Abstract
Background
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that leads to various systemic complications. This study aims to assess the association between RA and chronic dizziness, recurrent falls, and chronic imbalance in the Korean adult population.
Methods
Data from 4,754 (weighted n = 17,694,932) individuals aged 40 years or older in the 2019–2020 Korean National Health and Nutrition Examination Survey were analyzed. A questionnaire including information on chronic dizziness, recurrent falls, demographic variables, and laboratory test data was evaluated. RA was defined based on patient-reported physician diagnoses. Factors potentially associated with chronic dizziness, recurrent falls, and chronic imbalance were examined.
Results
The mean age was 56.7 years. The weighted prevalence of RA was 1.9%. In patients with RA, the rates of chronic dizziness (10.1% vs. 3.4%, p = 0.005), recurrent falls (3.9% vs. 0.4%, p < 0.001), and chronic imbalance (5.1% vs. 1.0%, p < 0.001) were significantly higher than in those without RA. In multivariable analysis, RA (OR 2.65, 95% CI 1.10–6.34, p = 0.030) was associated with an increased risk of chronic dizziness, alongside females, a body mass index under 25, hearing impairment, stroke, and stress. Additionally, females, hearing impairment, and RA (OR 8.29, 95% CI 2.79–24.67, p < 0.001) were associated with an increased risk of recurrent falls. For chronic imbalance, RA (OR 3.73, 95% CI 1.22–9.6, p = 0.020) was significantly associated with chronic imbalance, alongside being female, smoking, and hearing impairment.
Conclusion
RA was found to be independently associated with an increased risk of chronic dizziness, recurrent falls, and chronic imbalance.
Supplementary Information
The online version contains supplementary material available at 10.1186/s42358-026-00533-3.
Keywords: Rheumatoid arthritis, Chronic, Dizziness, Imbalance, Falls
Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by systemic inflammation and progressive joint destruction, affecting approximately 1% of the global population. Although RA primarily targets the joints, it can also present with extra-articular symptoms, affecting various organ systems and leading to significant morbidity and mortality. Sensorineural hearing loss, among these extra-articular manifestations, has been extensively investigated in individuals with RA. Studies have reported sensorineural hearing loss rates ranging from 24 to 60% in RA [1]. We previously demonstrated that RA is associated with low/mid-frequency hearing impairment after accounting for various known risk factors including smoking, alcohol consumption, occupational noise exposure, hypertension, diabetes, and dyslipidemia [2]. Another study identified a correlation between hearing impairment and extended disease duration [3].
It has been suggested that the pathophysiological mechanism of sensorineural hearing loss in RA involves damage such as vasculitis or neuritis, which may affect the inner ear structures [2]. Furthermore, autoantibodies might induce an immune complex-mediated vasculitis targeting inner ear structures or cause sensorineural hearing impairment in RA [1]. Given that the auditory and vestibular systems are intricately linked within the inner ear, sharing structures and neural pathways, vasculitis or neuritis could affect both systems. Despite advancements in understanding pathophysiology and management of RA, research on the vestibular system in RA patients remains scarce. Yilmaz et al. reported an association between RA and dysfunction in both the vestibular and auditory systems [4]. However, other studies have not observed vestibular system dysfunction in RA patients [5, 6]. Additionally, considering that dizziness and imbalance may result from multifactorial deficits in peripheral and central sensory functions (visual, vestibular, and somatosensory), identifying balance disorders in RA patients, who also often suffer from musculoskeletal disorders, is essential for comprehensive disease management and improving patient outcomes.
The aim of this study is to evaluate the association between RA and vestibular symptoms, including dizziness, recurrent falls, and chronic imbalance. Utilizing data from the 2019–2020 Korean National Health and Nutrition Examination Survey (KNHANES), this study seeks to determine the prevalence, risk factors, and clinical implications of vestibular symptoms in the Korean adult population.
Methods
Study population
The study utilized data collected during the 2019–2020 KNHANES. This periodic nationwide survey, conducted by the Korea Centers for Disease Control and Prevention, aims to assess the health and nutritional status of the Korean population [7]. Participants were selected through proportional allocation and systematic sampling with multistage stratification to accurately represent the Korean population. Although individual participants may not represent the entire Korean population, the survey yields representative estimates of the non-institutionalized civilian population using sample weights. ‘Weighted n’ indicates the estimated number of individuals in the target population after applying sampling weights.
Initially, the 2019–2020 KNHANES dataset included 15,469 participants. Of these, 9,296 individuals aged 40 and above, who underwent audiometric measurement, were selected for this study. The analysis excluded 4,542 participants due to missing data in relevant variables. Consequently, a total of 4,754 individuals (weighted n = 17,694,932) were included in the analysis.
Data collection
To collect demographic data, a trained investigator conducted standardized individual interviews using a questionnaire that included demographic and socioeconomic characteristics such as age, sex, smoking status, alcohol consumption, body mass index (BMI), and occupational noise exposure. The questionnaire items used to assess smoking status, alcohol consumption, and occupational noise exposure are provided in supplementary Table 1. Occupational noise exposure was defined as exposure to loud noises such as machines or generators in the workplace for more than three years, where the noise level prevents verbal communication. The diagnosis of rheumatoid arthritis (RA) was defined in the questionnaire as a diagnosis confirmed by a physician during a standardized interview. The question was, “Was your RA diagnosed by a physician?” Complementary diagnostic tests (rheumatoid factor, anti-cyclic citrullinated peptide antibodies, inflammatory markers, and radiographs) and detailed information on RA-specific medications (such as methotrexate, leflunomide, biologic agents, or Janus kinase inhibitors) were not available in the KNHANES dataset. Stroke and cataracts data were collected using the same method as for RA. Hypertension was defined as a systolic blood pressure of 140 mmHg or higher or diastolic blood pressure of 90 mmHg or higher, including participants on antihypertensive medication. Pre-hypertension was characterized as systolic blood pressure ranging from 120 to 139 mmHg and diastolic pressure from 80 to 89 mmHg. Diabetes was identified by a fasting glucose level of 126 mg/dL or higher, a physician’s diagnosis, the use of hypoglycemic drugs or insulin, or a HbA1c level of 6.5% or higher. Pre-diabetes was defined as a fasting glucose level of 100 to 125 mg/dL or an HbA1c of 5.7 to 6.4%. Hypercholesterolemia was defined as a total cholesterol level over 240 mg/dL or the use of cholesterol-lowering medications. Anemia was characterized by hemoglobin levels below 12 g/dL for non-pregnant women, below 11 g/dL for pregnant women, and below 13 g/dL for men.
