Effects of eccentric rotation on the human pitch vestibulo-ocular reflex.

CONCLUSION: The pitch plane vestibulo-ocular reflex (VOR) gain and symmetry at low frequencies (< or =0.3 Hz) are enhanced by otoliths and/or somatosensory sensory cues during combined angular and linear stimuli. We conclude that neural processing of these linear motion cues is used to improve the VOR when stimulus frequencies are below the optimal range for the canals. OBJECTIVE: The purpose of this study was to examine the effects of eccentric rotation on the passive pitch VOR responses in humans. SUBJECTS AND METHODS: Eleven subjects were placed on their left sides (90 degrees roll position) and rotated in the pitch plane about an earth-vertical axis at 0.13, 0.3, and 0.56 Hz. The inter-aural axis was either aligned with the axis of rotation (no modulation of linear acceleration) or offset from it by 50 cm (centripetal linear acceleration directed feet-ward). The modulation of pitch VOR responses was measured in the dark with a binocular videography system. RESULTS: The pitch VOR gain was significantly increased and the VOR asymmetry was significantly reduced at the lowest stimulus frequencies during eccentric rotation. There was no effect of eccentric rotation on the pitch gain or asymmetry at the highest frequency tested.

Influence of imaginary target on "dumping" of vestibulo-ocular reflexes and postural control.

Two studies explored 1) the effect of instruction set upon the well known "dumping" of the vestibulo-ocular (VOR) post-rotatory nystagmus long time constant (TC) and 2) the effect of imaginary earth-fixed targets on postural control. Imaginary targets do not produce dumping and do not improve postural stability, with or without pitch head movements.

Vestibular prostheses: the engineering and biomedical issues.

Currently available data demonstrate the need for balance prostheses. Recent technological and biomedical advances now make it feasible to produce miniaturized sensors, signal processors, electric stimulators, and stimulating electrodes that are roughly analogous to a cochlear implant but which provide information about self motion, instead of sound. Many areas require work before balance prostheses become a reality. Some of these include: the development of a motion sensor array, the conversion of the sensed motion into physiologically meaningful information, the delivery of the transformed information to the CNS, the training of vestibular deficient individuals to use the prosthesis, and developing methods to evaluate the efficacy of the device. In this "white paper", we consider these issues in the context of prototype baseline prosthetic devices.

What can posturography tell us about vestibular function?

Patients with balance disorders want answers to the following basic questions: (1) What is causing my problem? and (2) What can be done about my problem? Information to fully answer these questions must include status of both sensory and motor components of the balance control systems. Computerized dynamic posturography (CDP) provides quantitative assessment of both sensory and motor components of postural control along with how the sensory inputs to the brain interact. This paper reviews the scientific basis and clinical applications of CDP. Specifically, studies describing the integration of vestibular inputs with other sensory systems for postural control are briefly summarized. Clinical applications, including assessment, rehabilitation, and management are presented. Effects of aging on postural control along with prevention and management strategies are discussed.

Recovery from vestibular ototoxicity.

OBJECTIVE: Determine whether subjects with documented vestibular ototoxicity recover vestibular function and, if so, investigate the recovery dynamics. STUDY DESIGN: Prospective and retrospective reviews and repeated measures. SETTING: Clinical research and technology center. SUBJECTS: Twenty-eight subjects who received vestibulotoxic medications were followed for at least 12 months after initial treatment. CONTROLS: Our subject sample was compared with a published database of normal individuals. INTERVENTIONS: All 28 subjects received systemically administered medications known to be ototoxic. The subjects' treating physicians controlled medication, dosage, and administration schedules. MAIN OUTCOME MEASURES: Tests of horizontal canal vestibulo-ocular function were performed. Subjects' auditory and vestibular symptoms were recorded. RESULTS: Eleven subjects (39%) showed changes in horizontal canal vestibulo-ocular gain constant (GC) and/or time constant (TC) consistent with vestibular ototoxicity. When tested 1 year after ototoxic drug administration, eight of the nine subjects who experienced ototoxic decrease in GC showed a recovery of GC to normal limits. Only one of the eight subjects who experienced ototoxic decrease in TC showed recovery of TC to within normal limits. Ototoxicity onset and recovery were independent of baseline vestibular function, and ototoxicity onset did not correlate with cumulative dose of ototoxic medication. There was no relationship between subjective symptoms and ototoxicity onset. CONCLUSIONS: Recovery of GC after vestibular ototoxicity is more commonly observed than recovery of TC. Because ototoxic changes developed and continued in an unpredictable time and manner in relation to ototoxic drug administration, we propose that once ototoxic changes in vestibulo-ocular reflex are detected, ototoxic medications should be discontinued as soon as possible.

