Awareness and Knowledge of Vestibular Dysfunction among Individuals with Diabetes Mellitus: A Cross-sectional Study

1. Undergraduate Student (BPTh), Department of Physiotherapy, K.J. Somaiya College of Physiotherapy, Mumbai, Maharashtra, India. 2. Associate Professor, Department of Cardiovascular and Respiratory Physiotherapy, K.J. Somaiya College of Physiotherapy, Mumbai, Maharashtra, India.

Abstract

Introduction: Vestibular dysfunction is a debilitating yet under-recognised complication of Diabetes Mellitus (DM) that significantly elevates fall risk and diminishes quality of life. Clinical studies demonstrate a significant prevalence of vestibular impairment in diabetic populations; however, there is a notable deficiency of data concerning patient awareness of this relationship. Understanding this awareness gap is essential to justify the integration of vestibular screening into standard diabetes care and to develop targeted educational interventions that promote early diagnosis.

Aim: To assess awareness and knowledge regarding vestibular dysfunction among individuals with chronic Diabetes Mellitus (DM) Type 1 (T1DM) and Type 2 DM (T2DM) using a validated questionnaire.

Materials and Methods: This community-based cross-sectional observational study, was conducted in association with KJ Somaiya College of Physiotherapy, Mumbai, Maharashtra, India, from March 2025 to August 2025, involving 150 individuals aged 30 to 60 years. Participants were recruited using convenience sampling from KJ Somaiya Hospital (OPD and IPD) and residential communities in East Mumbai, Maharashtra, India. A validated questionnaire was used to collect data on the levels of awareness and knowledge of vestibular dysfunction in patients with DM. Microsoft Excel was used to perform descriptive statistics, and results were represented using tables and bar graphs.

Results: Only 23 of the 150 participants (15.3%) were aware that diabetes may contribute to vestibular impairment. While 79 (52.7%) participants understood that dizziness is not solely attributable to hypotension or hypoglycaemia, familiarity with specific vestibular terminology was limited. Vertigo was recognised by 92 (61.3%) participants, whereas nystagmus was recognised by only 17 (11.3%). While 108 (72.0%) recognised that glycaemic control could alleviate symptoms, only 54 (36.0%) were aware of physiotherapy-based Vestibular Rehabilitation (VR). A higher level of education was significantly associated with increased awareness and knowledge scores.

Conclusion: There is a substantial gap in patient awareness regarding the vestibular complications of diabetes. Awareness and knowledge levels were associated with educational status. Early screening, physiotherapy-based interventions and the integration of vestibular health education into diabetes care may reduce fall risk and improve quality of life.

Balance disorders, Diabetes complications, Fall risk, Physiotherapy intervention, Postural instability

DM is a metabolic disorder marked by increased blood glucose levels. T1DM accounts for less than 10% of cases and entails autoimmune destruction of β-cells. T2DM accounts for 90% of cases, characterised by insulin resistance and β-cell failure (1). In 2021, the global prevalence of diabetes was estimated at 537 million, with projections indicating an increase to 643 million cases by 2030. India, which ranks second worldwide in DM prevalence, had an estimated 74.9 million cases in 2021, projected to increase to 124.9 million cases by 2045 (2),(3).

Microvascular and neuropathic complications of diabetes, including retinopathy and peripheral neuropathy, are well known in clinical practice and significantly contribute to postural instability (4). In contrast, vestibular dysfunction is a less recognised secondary complication that is often overlooked during routine diabetes assessments (5). Altered peripheral vestibular function, influenced by varying glucose and insulin levels, may present as particular conditions, including Benign Paroxysmal Positional Vertigo (BPPV) (6).

Recent evidence suggests that chronic hyperglycaemia and the accumulation of Advanced Glycation End-products (AGEs) are associated with structural changes in the inner ear, including hair cell loss and saccular degeneration (7),(8). These pathological changes may present clinically as dizziness and postural instability, increasing the risk of falls. Although studies have reported that objective vestibular impairment may affect up to 84% of individuals with diabetes, awareness of these complications remains relatively low (9). As a result, patients may not seek specialised treatments, such as VR, or focus on glycaemic control for maintaining balance and postural stability.

Research studies have reported a high incidence of Vestibular Disorders (VD) in individuals with DM using various vestibular assessment methods, including cervical and ocular Vestibular Evoked Myogenic Potentials (cVEMP/oVEMP), bithermal caloric testing and Dix-Hallpike manoeuvre (9),(10),(11),(12),(13),(14).

The reported prevalence of VD in individuals with T2DM varies considerably across studies, likely due to differences in the diagnostic methodologies employed. However, when a thorough battery of objective tests is used, the detection rate for vestibular impairment has been reported to reach as high as 84% (9).