Blood samples were collected in the morning following an overnight fast of at least 8 h. They were immediately refrigerated and transported in cold storage to the central testing facility. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) study equation: eGFR (mL/min/1.73 m2) = 175 × (serum creatinine) − 1.154 × (age) − 0.203 × (0.742 if female) [8].
Dizziness, falls, imbalance, and audiometric measurements
Data on chronic dizziness, recurrent falls, and chronic imbalance were gathered through a standardized interview. Participants were initially queried, “Have you experienced dizziness or imbalance in the past 12 months?” Those who responded “Yes” were then asked follow-up questions:
“Have you felt chronically dizzy for the past three months or more?” Those who answered “Yes” were identified as having chronic dizziness.
“Have you repeatedly fallen for the past three months or more?” Those who answered “Yes” were identified as having recurrent falls.
“Have you had difficulty maintaining a standing position for the past three months or more?” Those who answered “Yes” were identified as having chronic imbalance.
This standardized interview technique facilitated the systematic identification and classification of individuals with these outcome measures. The use of a ≥ 3-month threshold to define chronic dizziness is consistent with established clinical guidance for chronic vestibular symptoms and has been widely applied in prior neuro-otologic and epidemiological research [9–11].
All individuals enrolled in the present study underwent pure-tone audiometry. Pure-tone air-conduction thresholds were measured in a soundproof booth using an automatic audiometer (AD629; Interacoustics, Denmark). Both the booth and audiometer were installed in mobile vehicles, adhering strictly to American National Standards Institute–Acoustical Society of America (ANSI-ASA) S3.1 regulation. Trained professionals independently collected data for each ear at frequencies of 0.5, 1.0, 2.0, 4.0, and 8.0 kHz. The average-frequency pure-tone threshold was calculated as the mean of thresholds at 0.5, 1.0, 2.0, and 4.0 kHz. Hearing impairment was defined as a pure-tone average (0.5, 1, 2, 4 kHz) threshold level ≥ 41 decibels for the superior ear.
Furthermore, tympanometric examinations in both ears were conducted to detect conditions likely to affect the hearing threshold or vertigo (otitis media, cholesteatoma, or drum perforation). The Titan device (Interacoustics, Denmark) was employed for impedance audiometry measurements. Abnormal tympanometry was characterized by (1) no peak; (2) a peak pressure below minus 100 daPa; or (3) a peak pressure above plus 100 daPa.
Statistical analyses
Descriptive statistics were used to identify the characteristics of the study population. Clinical comparisons were performed using t-tests, and the Mann–Whitney U-test was applied to continuous variables as needed. Chi-square tests were utilized for categorical variables. Factors such as age, alcohol consumption, anemia, hearing impairment, stroke, and cataract were examined for their association with these outcome measures, using both univariable and multivariable analyses. Initially, a crude analysis without adjustment was conducted, followed by a multivariate analysis that adjusted for potential factors related to all three outcomes. All clinically relevant covariates were included simultaneously in the multivariable logistic regression models, rather than applying statistical selection thresholds. The fully adjusted models incorporated age, alcohol consumption, anemia, hearing impairment, stroke, and cataract as prespecified variables based on prior epidemiological and clinical relevance. In the logistic regression analysis, adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for these outcome measures. Using the Bonferroni method, p-values were corrected. Statistical analyses were executed using SAS version 9.4 (SAS Institute, Cary, NC, USA). All p-values were two-sided, and p-values < 0.05 were deemed statistically significant.
Results
Demographics
A total of 4,754 adults aged 40 years or older (weighted n = 17,694,932) were included in this study. Table 1 presents the weighted demographic and clinical characteristics of the study population. The mean age of the participants was 56.7 years, with females comprising 51.5%. Of all participants, 1.96% were diagnosed with rheumatoid arthritis (RA) by physicians. Patients with RA constituted a higher proportion of older individuals and females, showed lower rates of current smoking and less frequent alcohol consumption, and had higher rates of hypercholesterolemia, anemia, and cataracts. Additionally, participants with RA were more likely to have hearing impairment. Within the entire study population, the prevalence of chronic dizziness was 3.5%, recurrent falls were 0.5%, and chronic imbalance was 1.1%. Rates of chronic dizziness, recurrent falls, and chronic imbalance were significantly higher among individuals with RA compared to those without.
Table 1.