Can imaginary head tilt shorten postrotatory nystagmus?

In healthy subjects, head tilt upon cessation of a constant-velocity yaw head rotation shortens the duration of postrotatory nystagmus. The presumed mechanism for this effect is that the velocity storage of horizontal semicircular canal inputs is being discharged by otolith organ inputs which signal a constant yaw head position when the head longitudinal axis is no longer earth-vertical. In the present study, normal subjects were rotated head upright in the dark on a vertical-axis rotational chair at 60 degrees/s for 75 s and were required to perform a specific task as soon as the chair stopped. Horizontal position of the right eye was recorded with an infra-red video camera. The average eye velocity (AEV) was measured over a 30-s interval following chair acceleration/deceleration. The ratios (postrotatory AEV/perrotatory AEV) were 1.1 (SD 0.112) when subjects (N=10) kept their head erect, 0.414 (SD 0.083) when subjects tilted their head forward, 1.003 (SD 0.108) when subjects imagined watching a TV show, 1.012 (SD 0.074) when subjects imagined looking at a painting on a wall, and 0.995 (SD 0.074) when subjects imagined floating in a prone position on a lake. Thus, while actual head tilt reduced postrotatory nystagmus, the imagination tasks did not have a statistically significant effect on postrotatory nystagmus. Therefore, velocity storage does not appear to be under the influence of cortical neural signals when subjects imagine that they are floating in a prone orientation.

Spatial orientation and balance control changes induced by altered gravitoinertial force vectors.

To better understand the mechanisms of human adaptation to rotating environments, we exposed 19 healthy subjects and 8 vestibular-deficient subjects ("abnormal"; four bilateral and four unilateral lesions) to an interaural centripetal acceleration of 1 g (resultant 45 degrees roll-tilt of 1.4 g) on a 0.8-m-radius centrifuge for periods of 90 min. The subjects sat upright (body z-axis parallel to centrifuge rotation axis) in the dark with head stationary, except during 4 min of every 10 min, when they performed head saccades toward visual targets switched on at 3- to 5-s intervals at random locations (within +/- 30 degrees) in the earth-horizontal plane. Eight of the normal subjects also performed the head saccade protocol in a stationary chair adjusted to a static roll-tilt angle of 45 degrees for 90 min (reproducing the change in orientation but not the magnitude of the gravitoinertial force on the centrifuge). Eye movements, including voluntary saccades directed along perceived earth- and head-referenced planes, were recorded before, during, and immediately after centrifugation. Postural center of pressure (COP) and multisegment body kinematics were also gathered before and within 10 min after centrifugation. Normal subjects overestimated roll-tilt during centrifugation and revealed errors in perception of head-vertical provided by directed saccades. Errors in this perceptual response tended to increase with time and became significant after approximately 30 min. Motion-sickness symptoms caused approximately 25% of normal subjects to limit their head movements during centrifugation and led three normal subjects to stop the test early. Immediately after centrifugation, subjects reported feeling tilted 10 degrees in the opposite direction, which was in agreement with the direction of their earth-referenced directed saccades. Postural COP, segmental body motion amplitude, and hip-sway frequency increased significantly after centrifugation. These postural effects were short-lived, however, with a recovery time of several postural test trials (minutes). There were also asymmetries in the direction of postcentrifugation COP and head tilt which depended on the subject's orientation during the centrifugation adaptation period (left ear or right ear out). The amount of total head movements during centrifugation correlated poorly or inversely with postcentrifugation postural stability, and the most unstable subject made no head movements. There was no decrease in postural stability after static tilt, although these subjects also reported a perceived tilt briefly after return to upright, and they also had COP asymmetries. Abnormal subjects underestimated roll-tilt during centrifugation, and their directed saccades revealed permanent spatial distortions. Bilateral abnormal subjects started out with poor postural control, but showed no postural decrements after centrifugation, while unilateral abnormal subjects had varying degrees of postural decrement, both in their everyday function and as a result of experiencing the centrifugation. In addition, three unilateral, abnormal subjects, who rode twice in opposite orientations, revealed a consistent orthogonal pattern of COP offsets after centrifugation. These results suggest that both orientation and magnitude of the gravitoinertial vector are used by the central nervous system for calibration of multiple orientation systems. A change in the background gravitoinertial force (otolith input) can rapidly initiate postural and perceptual adaptation in several sensorimotor systems, independent of a structured visual surround.