A study assessed vestibular function in asymptomatic patients with T1DM and healthy controls using the Subjective Visual Vertical and Horizontal (SVV/SVH), oVEMP/cVEMP and video Head Impulse Test (vHIT). Pathological vHIT responses were observed in 6.66% of the semicircular canals. In the diabetic group, cVEMP testing showed significantly smaller peak-to-peak P1-N1 amplitudes in the left ear, while oVEMP testing demonstrated prolonged P1 latencies bilaterally. Additionally, the mean deviation of dynamic SVV was significantly increased, suggesting subclinical otolith organ dysfunction (15).

While vestibular impairment is common among individuals with diabetes (9),(10),(11),(12),(13), awareness of these complications remains limited. Many patients remain unaware that blood glucose levels may influence their balance and vestibular function. As a result, the potential significance of glycaemic control and specialised interventions like vestibular physiotherapy remains under-recognised. In India, patient awareness of this association is still largely unexplored despite growing evidence.

The present study addresses an important gap by focusing on specific patient knowledge deficits, particularly with respect to physiotherapy-based rehabilitation, rather than on prevalence. It adds to the limited Indian literature by assessing awareness among individuals with chronic T1DM and T2DM. Understanding this baseline level of awareness is an important first step toward integrating vestibular health into routine diabetes care, which may help reduce fall-related morbidity. Hence, the study aimed to assess awareness and knowledge regarding vestibular impairment among individuals with chronic T1DM and T2DM using a validated questionnaire.

Material and Methods

This community-based cross-sectional observational study, was conducted in association with KJ Somaiya College of Physiotherapy, Mumbai, Maharashtra, India, from March 2025 to August 2025. Participants were recruited from various locations, including the Outpatient and Inpatient Departments (OPD and IPD) of KJ Somaiya Hospital and residential communities throughout East Mumbai, to ensure a representative sample. Data collection took place till period of six months, until the desired sample size of 150 participants was reached. Ethical approval was obtained from the Institutional Ethics Committee (IEC Approval No.: (KJSCPT/457a/24-25). Written informed consent was obtained from all participants before data collection.

Sample size calculation: A total of 150 participants (aged 30–60 years) with a diagnosis of T1DM and T2DM for more than 5 years were recruited using convenience sampling. The sample size was calculated using the formula:

where Z=1.96 corresponds to a 95% confidence level p, presents the prevalence, q=1 - p, and d denotes the allowable error. Based on previously published literature (9), a prevalence (p) of 84% was considered. With a precision (d) of 6%, the sample size was calculated as follows:

The sample size was rounded up, and a total of 150 participants were recruited to compensate for potential incomplete responses and to ensure adequate descriptive analysis. Convenience sampling was used to recruit participants, and they were then screened based on the inclusion criteria. Before participating, participants gave their informed consent. All identifying information was coded, and the data were preserved securely to maintain confidentiality. Efforts were taken to ensure patients’ comfort for accurate and unbiased responses.

Inclusion criteria:

• Diagnosed with DM (Type 1 and 2) for a minimum of five years;

• Age between 30 and 60 years. (Note: This age range was chosen to target the adult population most likely to experience the functional impact of vestibular-related balance issues on daily activities and employment);

• Participants who provided written informed consent.

Exclusion criteria: Individuals not willing to participate in the study;

• Cognitive impairment: Individuals with known cognitive deficits or those unable to comprehend the questionnaire;

• Pre-existing neurological conditions: Patients with a history of stroke, Parkinson’s disease, multiple sclerosis, or other central nervous system disorders that independently cause balance issues or cognitive slowing;

• Known non diabetic vestibular pathology: Individuals with a history of ear surgery, recent head trauma, or VDs diagnosed prior to the onset of diabetes.

Study Procedure

After getting approval from the Institution, people with diabetes were enrolled based on the inclusion criteria through the hospital’s OPD and IPD, as well as door-to-door visits in the community.

Before giving out the questionnaires, each participant received a standardised individual orientation in simplified terms to ensure the consistency of responses. In this one-on-one session, the term “vestibular dysfunction” was explained in simple terms as a “balance system disorder in the inner ear that causes dizziness or unsteadiness”. This made sure that participants understood the concepts while also reducing group answer bias. After the briefing, the primary investigator administered the 11-item questionnaire in a consistent manner. The average duration of each interview was approximately 10 minutes. Responses were recorded and tabulated for statistical analysis.

A structured questionnaire in English was created to assess awareness (recognition of vestibular dysfunction and its association with diabetes) and knowledge (clinical features and management strategies). A panel of senior experts from the musculoskeletal, cardiopulmonary and neurophysiotherapy departments evaluated each item on a 4-point relevance scale to determine content validity.

