Association between vestibular dysfunction and osteoporosis in adults: a systematic review and meta-analysis

Multiple clinical studies have demonstrated that vestibular dysfunctions, such as benign paroxysmal positional vertigo (BPPV) and Meniere's disease (MD), are associated with osteoporosis or osteopenia in adults. Animal studies have also indicated that selective ablation of peripheral vestibular organs leads to reduced bone mineral density in mice, potentially through effects on the sympathetic nervous system. This review systematically evaluates the association between vestibular dysfunction and osteoporosis in adults and reports the prevalence of this comorbidity. We systematically searched PubMed, MEDLINE, EMBASE, the Cochrane Library, Scopus, and Web of Science databases for studies published from January 2000 to December 2025. Two authors independently screened and extracted data. Meta-analyses were performed to compare vestibular function test results between adults with and without osteoporosis and to compare the morbidity of osteoporosis between individuals with and without vestibular dysfunction. A total of 33 studies were included. Among these, 21 case-control studies examined the risk of osteoporosis in adults with vestibular dysfunction, and the remaining cross-sectional/prospective studies reported its prevalence. Findings are presented in four sections. (1) Risk of vestibular dysfunction: osteoporosis vs non-osteoporosis controls: due to moderate heterogeneity persisting after sensitivity analysis (I² = 58%, P = 0.03), 7 studies were analyzed descriptively. Three large-sample studies associated osteoporosis with increased BPPV risk (OR (odds ratio) = 1.77, 95% CI = 1.69-1.86; OR = 1.28, 95%CI = 1.15-1.42; OR = 2.03, 95%CI = 1.52-2.70). One large-sample study showed higher MD history risk in osteoporosis patients (OR = 1.88, 95%CI = 1.76-2.02). Three studies on VEMP abnormalities had very small samples, limiting conclusion reliability. (2) Risk of osteoporosis: vestibular dysfunction vs normal controls: most studies (13 of 16) focused on osteoporosis risk in BPPV patients, 11 of these 13 studies were included in the meta-analysis. Overall heterogeneity was high even after sensitivity analysis (I² = 74%, P < 0.0001). Subgroup analysis of four Chinese studies showed very low heterogeneity (I² = 0%, P = 0.43), with a significantly higher osteoporosis risk in BPPV patients (OR = 3.42, 95% CI = 2.12-5.50, P < 0.00001). Conversely, five Korean studies exhibited high heterogeneity (I² = 94%, P < 0.00001), but each study also reported a significantly increased risk in BPPV patients (OR = 1.65, 95% CI = 1.57-1.73; OR = 8.63, 95% CI = 1.75-42.54; OR = 3.32, 95% CI = 1.78-6.19; OR = 1.26, 95% CI = 1.19-1.33; OR = 5.09, 95% CI = 1.86-13.91). (3) Prevalence of vestibular dysfunction in osteoporosis: due to substantial heterogeneity, a random-effects model was used to pool effect sizes. The prevalence of BPPV in the osteoporotic population was approximately 8.3% (95% CI = 3.8-14.5%; I² = 97%, P < 0.00001); the prevalence of abnormal Romberg test results in the osteoporotic population was 10.7% (95% CI = 2.0-46.8%; I² = 100%, P < 0.00001). (4) Prevalence of osteoporosis in BPPV: using a random-effects model, the pooled prevalence was 17.4% (95%C I = 9.1-31.5%; I² = 96%, P < 0.00001). A close bidirectional association may exist between vestibular dysfunction, particularly BPPV, and osteoporosis in adults. Data from Chinese populations showed robust results with very low heterogeneity. However, due to substantial heterogeneity across most studies and limited sample sizes in some subgroup analyses, these findings should be interpreted with caution. Attention to bone health is recommended in the management of vestibular disorders, especially BPPV. Well-designed prospective studies are warranted to further elucidate causal relationships and underlying mechanisms.