A vestibular phenotype for Waardenburg syndrome?

OBJECTIVE: To investigate vestibular abnormalities in subjects with Waardenburg syndrome. STUDY DESIGN: Retrospective record review. SETTING: Tertiary referral neurotology clinic. SUBJECTS: Twenty-two adult white subjects with clinical diagnosis of Waardenburg syndrome (10 type I and 12 type II). INTERVENTIONS: Evaluation for Waardenburg phenotype, history of vestibular and auditory symptoms, tests of vestibular and auditory function. MAIN OUTCOME MEASURES: Results of phenotyping, results of vestibular and auditory symptom review (history), results of vestibular and auditory function testing. RESULTS: Seventeen subjects were women, and 5 were men. Their ages ranged from 21 to 58 years (mean, 38 years). Sixteen of the 22 subjects sought treatment for vertigo, dizziness, or imbalance. For subjects with vestibular symptoms, the results of vestibuloocular tests (calorics, vestibular autorotation, and/or pseudorandom rotation) were abnormal in 77%, and the results of vestibulospinal function tests (computerized dynamic posturography, EquiTest) were abnormal in 57%, but there were no specific patterns of abnormality. Six had objective sensorineural hearing loss. Thirteen had an elevated summating/action potential (>0.40) on electrocochleography. All subjects except those with severe hearing loss (n = 3) had normal auditory brainstem response results. CONCLUSION: Patients with Waardenburg syndrome may experience primarily vestibular symptoms without hearing loss. Electrocochleography and vestibular function tests appear to be the most sensitive measures of otologic abnormalities in such patients.

Outcome analysis of individualized vestibular rehabilitation protocols.

OBJECTIVE: To determine the outcome of vestibular rehabilitation protocols in subjects with peripheral vestibular disorders compared with normal and abnormal control subjects. STUDY DESIGN: Prospective study using repeated measure, matched control design. Subjects were solicited consecutively according to these criteria: vestibular disorder subjects who had abnormal results of computerized dynamic posturography (CDP) sensory organization tests (SOTs) 5 and 6 and underwent rehabilitation; vestibular disorder subjects who had abnormal results of SOTs 5 and 6 and did not undergo rehabilitation; and normal subjects (normal SOTs). SETTING: Tertiary neurotology clinic. SUBJECTS: Men and women over age 18 with chronic vestibular disorders and chief complaints of unsteadiness, imbalance, and/or motion intolerance, and normal subjects. INTERVENTIONS: Pre- and post-rehabilitation assessment included CDP, vestibular disability, and activities of daily living questionnaires. Individualized rehabilitation plans were designed and implemented to address the subject's specific complaints and functional deficits. Supervised sessions were held at weekly intervals, and self-administered programs were devised for daily home use. MAIN OUTCOME MEASURES: CDP composite and SOT scores, number of falls on CDP, and self-assessment questionnaire results. RESULTS: Subjects who underwent rehabilitation (Group A) showed statistically significant improvements in SOTs, overall composite score, and reduction in falls compared with abnormal (Group B) control groups. Group A's performances after rehabilitation were not significantly different from those of normal subjects (Group C) in SOTs 3 through 6, and close to normal on SOTs 1 and 2. Subjects in Group A also reported statistically significant symptomatic improvement. CONCLUSIONS: Outcome measures of vestibular protocol physical therapy confirmed objective and subjective improvement in subjects with chronic peripheral vestibular disorders. These findings support results reported by other investigators.

Disruption of postural readaptation by inertial stimuli following space flight.