Baseline characteristics according to the presence of rheumatoid arthritis (RA)
| Variable | Total (Weighted n = 17,694,932) |
Non-RA (Weighted n = 17,354,105) |
RA (Weighted n = 340,827) |
p |
|---|---|---|---|---|
| Age | 56.7 ± 0.31 | 56.6 ± 0.32 | 63.7 ± 1.4 | < 0.001 |
| Sex | < 0.001 | |||
| Male | 8,575,286 (48.5) | 8,501,416 (49.0) | 73,870 (21.7) | |
| Female | 9,119,646 (51.5) | 8,852,689 (51.0) | 266,957 (78.3) | |
| Smoking Status | 0.003 | |||
| Non-smoker | 9,935,405 (56.2) | 9,686,267 (55.8) | 249,139 (73.1) | |
| Ex-smoker | 4,709,306 (26.6) | 4,642,854 (26.8) | 66,452 (19.5) | |
| Current Smoker | 3,050,221 (17.2) | 3,024,984 (17.4) | 25,236 (7.4) | |
| Alcohol Consumption | 0.020 | |||
| Never | 5,366,283 (30.4) | 5,222,580 (30.1) | 143,703 (42.2) | |
| 1 ≤ week | 8,338,273 (47.1) | 8,175,722 (47.1) | 162,551 (47.7) | |
| 2–3 / week | 2,855,992 (16.1) | 2,833,404 (16.3) | 22,588 (6.6) | |
| 4 ≥ week | 1,134,384 (6.4) | 1,122,399 (6.5) | 11,985 (3.5) | |
| BMI (kg/m²) | 0.753 | |||
| < 25 | 10,729,178 (60.6) | 10,516,869 (60.6) | 212,309 (62.3) | |
| ≥ 25 | 6,965,754 (39.4) | 6,837,236 (39.4) | 128,518 (37.7) | |
| Occupational Noise Exposure | 0.2166 | |||
| Yes | 2,896,052 (16.4) | 2,823,344 (16.3) | 72,708 (21.3) | |
| No | 14,798,880 (83.6) | 14,530,761 (83.7) | 268,119 (78.7) | |
| Tympanic Disease | 0.433 | |||
| Yes | 16,610,790 (93.9) | 16,284,911 (93.8) | 325,879 (95.6) | |
| No | 1,084,142 (6.1) | 1,069,194 (6.2) | 14,948 (4.4) | |
| SBP, mmHg | 121.1 ± 0.4 | 121.0 ± 0.4 | 124.5 ± 1.7 | 0.047 |
| DBP, mmHg | 77.2 ± 0.2 | 77.2 ± 0.2 | 75.3 ± 0.9 | 0.057 |
| Total Cholesterol, mg/dL | 193.5 ± 0.8 | 193.5 ± 0.8 | 191.7 ± 5.6 | 0.737 |
| HDL, mg/dL | 50.9 ± 0.3 | 50.9 ± 0.3 | 52.9 ± 1.5 | 0.189 |
| Triglycerides, mg/dL | 141.6 ± 2.5 | 141.7 ± 2.5 | 138.0 ± 8.2 | 0.683 |
| LDL, mg/dL | 114.3 ± 0.8 | 114.3 ± 0.8 | 111.3 ± 4.4 | 0.484 |
| AST, IU/L | 25.2 ± 0.2 | 25.2 ± 0.2 | 27.1 ± 1.3 | 0.157 |
| ALT, IU/L | 24.0 ± 0.3 | 24.0 ± 0.3 | 21.6 ± 1.2 | 0.058 |
| Uric Acid, mg/dL | 5.10 ± 0.02 | 5.10 ± 0.02 | 4.66 ± 0.11 | < 0.001 |
| BUN, mg/dL | 15.6 ± 0.1 | 15.5 ± 0.1 | 17.4 ± 0. 7 | 0.005 |
| Creatinine, mg/dL | 0.82 ± 0.0 | 0.82 ± 0.0 | 0.8 ± 0.03 | 0.565 |
| eGFR, mL/min/1.73 m2 | 88.4 ± 0.4 | 88.4 ± 0.4 | 85.3 ± 2.2 | 0.152 |
| Hypertension | 0.073 | |||
| Normal | 6,211,085 (35.1) | 6,126,255 (35.3) | 84,830 (24.9) | |
| Pre-hypertension | 4,856,076 (27.4) | 4,773,900 (27.5) | 82,177 (24.1) | |
| Hypertension | 6,627,771 (37.5) | 6,453,950 (37.2) | 173,820 (51.0) | |
| Diabetes | 0.187 | |||
| Normal | 6,151,446 (34.8) | 6,060,689 (34.9) | 90,757 (26.6) | |
| Pre-diabetes | 8,275,982 (46.7) | 8,088,125 (46.6) | 187,856 (55.1) | |
| Diabetes | 3,267,504 (18.5) | 3,205,291 (18.5) | 62,214 (18.3) | |
| Hypercholesterolemia | 5,491,917 (31.0) | 5,320,065 (30.7) | 171,852 (50.4) | < 0.001 |
| Anemia | 2,022,453 (11.4) | 1,956,020 (11.3) | 66,433 (19.5) | 0.013 |
| Stroke | 396,403 (2.2) | 381,365 (2.2) | 15,039 (4.41) | 0.145 |
| Myocardial Infarction or Angina | 595,089 (3.4) | 574,455 (3.3) | 20,634 (6.1) | 0.127 |
| Stroke | 396,403 (2.2) | 381,365 (2.2) | 15,039 (4.4) | 0.145 |
| Cataract | 3,146,642 (17.8) | 3,014,304 (17.4) | 132,338 (38.8) | < 0.001 |
| Stress | 14,992,261 (84.7) | 14,710,120 (84.8) | 282,141 (82.8) | 0.594 |
| Hearing Impairment | 2,249,348 (12.7) | 2,187,559 (12.6) | 61,789 (18.1) | 0.0825 |
| Chronic dizziness | 0.005 | |||
| No | 17,079,234 (96.5) | 16,772,900 (96.6) | 306,334 (89.9) | |
| Yes | 615,698 (3.5) | 581,205 (3.4) | 34,493 (10.1) | |
| Recurrent falls | < 0.001 | |||
| No | 17,614,601 (99.5) | 17,286,919 (99.6) | 327,682 (96.1) | |
| Yes | 80,331 (0.5) | 67,186 (0.4) | 13,145 (3.9) | |
| Chronic imbalance | < 0.001 | |||
| No | 17,503,301 (98.9) | 17,179,777 (99.0) | 323,524 (94.9) | |
| Yes | 191,631 (1.1) | 174,328 (1.0) | 17,303 (5.1) |
Continuous variables are expressed as mean ± standard error of the mean
BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; BUN, blood urea nitrogen; eGFR, estimated glomerular filtration rate
Associated factors
Table 2 Analyzed factors associated with chronic dizziness. Individuals with chronic dizziness were significantly older and had a higher proportion of females compared to those without chronic dizziness. The proportion of individuals with hearing impairment was higher in the chronic dizziness group (26.1%) compared to the control group (12.2%). The chronic dizziness group exhibited poorer kidney function and higher rates of hypertension, anemia, stroke, and cataracts. Furthermore, the prevalence of RA was significantly higher in the chronic dizziness group. After multivariable logistic regression analysis, RA (OR 2.65, 95% CI 1.1–6.34, p = 0.03) emerged as a significant risk factor for chronic dizziness, along with female gender, BMI < 25, hearing impairment, stress, and stroke.
