to be important. For example, for patients with unilateral vestibular hypofunction, there is an optimal early window of opportunity to initiate gaze stabilization exercises to improve dynamic visual acuity and restore vestibulo-ocular reflex gain, reducing the need for recruitment of compensatory saccades.18 Vestibular PT may also entail canalith repositioning maneuvers, which are effective for treating BPPV.19 However, rather than measuring actual falls, trials of PT interventions for dizziness and balance disorders largely use surrogate outcome measures to assess fall risk, such as the timed up and go test or Falls Efficacy Scale.8 In part, this practice has been attributed to falls being rare events in clinical trial settings, making it difficult to achieve sufficient sample size or duration of follow-up to detect differences in fall rates between study arms.
Our large data set with longitudinal follow-up facilitated the examination of the potential value of timely PT intervention on fall risk among adults with dizziness. We observed that receiving PT services within 3 months of presentation for dizziness was associated with a lower risk of documented falls for 12 months after presentation. We anticipated that fall risk would decrease from the time of presentation for dizziness for the cohort as a whole, as dizziness may resolve spontaneously and respond to other interventions. However, the addition of PT was associated with an 86% reduction in the risk of falls over 12 months. The effect size of PT exposure was time-dependent, decreasing in each 3-month interval, underscoring the possibility that PT was associated with reduced fall risk.
These data emphasize the importance of counseling and initiating preventive measures at the time of dizziness presentation in any setting (ED or outpatient) to potentially reduce the burden of fall-related injuries and deaths. However, there is evidence that PT is underused for patients with dizziness.20,21,22 In the National Ambulatory Medical Care Survey, PT referral was placed for less than 1% of ambulatory visits assigned a diagnosis code of unspecified dizziness; referral rates were higher for BPPV (13%) but were just 0.5% for other vestibular diagnoses.23 Similar to the findings of the present study, referral to PT differed by clinician specialty, and the greatest opportunity to increase awareness and education around the benefits of PT was among primary care clinicians.23 Development and dissemination of guidelines for the management of dizziness, such as those for BPPV and Meniere disease, may be effective in influencing clinician practice.
These data suggest that increased PT referrals and improved access to PT may be associated with reduced fall risk in patients with dizziness. Nonetheless, the present findings also suggest that PT was not associated with an absence of falls among patients with dizziness. Other factors may mitigate the benefits of PT, including comorbidity and female sex.24 Patients with dizziness and multiple comorbidities may require additional fall prevention strategies, including but not limited to low-intensity exercise, step training, home safety modifications, and support for caregivers.25,26 Medications taken for dizziness, particularly sedatives and vestibular suppressants, may also be associated with an increase in fall risk27 and their potential interaction with PT should be assessed in future work. Consistent with prior studies, we observed that the risk of falls resulting in a medical encounter after presentation for dizziness was lowest for racial and ethnic minority populations.28,29 These disparities may be associated with a decreased fear of falling29 and true differences in medical need among racial and ethnic groups, but may also be a construct of differential insurance coverage and access to care.30
Limitations
This study has limitations. This claims-based study captured dizziness and falls that resulted in a medical encounter and could not account for symptom intensity or duration. Claims may have selected for patients with greater severity of symptoms or injury compared with those who managed falls at home and would not detect a failure to seek care when needed. There are several claims-based methods for capturing falls that result in medical care that yield varying degrees of sensitivity and specificity.13,31,32 Because E-codes are frequently missing in claims data, reliance on E-codes alone to indicate fall severity is insufficiently sensitive.13 We selected an established method that also captures injuries attributable to falling, but we could not prove that all injuries resulted from falls; thus, our method may have overestimated the prevalence of falls, although it did not overestimate the rate of injuries requiring medical care. Billing codes for PT encompass a range of exercises and services. We focused on PT claims within 3 months after presentation for dizziness so that, even if not explicitly defined as vestibular therapy, it is highly likely that the proceeding symptom complex would have been considered in the care plan. Additional investigation will be needed to determine which components of PT, such as specific exercises, education, and adherence, are most helpful. Furthermore, findings of this study may have been influenced by selection bias, as patients sufficiently well and willing to seek PT may have been less inclined to fall than their counterparts who did not receive PT. However, after controlling for comorbidity and age, the association of PT with decreased fall risk persisted and we maintained a compact 1-year time frame to capture claims close to the presentation for dizziness. Finally, we did not assess the implications of other treatments or medications on the association between PT and fall risk, and linkage with pharmacy claims is planned for future analyses.
Conclusions
Recent health care patterns have placed an emphasis on technological advances and devices to detect falls, mitigate fall risk, and prompt a rapid response to avoid major fall injuries among patients with dizziness.6 Findings of this cohort study suggest that timely PT referrals are associated with a reduction in risk of falls among adults with varying diagnoses of dizziness. Future research, ideally with a clinical trial design, is needed to explore the independent impact of PT on the risk of subsequent falls for adults with dizziness.
eTable. Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) Codes Used to Identify Physical Therapy Services and Falls
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable. Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) Codes Used to Identify Physical Therapy Services and Falls
Data Sharing Statement