Postural instability (relative to pre-flight) has been observed in all shuttle astronauts studied upon return from orbital missions. Postural stability was more closely examined in four shuttle astronaut subjects before and after an 8 day orbital mission. Results of the pre- and post-flight postural stability studies were compared with a larger (n = 34) study of astronauts returning from shuttle missions of similar duration. Results from both studies indicated that inadequate vestibular feedback was the most significant sensory deficit contributing to the postural instability observed post flight. For two of the four IML-1 astronauts, post-flight postural instability and rate of recovery toward their earth-normal performance matched the performance of the larger sample. However, post-flight postural control in one returning astronaut was substantially below mean performance. This individual, who was within normal limits with respect to postural control before the mission, indicated that recovery to pre-flight postural stability was also interrupted by a post-flight pitch plane rotation test. A similar, though less extreme departure from the mean recovery trajectory was present in another astronaut following the same post-flight rotation test. The pitch plane rotation stimuli included otolith stimuli in the form of both transient tangential and constant centripetal linear acceleration components. We inferred from these findings that adaptation on orbit and re-adaptation on earth involved a change in sensorimotor integration of vestibular signals most likely from the otolith organs.

Time constant of nystagmus slow-phase velocity to yaw-axis rotation as a function of the severity of unilateral caloric paresis.

OBJECTIVE: Complete unilateral loss of vestibular function results in a phase advance (reduced time constant) of the horizontal slow-phase nystagmus response to yaw-axis rotation. The objective of this study was to determine whether partial losses of lateral semicircular canal function would result in proportional reductions in the time constant. SETTING AND STUDY DESIGN: This was a retrospective study of consecutive patients' records at two tertiary referral centers for vestibular disorders. PATIENTS: Four hundred fifty-four patients who presented for evaluation of vertigo or imbalance or both and who were found to have partial or complete unilateral canal paresis on caloric testing. MAIN OUTCOME MEASURES: In 372 patients, the gain and time constant of the horizontal nystagmus response was measured using a 5-second velocity ramp of constant yaw-axis acceleration. Caloric responses to standard bithermal irrigations at 30 degrees and 44 degrees were obtained using an open-loop irrigation system. In a second group of 82 patients, the gain and time constant of the horizontal vestibulo-ocular reflex were measured using a sum-of-sines (pseudorandom) yaw-axis acceleration. The caloric response was measured using a closed-loop system. RESULTS: In both groups, the peak gain of the nystagmus response was independent of the level of the canal paresis. However, the time constant of the response both toward and away from the lesioned side decreased proportionally with increasing canal paresis. CONCLUSION: This result supports the hypothesis that bilateral symmetrical peripheral vestibular input is a necessary condition for the mechanisms or processes underlying normal horizontal slow-phase velocity storage.

Clinical use of three-dimensional video measurements of eye movements.

Noninvasive measurements of three-dimensional eye position can be accurately achieved with video methods. A case study showing the potential clinical benefit of these enhanced measurements is presented along with some thoughts about technological advances, essential for clinical application, that are likely to occur in the next several years.

Computerized dynamic posturography: What have we learned from space?

Computerized dynamic posturography (CDP) has been under development since 1970. Several reviews summarize key basic and clinical research studies and outline important clinical uses of CDP along with research applications. This report summarizes new information about the otolith control of posture obtained from the study of astronauts. The dynamics of recovery of postural control upon return from orbital flight provide insight to the peripheral vestibular and central nervous system components of vestibular compensation. The dynamics of postural compensation should aid the clinician in the diagnosis and management of imbalance of vestibular origin.

Medical investigations and resulting countermeasures in support of 16-day Space Shuttle missions.

Investigations with crew subject participants were flown on over 40 Shuttle missions (STS-32 through STS-73). All Astronauts who flew volunteered to participate in one or more of these studies, resulting in approximately 700 individual performances or data points for the 45 Detailed Supplementary Objectives (DSOs).

What is the minimal vestibular function required for compensation?

Living with an uncompensated, abnormal vestibular system requires oppressive modification of life style and often prevents return to work and activities of daily living. Patients with vestibular abnormalities were studied to determine the minimal residual vestibular function required to achieve compensation. Three groups of patients with (a) complete unilateral loss of vestibular function with normal horizontal canal-vestibulo-ocular (HCVOR) function in the opposite ear, (b) complete unilateral loss with abnormal HCVOR function in the opposite ear, and (c) bilateral reduction of vestibular function from aminoglycoside toxicity underwent vestibuloocular (VOR), optokinetic (OKN), visual-VOR (VVOR), and computerized dynamic posturography (CDP) tests before and after therapeutic procedures. Results suggest that a minimal VOR response amplitude must be present for compensation of VVOR function to occur. The roles of VOR and OKN phase shifts in vestibular compensation are more complicated and require further study. Compensation of vestibulospinal function does not necessarily accompany VOR or VVOR compensation. Ascending and descending vestibular compensatory mechanisms may involve different spatial sensory inputs. Results of these studies have important implications for the diagnosis and treatment of patients with vestibular disorders, including selection and monitoring of patients for therapeutic regimens such as vestibular nerve section and streptomycin therapy.