Table 2.
Factors associated with chronic dizziness
| Variable | No dizziness (Weighted n = 17,079,234) |
Chronic dizziness (Weighted n = 615,698) |
p | Univariable analysis | Multivariable analysis | ||
|---|---|---|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | P | ||||
| Age | 56.57 ± 0.32 | 60.06 ± 1.14 | 0.004 | 1.03 (1.01, 1.05) | 0.003 | 1.01 (0.99, 1.04) | 0.321 |
| Sex | < 0.001 | ||||||
| Male | 8,376,222 (49.0) | 199,063 (32.3) | 1.00 | 1.00 | |||
| Female | 8,703,012 (51.0) | 416,635 (67.7) | 2.01 (1.39, 2.93) | < 0.001 | 2.65 (1.6, 4.39) | < 0.001 | |
| Smoking Status | 0.176 | 0.174 | 0.176 | ||||
| Non-smoker | 9,542,272 (55.9) | 393,133 (63.9) | 1.00 | 1.00 | |||
| Ex-smoker | 4,589,057 (26.9) | 120,249 (19.5) | 0.64 (0.39, 1.04) | 0.071 | 1.28 (0.71, 2.3) | 0.411 | |
| Current Smoker | 2,947,905 (17.2) | 102,316 (16.6) | 0.84 (0.51, 1.38) | 0.498 | 1.83 (0.97, 3.47) | 0.064 | |
| Alcohol Consumption | 0.016 | 0.026 | 0.523 | ||||
| Never | 5,103,975 (29.9) | 262,308 (42.6) | 1.00 | 1.00 | |||
| 1 ≤ week | 8,099,525 (47.4) | 238,749 (38.8) | 0.57 (0.38, 0.86) | 0.008 | 0.75 (0.5, 1.14) | 0.178 | |
| 2–3 / week | 2,774,960 (16.3) | 8,1032 (13.1) | 0.57 (0.33, 0.98) | 0.043 | 1 (0.54, 1.85) | 0.995 | |
| 4 ≥ week | 1,100,774 (6.4) | 33,609 (5.5) | 0.59 (0.3, 1.18) | 0.137 | 1 (0.48, 2.1) | 0.998 | |
| BMI (kg/m²) | 0.003 | 0.004 | 0.019 | ||||
| BMI < 25 | 10,274,382 (60.2) | 454,796 (73.9) | 1.00 | . | 1.00 | ||
| ≥ 25 | 6,804,852 (39.8) | 160,902 (26.1) | 0.53 (0.35, 0.82) | 0.62 (0.42, 0.92) | |||
| Uric Acid (mg/dL) | 5.1 ± 0.02 | 4.88 ± 0.13 | 0.117 | 0.88 (0.75, 1.04) | 0.131 | 1 (0.84, 1.19) | 0.970 |
| eGFR (mL/min/1.73 m²) | 88.51 ± 0.42 | 84.75 ± 1.41 | 0.009 | 0.99 (0.98, 1) | 0.009 | 0.99 (0.98, 1) | 0.081 |
| Tympanic Disease | 0.107 | 0.111 | 0.451 | ||||
| No | 16,051,610 (94.0) | 559,181 (90.8) | 1.00 | 1.00 | |||
| Yes | 1,027,624 (6.0) | 56,517 (9.2) | 1.58 (0.9, 2.76) | 1.25 (0.7, 2.23) | |||
| Hearing Impairment | < 0.001 | < 0.001 | < 0.001 | ||||
| No | 14,990,504 (87.8) | 455,080 (73.9) | 1.00 | . | 1.00 | ||
| Yes | 2,088,730 (12.2) | 160,618 (26.1) | 2.53 (1.76, 3.64) | 2.16 (1.5, 3.13) | |||
| Stress | 0.004 | 0.005 | < 0.001 | ||||
| No | 2,651,081 (15.5) | 51,590 (8.4) | 1.00 | 1.00 | |||
| Yes | 14,428,153 (84.5) | 564,108 (91.6) | 2.01 (1.23, 3.27) | 2.67 (1.61, 4.42) | |||
| Hypertension | 0.027 | 0.016 | 0.122 | ||||
| Normal | 5,957,748 (34.9) | 253,337 (41.2) | 1.00 | 1.00 | |||
| Pre-Hypertension | 4,749,230 (27.8) | 106,847 (17.3) | 0.53 (0.32, 0.87) | 0.012 | 0.58 (0.35, 0.98) | 0.041 | |
| Hypertension | 6,372,256 (37.3) | 255,514 (41.5) | 0.94 (0.62, 1.43) | 0.781 | 0.82 (0.54, 1.24) | 0.355 | |
| Diabetes | 0.251 | 0.204 | 0.311 | ||||
| Normal | 5,926,026 (34.7) | 225,420 (36.6) | 1.00 | 1.00 | |||
| Pre-Diabetes | 8,027,291 (47.0) | 248,691 (40.4) | 0.81 (0.54, 1.24) | 0.337 | 0.82 (0.53, 1.26) | 0.370 | |
| Diabetes | 3,125,917 (18.3) | 141,587 (23.0) | 1.19 (0.74, 1.93) | 0.477 | 1.17 (0.72, 1.9) | 0.526 | |
| Hypercholesterolemia | 0.453 | 0.455 | 0.946 | ||||
| No | 11,797,562 (69.1) | 405,453 (65.8) | 1.00 | . | 1.00 | ||
| Yes | 5,281,672 (30.9) | 210,245 (34.2) | 1.16 (0.79, 1.7) | 1.01 (0.7, 1.47) | |||
| Stroke | 0.001 | 0.002 | 0.021 | ||||
| No | 16,715,904 (97.9) | 582,624 (94.6) | 1.00 | . | 1.00 | ||
| Yes | 363,330 (2.1) | 33,074 (5.4) | 2.61 (1.41, 4.84) | 2.19 (1.13, 4.27) | |||
| Cataract | 0.012 | 0.013 | 0.516 | ||||
| No | 14,090,004 (82.5) | 458,286 (74.4) | 1.00 | . | 1.00 | ||
| Yes | 2,989,230 (17.5) | 157,412 (25.6) | 1.62 (1.11, 2.37) | 0.85 (0.53, 1.38) | |||
| Anemia | 0.009 | 0.009 | 0.475 | ||||
| No | 15,169,293 (88.8) | 503,186 (81.7) | 1.00 | . | 1.00 | ||
| Yes | 1,909,941 (11.2) | 112,512 (18.3) | 1.78 (1.15, 2.74) | 1.18 (0.75, 1.88) | |||