Each question’s Item-Level Content Validity Index (I-CVI) was calculated, and the Scale-Level Content Validity Index (S-CVI/Ave) was 0.95, indicating excellent overall content validity (Table/Fig 1).

The internal consistency of the 11-item questionnaire was statistically evaluated using Cronbach’s alpha coefficient, yielding a value of 0.7. This indicates acceptable reliability and suggests that the items consistently measure the intended levels of awareness and knowledge. In addition, responses obtained during the pilot phase were consistent across repeated administrations, indicating stability of the instrument.

To ensure conceptual equivalence between the Hindi and English versions, the questionnaire was translated into Hindi using a forward-backward translation procedure. A pilot study was conducted on 15 participants (10% of the sample size) to assess face validity and linguistic clarity. Feedback from the pilot phase indicated that the questionnaire items were easily understood by lay persons and were suitable for administration to the larger study population.

The questionnaire had 11 items, including four awareness-related and seven knowledge-related questions. Awareness questions assessed the recognition of symptoms such as dizziness, imbalance and as well the possible connection with inner ear involvement in diabetes. Knowledge questions assessed the participants’ understanding of the vestibular system, associated symptoms, clinical terms (such as vertigo and nystagmus), diabetes-related receptor degeneration, VR exercises, and the role of glycaemic control in symptom management.

All items had “Yes/No/Maybe” response options. The questionnaire was scored using a binary system to quantify the levels of awareness and knowledge. A score of one was given for ‘Yes’ (indicating correct awareness and knowledge), while a score of zero was assigned for ‘No’ and ‘Maybe’ responses. “Maybe” responses were treated as incorrect because they indicated uncertainty rather than a clear understanding of the concept being evaluated. The maximum attainable score for the awareness section was four and for the knowledge section was seven. Total scores were then converted into percentages for descriptive analysis.

A composite score was obtained through the combination of the scores for awareness and knowledge. The maximum possible score was 11. Based on their total score, participants were categorised into groups of high and low awareness and knowledge. A score of 6 or higher was considered as indicative of high level of knowledge and awareness, while a score of less than 6 was considered as low. This categorisation was implemented for Chi-square tests.

For the present study, awareness was defined as the participants’ capacity to recognise or acknowledge the potential for VD and its correlation with diabetes, as reflected by their responses to the questionnaire items.

Both versions of the questionnaire are given in [ANNEXURE 1].

STATISTICAL ANALYSIS

Descriptive and inferential statistics were used to analyse the data. Categorical variables were summarised as frequencies and percentages {n (%)}. The internal consistency of the questionnaire was assessed using Cronbach’s alpha coefficient. For inferential statistical analysis, age was regrouped into two categories (≤45 years and >45 years) for Chi-square testing. The Chi-square (χ2) test was used to examine the association between demographic variables (age and educational level) and awareness and knowledge score categories. A p-value<0.05 was considered statistically significant.

Results

The study included 150 people who had diabetes. The overall mean age of the participants was 52.0±6.57 years, and most of them, 94 (62.7%), were between the ages of 51 and 60. The majority of participants were diagnosed with T2DM, 138 (92%), whereas a smaller proportion had T1DM, 12 (8%).

There were 83 males (55.3%) and 67 females (44.7%), so the gender distribution was pretty even. In terms of clinical history, most of the people who took part, 120 (80%) had been living with diabetes for 5 to 10 years added comma. A full list of the study population’s demographic and clinical traits is shown (Table/Fig 2).

An evaluation of awareness and knowledge concerning the relationship between diabetes and vestibular dysfunction showed considerable variability across domains. People were unfamiliar with the vestibular system in general.

While 79 (52.7%) of the participants were aware that dizziness and imbalance are not always caused by changes in metabolism like low blood glucose levels, only 55 (36.7%) of them connected these symptoms to structures in the inner ear.

Furthermore, only 23 (15.3%) acknowledged that diabetes might have an impact on these structures. Half of the participants, 75 (50.0%), were aware that short-term increases in blood glucose levels can increase the risk of these symptoms.

In terms of terminology, 92 (61.3%) knew what vertigo meant, but only 17 (11.3%) were familiar with the term ‘nystagmus’. There was also a lack of specific knowledge about complications that can occur due to DM.

Only 39 (26.0%) knew that the vestibular system located behind the eardrum is responsible for balance, and merely 11 (7.3%) understood that diabetes could lead to degeneration of vestibular receptors. Of the participants, 54 (36.0%) were aware of VR services offered in physiotherapy, and 108 (72.0%) acknowledged that glycaemic control could help regulate symptoms. A summary of all responses to the questionnaire is shown in (Table/Fig 3).