Preservation of auditory and vestibular function after surgical removal of bilateral vestibular schwannomas in a patient with neurofibromatosis type 2.

The outcome of acoustic neuroma (vestibular schwannoma) surgery continues to improve rapidly. Advances can be attributed to several fields, but the most important contributions have arisen from the identification of the genes responsible for the dominant inheritance of neurofibromatosis types 1 (NF1) and 2 (NF2) and the development of magnetic resonance imaging with gadolinium enhancement for the early anatomic confirmation of the pathognomonic, bilateral vestibular schwannomas in NF2. These advances enable early diagnosis and treatment when the tumors are small in virtually all subjects at risk for NF2. The authors suggest that advising young NF2 patients to wait until complications develop, especially hearing loss, before diagnosing and operating for bilateral eighth nerve schwannomas may not always be in the best interest of the patient. To the authors' knowledge, this is the first reported case of preservation of both auditory and vestibular function in a patient after bilateral vestibular schwannoma excision.

Vestibular plasticity following orbital spaceflight: recovery from postflight postural instability.

Results of previous studies suggested that the vestibular mediated postural instability observed in astronauts upon return to earth from orbital spaceflight may be exacerbated by an increased weighting of visual inputs for spatial orientation and control of movement. This study was performed to better understand the roles of visual and somatosensory contributions to recovery of normal sensori-motor postural control in returning astronauts. Preflight and postflight, 23 astronaut volunteers were presented randomly with three trials of six sensory organization test (SOT) conditions in the EquiTest system test battery. Sagittal plane center-of-gravity (COG) excursions computed from ground reaction forces were significantly higher on landing day than preflight for those test conditions presenting sway-referenced visual and/or somatosensory orientation cues. The ratio of summed peak-to-peak COG sway amplitudes on the two sway-referenced vision tests (SOTs 3 + 6) compared to the two eyes closed tests (SOTs 2 + 5) was increased on landing day, indicating an increased reliance on visual orientation cues for postural control. The ratio of peak-to-peak COG excursions on sway-referenced surfaces (SOTs 4, 5 & 6) to an earth fixed support surfaces (SOTs 1, 2 & 3) increased even more after landing suggesting primary reliance on somatosensory orientation cues for recovery of postflight postural stability. Readaptation to sway-referenced support surfaces took longer than readaptation to sway-referenced vision. The increased reliance on visual and somatosensory inputs disappeared in all astronauts 4-8 days following return to earth.

Hip sway associated with vestibulopathy.

We identify a population of patients with vestibular complaints who show excessive hip sway and center of gravity movement during clinical balance testing. To determine the postural control strategy used by these patients, the body movement and muscle activation patterns of 9 patients responding to backward support surface translations were studied. Patients' responses were compared to those of normal subjects tested both under the same conditions and while using hip sway to balance across a narrow beam. Unlike normal subjects responding to translations of a flat support surface, all patients showed hip movement patterns that kinematically resembled the movements of normal subjects balancing across a beam. Although all patients showed the same body movement patterns, they showed two different muscle activation patterns, neither of which was similar to those of normal subjects responding to flat support surface translations. Four patients showed bursts in abdominal and/or quadriceps muscles characteristic of active hip flexion to move the center of mass, although the timing of these bursts was variable. The remaining 5 patients showed minimal activation of any proximal muscles, suggesting a failure to control upper body motion resulting from activation of ankle muscles. To determine whether the excessive hip sway observed in these patients could be a voluntary response to platform translation, the patients' responses were compared to those of a second group of normal subjects voluntarily responding to backward support surface translations with hip sway. Unlike the patients, all normal subjects responding voluntarily consistently activated abdominal muscles slightly later than ankle muscles. It is therefore unlikely that the patients' responses to platform translations were simply voluntary responses. Thus, vestibular deficits can result in abnormally coordinated postural movement strategies that result in excessive hip sway.