| Rheumatoid arthritis | 0.005 | 0.008 | 0.030 | ||||
| No | 16,772,900 (98.2) | 581,205 (94.4) | 1.00 | 1.00 | |||
| Yes | 306,334 (1.8) | 34,493 (5.6) | 3.25 (1.36, 7.79) | 2.65 (1.1, 6.34) | |||
BMI, body mass index; eGFR, estimated glomerular filtration rate
Table 3 Analyzed factors associated with recurrent falls. Similar to the chronic dizziness group, individuals in the recurrent fall group were significantly older and had a higher proportion of females compared to those without recurrent falls. The recurrent fall group exhibited significantly higher prevalence rates of tympanic disease and hearing impairment. Furthermore, diagnoses of stroke, cataracts, anemia, and RA were significantly more prevalent in the recurrent fall group than in the non-recurrent fall group. In the multivariable analysis, RA (OR 8.29, 95% CI 2.79–24.67, p = 0.0002) emerged as a significant factor for recurrent falls, alongside being female and having hearing impairment.
Table 3.
Factors associated with recurrent falls
| Variable | No falls (Weighted n = 17,614,601) |
Recurrent falls (Weighted n = 80,331) |
p | Univariable analysis | Multivariable analysis | ||
|---|---|---|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | P | ||||
| Age | 56.65 ± 0.31 | 66.02 ± 1.88 | < 0.001 | 1.08 (1.04, 1.12) | < 0.001 | 1.03 (0.98, 1.08) | 0.274 |
| Sex | 0.001 | 0.002 | 0.006 | ||||
| Male | 8,558,787 (48.6) | 16,498 (20.5) | 1.00 | . | 1.00 | ||
| Female | 9,055,814 (51.4) | 63,833 (79.5) | 3.66 (1.59, 8.39) | 5.72 (1.66, 19.68) | |||
| Smoking Status | 0.103 | 0.084 | 0.360 | ||||
| Non-smoker | 9,876,833 (56.1) | 58,572 (72.9) | 1.00 | 1.00 | |||
| Ex-smoker | 4,700,167 (26.7) | 9,139 (11.4) | 0.33 (0.12, 0.88) | 0.027 | 0.89 (0.35, 2.3) | 0.816 | |
| Current Smoker | 3,037,601 (17.2) | 12,620 (15.7) | 0.7 (0.24, 2) | 0.507 | 2.32 (0.65, 8.33) | 0.197 | |
| Alcohol Consumption | 0.025 | 0.023 | 0.180 | ||||
| Never | 5,322,141 (30.2) | 44,141 (55.0) | 1.00 | 1.00 | |||
| 1 ≤ week | 8,319,314 (47.2) | 18,960 (23.6) | 0.27 (0.12, 0.62) | 0.002 | 0.51 (0.2, 1.33) | 0.168 | |
| 2–3 / week | 2,842,726 (16.2) | 13,266 (16.5) | 0.56 (0.19, 1.66) | 0.299 | 2.52 (0.68, 9.4) | 0.170 | |
| 4 ≥ week | 1,130,420 (6.4) | 3,964 (4.9) | 0.42 (0.07, 2.54) | 0.347 | 1.34 (0.24, 7.56) | 0.741 | |
| BMI (kg/m²) | 0.094 | 0.102 | 0.244 | ||||
| BMI < 25 | 10,668,821 (60.6) | 60,357 (75.1) | 1.00 | . | 1.00 | ||
| ≥ 25 | 6,945,780 (39.4) | 19,974 (24.9) | 0.51 (0.23, 1.14) | 0.59 (0.24, 1.43) | |||
| Uric Acid (mg/dL) | 5.1 ± 0.02 | 4.94 ± 0.15 | 0.603 | 0.91 (0.64, 1.3) | 0.614 | 1.1 (0.73, 1.65) | 0.657 |
| eGFR (mL/min/1.73 m²) | 88.42 ± 0.41 | 81.27 ± 2.66 | 0.109 | 0.98 (0.95, 1) | 0.096 | 1 (0.97, 1.02) | 0.707 |
| Tympanic Disease | 0.018 | 0.026 | 0.239 | ||||
| No | 16,543,953 (93.9) | 66,837 (83.2) | 1.00 | 1.00 | |||
| Yes | 1,070,648 (6.1) | 13,494 (16.8) | 3.12 (1.15, 8.47) | 1.91 (0.65, 5.6) | |||
| Hearing Impairment | < 0.001 | < 0.001 | 0.027 | ||||
| No | 15,401,139 (87.4) | 44,445 (55.3) | 1.00 | 1.00 | |||
| Yes | 2,213,462 (12.6) | 35,886 (44.7) | 5.62 (2.53, 12.48) | 3.03 (1.14, 8.07) | |||
| Stress | 0.331 | < 0.001 | 0.780 | ||||
| No | 2,685,264 (15.2) | 17,407 (21.7) | 1.00 | 1.00 | |||
| Yes | 14,929,337 (84.8) | 62,924 (78.3) | 10.32 (3.69, 28.84) | 1.14 (0.45, 2.88) | |||
| Hypertension | 0.639 | 0.598 | 0.445 | ||||
| Normal | 6,181,540 (35.1) | 29,545 (36.8) | 1.00 | 1.00 | |||
| Pre-hypertension | 4,840,135 (27.5) | 15,942 (19.8) | 0.69 (0.25, 1.87) | 0.465 | 0.59 (0.20, 1.78) | 0.354 | |
| Hypertension | 6,592,926 (37.4) | 34,844 (43.4) | 1.11 (0.46, 2.66) | 0.822 | 0.57 (0.23, 1.45) | 0.237 | |
| Diabetes | 0.141 | 0.150 | 0.296 | ||||
| Normal | 6,134,837 (34.8) | 16,609 (20.7) | 1.00 | . | 1.00 | ||