The mean percentage scores for the awareness (Q1-Q4) and knowledge (Q5-Q11) domains are shown in (Table/Fig 4). The mean awareness score was 38.7%, while the mean knowledge score was 36.3%, according to a domain-wise comparison. Both domains showed generally low levels of correct responses, indicating a lack of general understanding of vestibular involvement in diabetes even though awareness scores were slightly higher than knowledge scores.

The association between educational level and participants’ awareness and knowledge of the diabetes-VD relationship was analysed using the Chi-square test. A significant association was observed between educational level and high awareness and knowledge score category (χ2=18.47, df=1, p<0.001) Participants with graduate-level education or above had significantly higher odds of obtaining a high score compared to those with lower educational attainment (OR=5.50, 95% CI 2.43-12.48) (Table/Fig 5).

No statistically significant association was observed between awareness and knowledge score category and age group (χ² (1)=1.19, p=0.27). While the younger participants had higher odds of obtaining a high score than older participants, this relationship did not reach statistical significance (OR=1.68, 95% CI 0.66–4.30) (Table/Fig 6).

Discussion

The current study indicates a notable gap between overall diabetes awareness and knowledge concerning vestibular health. Participants showed relatively good awareness of metabolic management strategies; however, their knowledge regarding the physiological relationship between chronic hyperglycaemia and vestibular impairment remained limited. The current study finding that only 23 (15.3%) participants were aware of the relationship between diabetes and VD aligns with previous studies that suggest vestibular complications of diabetes remain under-recognised compared with other diabetic complications (1),(2). This difference in awareness may reflect the traditional clinical focus on retinopathy and nephropathy, while the vestibular involvement in diabetes has received comparatively less attention (5),(6).

A notable knowledge gap was detected concerning the term ‘nystagmus’ (11.3%). In the context of diabetic vestibulopathy, nystagmus (involuntary, rhythmic eye movements) is a key clinical sign of VD resulting from asymmetry in vestibular input. While the literature has reported a higher prevalence of vestibular impairment in individuals with diabetes than in non-diabetic individuals (9),(10),(11),(12),(13),(14), the present study findings suggest the present study findings suggest that many patients may not recognise these warning signs. One possible explanation is that patients may attribute symptoms of vertigo or imbalance to transient metabolic changes rather than recognising them as possible manifestations of vestibular impairment.

While 108 participants (72.0%) were aware of glycaemic control, only 54 (36.0%) were aware of VR, indicating a significant awareness gap. Participants demonstrated a greater familiarity with biochemical management approaches such as glycaemic control, whereas awareness of rehabilitative strategies aimed at improving balance function remained relatively low.

The Chi-square test showed that education level was significantly associated with awareness and knowledge scores (χ²(1)=18.47, p<0.001) but age was not (χ²(1)=1.19, p=0.27). This finding suggests that people with lower educational attainment may have reduced awareness of vestibular complications associated with diabetes.

These findings support the inclusion of vestibular evaluation as part of routine diabetes care (16),(17),(18). VR, a specialised type of physiotherapy that aims to stabilise gaze and improve postural stability, may help reduce fall-related morbidity (19). However, VR appears to be underutilised, possibly because patients may not recognise balance problems as potential complications of diabetes requiring specialised care. Addressing this lack of awareness may require coordinated interdisciplinary educational efforts involving endocrinologists, physiotherapists and other healthcare professionals involved in diabetes management.

Limitation(s)

The current study highlights the need for greater awareness of vestibular health in patients with DM. The findings should be interpreted with caution due to the limited sample size and the reliance on self-reported questionnaire responses, which may introduce response bias. Furthermore, the standardised individual orientation provided to explain vestibular dysfunction and ensure participant comprehension may have introduced response priming and influenced participants’ knowledge and awareness scores on certain questionnaire items. Future research involving more diverse populations supplemented by objective clinical evaluations may help expand and validate these findings.

Conclusion

The present study identified a significant gap in patient awareness about the vestibular complications associated with diabetes within the Indian population. While participants showed awareness about glycaemic control, the knowledge about the relationship between diabetes and vestibular impairment as well as specialised treatments like VR remained limited.

The significant association between education levels and awareness and knowledge scores highlights the need to have educational programs that use simplified and accessible language. Adding vestibular health screening and patient education to standard diabetes care is important to improve early intervention and reduce the risk of falls in patients with chronic diabetes.

DOI and Others

DOI: 10.7860/JCDR/2026/84739.24405

Date of Submission: Oct 10, 2025
Date of Peer Review: Jan 10, 2026
Date of Acceptance: Jul 11, 2026
Date of Publishing: Sep 01, 2026

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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