| Pre-diabetes | 8,236,094 (46.8) | 39,887 (49.6) | 1.79 (0.70, 4.58) | 0.227 | 1.78 (0.61, 5.21) | 0.295 | |
| Diabetes | 3,243,670 (18.4) | 23,835 (29.7) | 2.71 (1.00, 7.37) | 0.051 | 2.3 (0.80, 6.61) | 0.122 | |
| Hypercholesterolemia | 0.566 | 0.567 | 0.649 | ||||
| No | 12,151,481 (69.0) | 51,534 (64.2) | 1.00 | 1.00 | |||
| Yes | 5,463,120 (31.0) | 28,797 (35.8) | 1.24 (0.59, 2.62) | 0.82 (0.35, 1.91) | |||
| Stroke | 0.001 | < 0.001 | 0.204 | ||||
| No | 17,225,937 (97.8) | 72,592 (90.4) | 1.00 | 1.00 | |||
| Yes | 388,664 (2.2) | 7,739 (9.6) | 4.73 (1.66, 13.48) | 2.25 (0.64, 7.89) | |||
| Cataract | < 0.001 | < 0.001 | 0.605 | ||||
| No | 14,505,272 (82.4) | 43,018 (53.5) | 1.00 | 1.00 | |||
| Yes | 3,109,329 (17.6) | 37,313 (46.5) | 4.05 (1.93, 8.50) | 1.29 (0.49, 3.43) | |||
| Anemia | 0.002 | 0.004 | 0.180 | ||||
| No | 15,617,700 (88.7) | 54,779 (68.2) | 1.00 | 1.00 | |||
| Yes | 1,996,901 (11.3) | 25,552 (31.8) | 3.65 (1.52, 8.75) | 1.88 (0.75, 4.70) | |||
| Rheumatoid Arthritis | < 0.001 | < 0.001 | < 0.001 | ||||
| No | 17,286,919 (98.1) | 67,186 (83.6) | 1.00 | 1.00 | |||
| Yes | 327,682 (1.9) | 13,145 (16.4) | 10.32 (3.69, 28.84) | 8.29 (2.79, 24.67) | |||
BMI, body mass index; eGFR, estimated glomerular filtration rate
Table 4 Examined factors associated with chronic imbalance. The chronic imbalance group was older and had a higher proportion of females. Additionally, prevalence rates of hearing impairment, hypertension, stroke, cataracts, and RA were significantly higher in the chronic imbalance group compared to controls. In the multivariable analysis, being female, smoking, hearing impairment, and hypertension were significantly linked to chronic dizziness. Furthermore, RA (OR 3.43, 95% CI 1.22–9.6, p = 0.0201) was also identified as a risk factor for chronic imbalance.
Table 4.
Factors associated with chronic imbalance
| Variable | No Imbalance (Weighted n = 17,503,301) |
Chronic Imbalance (Weighted n = 191,631) |
p | Univariable | Multivariable | ||
|---|---|---|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | P | ||||
| Age | 56.63 ± 0.32 | 62.57 ± 2.33 | 0.011 | 1.05 (1.01, 1.08) | 0.010 | 1 (0.96, 1.05) | 0.924 |
| Sex | 0.054 | 0.060 | |||||
| Male | 8,512,587 (48.6) | 62,699 (32.7) | 1.00 | 1.00 | |||
| Female | 8,990,714 (51.4) | 128,932 (67.3) | 1.95 (0.98, 3.89) | 7.31 (3.05, 17.53) | < 0.001 | ||
| Smoking Status | 0.879 | 0.879 | < 0.001 | ||||
| Non-smoker | 9,832,744 (56.2) | 102,662 (53.6) | 1.00 | . | 1.00 | ||
| Ex-smoker | 4,659,460 (26.6) | 49,846 (26.0) | 1.02 (0.48, 2.17) | 0.949 | 4.08 (1.79, 9.3) | < 0.001 | |
| Current Smoker | 3,011,097 (17.2) | 39,123 (20.4) | 1.24 (0.53, 2.9) | 0.612 | 5.86 (1.82, 18.82) | 0.003 | |
| Alcohol Consumption | 0.547 | 0.529 | 0.973 | ||||
| Never | 5,289,152 (30.2) | 77,131 (40.3) | 1.00 | . | 1.00 | ||
| 1 ≤ week | 8,262,562 (47.2) | 75,711 (39.5) | 0.63 (0.31, 1.26) | 0.194 | 0.87 (0.48, 1.58) | 0.644 | |
| 2–3 / week | 2,828,346 (16.6) | 27,647 (14.4) | 0.67 (0.29, 1.57) | 0.358 | 0.97 (0.32, 2.95) | 0.950 | |
| 4 ≥ week | 1,123,241 (6.4) | 11,142 (5.8) | 0.68 (0.17, 2.77) | 0.591 | 0.78 (0.18, 3.36) | 0.739 | |
| BMI (kg/m²) | 0.288 | 0.291 | 0.121 | ||||
| BMI < 25 | 10,597,328 (60.5) | 131,849 (68.8) | 1.00 | 1.00 | |||
| ≥ 25 | 6,905,973 (39.5) | 59,782 (31.2) | 0.7 (0.36, 1.36) | 0.65 (0.37, 1.12) | |||
| Uric Acid (mg/dL) | 5.1 ± 0.02 | 5.0 ± 0.23 | 0.710 | 0.95 (0.71, 1.26) | 0.715 | 1.08 (0.81, 1.43) | 0.599 |
| eGFR (mL/min/1.73 m²) | 88.43 ± 0.41 | 84.15 ± 2.55 | 0.087 | 0.99 (0.97, 1) | 0.085 | 1 (0.98, 1.02) | 0.689 |
| Stress | 0.406 | 0.411 | 0.078 | ||||
| No | 2,680,590 (15.3) | 22,081 (11.52) | 1.00 | 1.00 | |||
| Yes | 14,822,711 (84.7) | 169,550 (88.5) | 1.39 (0.64, 3.03) | 2.04 (0.93, 4.48) | |||
| Tympanic Disease | 0.136 | 0.145 | 0.547 | ||||
| No | 16,439,906 (93.9) | 170,885 (89.2) | 1.00 | 1.00 | |||
| Yes | 1,063,395 (6.1) | 20,746 (10.8) | 1.88 (0.81, 4.37) | 1.29 (0.56, 3.00) | |||
| Hearing Impairment | < 0.001 | < 0.001 | < 0.001 | ||||
| No | 15,323,014 (87.5) | 122,570 (64.0) | 1.00 | 1.00 | |||
| Yes | 2,180,287 (12.5) | 69,061 (36.0) | 3.96 (2.12, 7.41) | 3.28 (1.91, 5.64) | |||
| Hypertension | 0.020 | 0.049 | 0.032 | ||||
| Normal | 6,181,979 (35.3) | 29,105 (15.2) | 1.00 | 1.00 | |||
| Pre-hypertension | 4,784,468 (27.3) | 71,609 (37.4) | 3.18 (1.22, 8.27) | 0.018 | 4.1 (1.43, 11.73) | 0.009 | |
| Hypertension | 6,536,854 (37.4) | 90,917 (47.4) | 2.95 (1.18, 7.41) | 0.022 | 2.61 (1, 6.78) | 0.050 | |
| Diabetes | 0.0850 | 0.051 | 0.086 | ||||
| Normal | 6,087,450 (34.8) | 63,996 (33.4) | 1.00 | 1.00 | |||
| Pre-diabetes | 8,207,696 (46.9) | 68,286 (35.6) | 0.79 (0.39, 1.61) | 0.519 | 0.63 (0.31, 1.30) | 0.212 | |
| Diabetes | 3,208,155 (18.3) | 59,349 (31.0) | 1.76 (0.76, 4.08) | 0.189 | 1.37 (0.64, 2.93) | 0.422 | |
| Hypercholesterolemia | 0.338 | 0.342 | 0.842 | ||||
| No | 12,086,919 (69.1) | 116,096 (60.6) | 1.00 | 1.00 | |||
| Yes | 5,416,382 (30.9) | 75,535 (39.4) | 1.45 (0.67, 3.13) | 1.08 (0.52, 2.24) | |||
| Stroke | < 0.001 | 0.002 | 0.132 | ||||
| No | 17,123,016 (97.8) | 175,513 (91.6) | 1.00 | 1.00 | |||
| Yes | 380,285 (2.2) | 16,118 (8.4) | 4.14 (1.67, 10.25) | 2.42 (0.77, 7.64) | |||
| Cataract | < 0.001 | < 0.001 | 0.146 | ||||
| No | 14,432,905 (82.5) | 115,384 (60.2) | 1.00 | 1.00 | |||
| Yes | 3,070,396 (17.5) | 76,247 (39.8) | 3.11 (1.89, 5.12) | 1.63 (0.84, 3.15) | |||
| Anemia | 0.377 | 0.380 | 0.655 | ||||
| No | 15,510,114 (88.6) | 162,365 (84.7) | 1.00 | 1.00 | |||
| Yes | 1,993,187 (11.4) | 29,266 (15.3) | 1.4 (0.66, 2.98) | 0.84 (0.39, 1.81) | |||
| Rheumatoid Arthritis | < 0.001 | < 0.001 | 0.020 | ||||
| No | 17,179,776 (98.15) | 174,328 (90.97) | 1.00 | 1.00 | |||
| Yes | 323,525 (1.85) | 17,303 (9.03) | 5.27 (2.14, 12.98) | 3.43 (1.22, 9.60) | |||
BMI, body mass index; eGFR, estimated glomerular filtration rate
Discussion
Using data from the 2019–2020 KNHANES for individuals aged 40 years or older, this study has shown that rheumatoid arthritis (RA) is significantly associated with chronic dizziness, recurrent falls, and chronic imbalance. The novelty of our study lies in its examination of RA as a contributing factor to these chronic balance-related symptoms in the general population, considering various risk factors. Our results reveal that the prevalence rates of these chronic balance-related symptoms in individuals with RA are 10.1%, 3.9%, and 5.1%, respectively.
These chronic balance-related symptoms in RA can be attributed to vestibular dysfunction and arthritis. A recent study investigates the impact of RA on postural balance related to vestibular function, revealing significant dysfunctional patterns in these patients compared to healthy controls [12, 13]. Analyzing Vestibular Evoked Myogenic Potentials (VEMP) results, several studies have reported that autoimmune rheumatic disease leads to otolith dysfunction in patients with RA [12–14]. Additionally, Elbeltagy et al. reported the absence of spontaneous gaze-evoked positional nystagmus and positioning nystagmus, which suggests the absence of acute vestibular disease and therefore, implies that the vestibular dysfunction observed in their study may be linked with the chronic inflammatory process of RA. Yilmaz et al. similarly report normal saccade velocity, accuracy, and latency in oculomotor tests, alongside abnormal results in caloric tests for RA patients [4]. Therefore, it appears that RA patients may experience vestibular dysfunction associated with the chronic inflammatory process of RA.
Secondly, the prominent clinical manifestations of RA, such as arthritis, contribute to these chronic balance-related symptoms. The pathological changes in the synovial tissue of peripheral joints such as hands and feet in RA may affect postural balance due to musculoskeletal impairment. Previous studies have demonstrated that RA leads to significant changes in posture because it causes a larger center of pressure excursion during quiet standing [15–17]. Lorenzis et al. evaluated the association between early RA patients and postural control using a sensory organization test, which objectively evaluates the contribution of various sensory afferences to postural control [17]. They noted that early RA patients exhibited reduced composite equilibrium scores, and lower somatosensory, visual, and vestibular ratios compared to controls. In addition, the presence of ankle arthritis was associated with a reduced somatosensory ratio, consistent with the known contribution of ankle proprioception to postural stability [18] and the effect of ankle involvement on disability and lower extremities function in early RA patients.
Chronic dizziness and imbalance can lead to decreased quality of life, increased mortality, socioeconomic loss, and a higher risk of falls [19, 20]. Previous studies reported fall rates ranging from 27% to 50% [21–25]. In a recent meta-analysis, Guo et al. reported the prevalence and risk factors for falls among adults with RA. Based on data from 34 studies involving 24,123 subjects, the prevalence of falls was 34%, with 16% experiencing recurrent falls [26]. This study found a recurrent fall rate of 3.9% among RA patients, significantly lower than that reported in previous studies. This difference may be due to the varying time frames considered for recurrent falls; this study considered the last three months, while previous studies considered the past year. After adjusting for various confounding factors, this study confirmed that RA is a significant risk factor for recurrent falls. These findings highlight the need for enhanced focus on reducing fall risk in RA patients. Significant risk factors for falls include swollen and tender lower extremity joints, use of psychotropic medications, antihypertensives and/or diuretics, taking four or more medications, history of falls and fractures, use of walking aids, dizziness, fatigue, and disease activity in RA [21–23, 26]. Given that RA is a chronic and progressive disease, managing modifiable risk factors such as disease activity and medication use is crucial for preventing falls in RA patients.
In this study, we found that these chronic balance-related symptoms significantly increase with female sex and hearing impairment alongside RA. Numerous studies indicate a female predominance that contributes to dizziness and recurrent falls [27–30]. This female predominance corresponds with a higher incidence of various vertiginous diseases in females and relatively low muscle volume and strength. In females, the increased presence of various vertiginous diseases might be associated with migraines, which are linked both to female sex and specific vestibular diagnoses such as migrainous vertigo [31], Ménière disease [32], and benign paroxysmal positional vertigo [33], as well as unclassified recurrent vestibulopathy [34, 35]. Furthermore, reduced muscle volume and strength may impact balance mechanisms. Proprioception, a key sensory input for balance, relates to muscle mass and strength. Hence, the lower muscle mass or strength typically found in females may explain why these chronic balance-related symptoms are associated with the female sex [36].
The other associated factor, hearing impairment, may be influenced by the structural proximity of the auditory and vestibular systems within the inner ear. Various otologic diseases such as chronic otitis media [37], Ménière disease [38], sudden sensorineural hearing loss [39], autoimmune inner ear diseases [40], or vestibular schwannoma [41] can impact the structures of the inner ear, potentially causing both dizziness and hearing impairment. Therefore, it is reasonable to associate these chronic balance-related symptoms with hearing impairment.
Stress was also identified as an independent factor associated with chronic dizziness. Elevated stress levels are known to influence the central processing of sensory and balance information, potentially altering neural integration involved in spatial orientation and postural control [42, 43]. Prior studies support that heightened stress responses can increase susceptibility to dizziness. Our epidemiological findings, therefore, underscore the clinical importance of considering psychological and emotional factors when evaluating dizziness in individuals with RA.
This study had several limitations. First, RA was defined based on patient-reported doctor diagnoses from a survey, rather than specific criteria. Although the standardized survey format provides a reasonable estimation of current disease status, the absence of clinical or laboratory verification introduces some diagnostic uncertainty. In addition, disease severity or the degree of RA control may also be important determinants, yet our dataset did not allow for their evaluation. Second, verifying the clear causal relationships between all three outcomes and other associated factors is challenging in a nationwide cross-sectional study. Third, we could not evaluate one of the most important factors, the function of the vestibular system. In this nationwide survey conducted during 2019–2020, no tests for evaluating the vestibular system were included. This omission might affect the significant association of hearing impairment, which can be used to infer vestibular function, as previously mentioned. Furthermore, data on neurological or musculoskeletal comorbidities and relevant medications that could influence vestibular function, such as peripheral neuropathy, osteoarthritis, or corticosteroid and psychotropic use, was not available in the dataset, and these unmeasured factors may have acted as potential confounders. In addition, we collected data on these chronic balance-related symptoms through self-reported questionnaires, which are inherently susceptible to recall and perception bias. Such bias may lead to differential misclassification of these outcomes, necessitating caution when interpreting the observed associations, even though stress was included as a potential related factor. Nevertheless, the findings may still offer meaningful insight into the broader spectrum of extra-articular manifestations in RA, particularly regarding chronic dizziness, recurrent falls, and balance impairment. Therefore, further validation studies including detailed vestibular function and dizziness/balance assessment are needed.
In summary, this study evaluates the association between RA and vestibular symptoms, including dizziness, recurrent falls, and chronic imbalance by utilizing nationwide survey data. Our results highlight the importance of addressing the increased risks of falls and dizziness in patients with RA.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to thank Sun-Young Baek for her excellent statistical assistance.
Author contributions
H.J., C.-H.J. and Y.-S.C. designed the study; H.J. and Y.-S.C. analyzed the data and wrote the manuscript; C.-H.J. revised the manuscript. All authors interpreted the results, commented on the draft manuscript, and approved the final manuscript. All authors have read and agreed to the published version of the manuscript.
Funding
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2021R1G1A1094093). This study was also supported by the Soonchunhyang University Research Fund.
Data availability
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This research was conducted in accordance with the Declaration of Helsinki and relevant institutional guidelines and regulations. This study received approval from the Institutional Review Board of Soonchunhyang University Hospital (IRB No. 2024-09-005). Informed consent was obtained from all participants prior to the survey.
Consent for publication
Not applicable.
Patient and public involvement
Neither patients nor the public were involved in the design, conduct, reporting, or planning for the dissemination of the research.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.