Noise-Enhanced Vestibular Input Improves Dynamic Walking Stability in Healthy Subjects

BACKGROUND

White noise galvanic vestibular stimulation (GVS) is thought to enhance the sensitivity of vestibular organs.

OBJECTIVE

To examine the effects of noise-enhanced vestibular input on the walking performance in healthy subjects walking with eyes closed.

METHODS

Walking performance of 17 healthy subjects (mean age 28.8 ± 1.7 years) at slow, preferred, and fast speeds was examined during three different conditions: (1) walking with eyes open (EO) as baseline condition, (2) walking with eyes closed and sham noisy GVS (EC), and (3) walking with eyes closed and non-zero amplitude noisy GVS set to 80% of the individual sensory threshold for GVS (EC-GVS). Ten gait parameters were examined: stride time, stride length, base of support, swing time percentage, double support time percentage as well as gait asymmetry, bilateral phase coordination and the coefficient of variation (CV) of stride time, stride length and base of support.

RESULTS

Noisy GVS improved stride time CV by 36% (p < 0.034), stride length CV by 31% (p < 0.037), base of support CV by 14% (p < 0.009), and bilateral phase coordination by 23% (p < 0.034). The ameliorating effects of noisy GVS on locomotion function were primarily observable during slow walking speeds.

CONCLUSION

Noise-enhanced vestibular input is effective in improving locomotion function and is accompanied by a subjectively felt improvement of walking balance. It predominantly targets the variability and bilateral coordination characteristics of the walking pattern, which are critically linked to dynamic walking stability. Noisy GVS might present an effective treatment option to improve walking performance in patients with bilateral vestibular dysfunction.

Appraisal of the signal-to-noise-ratio of uni- and bipolar recordings of ocular vestibular evoked myogenic potentials

Ocular vestibular evoked myogenic potentials (oVEMPs) are a non-invasive method to investigate otolith function mediated via the superior vestibular nerve. However, the herein used recordings and protocols may alter within different studies. In particular the diverging use of electrode configuration regarding polarity or even electrode position varies across studies. Therefore, a systematic analysis and appraisal of the different electrode configuration seems mandatory. In this study we compared the quality of uni- and bipolar recordings based on the signal to noise ratio (SNR). We recoded oVEMPs using a uni- and bipolar electrode configuration simultaneously and compared the recorded amplitudes and latencies and calculated the SNR. The amplitudes recorded by the unipolar configurations were significantly (p < 0.01) increased compared to the bipolar configuration. However, the SNR of the bipolar setup was significantly better (p < 0.05) when compared to the unipolar setup. Additionally, we estimated a transfer function that enabled a comparison of uni- and bipolar recordings. To conclude, the variety of setups used for oVEMP recording hinder a comparison of results and unipolar electrode configurations have clear disadvantages.

Postural imbalance and falls in PSP correlate with functional pathology of the thalamus

OBJECTIVE

To determine how postural imbalance and falls are related to regional cerebral glucose metabolism (PET) and functional activation of the cerebral postural network (fMRI) in patients with progressive supranuclear palsy (PSP).

METHODS

Sixteen patients with PSP, who had self-monitored their frequency of falls, underwent a standardized clinical assessment, posturographic measurement of balance during modified sensory input, and a resting [¹⁸F]FDG-PET. In addition, patients performed an fMRI paradigm using mental imagery of standing. Results were compared to healthy controls (n = 16).

RESULTS

The frequency of falls/month in patients (range 1-40) correlated with total PSP rating score (r = 0.90). Total sway path in PSP significantly correlated with frequency of falls, especially during modulated sensory input (eyes open: r = 0.62, eyes closed: r = 0.67, eyes open/head extended: r = 0.84, eyes open/foam-padded platform: r = 0.87). Higher sway path values and frequency of falls were associated with decreased regional glucose metabolism (rCGM) in the thalamus (sway path: r = -0.80, falls: r = -0.64) and increased rCGM in the precentral gyrus (sway path: r = 0.79, falls: r = 0.64). Mental imagery of standing during fMRI revealed a reduced activation of the mesencephalic brainstem tegmentum and the thalamus in patients with postural imbalance and falls.

CONCLUSIONS

The new and clinically relevant finding of this study is that imbalance and falls in PSP are closely associated with thalamic dysfunction. Deficits in thalamic postural control get most evident when balance is assessed during modified sensory input. The results are consistent with the hypothesis that reduced thalamic activation via the ascending brainstem projections may cause postural imbalance in PSP.

Fahrradfahren Querschnittgel�hmter mittels funktioneller Elektrostimulation

Cycling using functional electrical stimulation offers paraplegics the possibility of muscle and cardiovascular training as well as the chance for independent locomotion. To investigate whether this method might be suitable for a large group of paraplegics, the first German feasibility study of functional electrical stimulation (FES) cycling with seven paraplegic patients was started at the beginning of 2003. Even at the beginning of the study, and without training, these patients were able to drive distances of 0.5-1.6 km. To stimulate cardiovascular adaptation processes in the case of FES ergometer training or to cover useful distances in the case of FES cycling, a minimum amount of generated mechanical output power is required, which as a rule cannot be achieved yet. In this study, we point out two particular aspects of FES cycling, which impair power output: prolonged fatigue mode and viscous joint friction of the paraplegic FES cyclist. We discuss current possibilities for increasing output power and endurance.

[The electrical stimulation bicycle: a neuroprosthesis for the everyday use of paraplegic patients]

Until recently, few patients with complete paraplegia could walk or stand with the help of functional electrical stimulation (FES) of the leg muscles regularly at home. In comparison, FES cycling with an adapted tricycle is easy to put into practice because the legs remain connected to the pedals and through the use of a tricycle or stationary bicycle, the balancing problems of the patient recedes into the background. In the first German feasibility studies for paraplegic cycling, eleven completely paraplegic patients have been tested so far. The goal is to make FES cycling a daily activity in the lives of as many patients as possible.

Treatment of downbeat nystagmus with 3,4-diaminopyridine: a placebo-controlled study

BACKGROUND

Several drugs that primarily act on gamma-aminobutyrate or muscarinic receptors have been used to treat downbeat nystagmus (DBN) syndrome despite their having only moderate success and causing several side effects that limit their effectiveness. These drugs were tested under the assumption that DBN was caused by a disinhibition of a physiologic inhibitory cerebellar input on vestibular nuclei.

OBJECTIVE

To evaluate the effects of a single dose of the potassium channel blocker 3,4-diaminopyridine (3,4-DAP), which is known to increase the excitability of Purkinje cells, on DBN in a prospective, placebo-controlled, double-blind study with a crossover design.

METHODS

Seventeen patients with DBN due to cerebellar atrophy (5), infarction (3), Arnold-Chiari malformation (1), or unknown etiology (8) were included in the study (1 of 18 patients had to be excluded). Mean peak slow-phase velocity (PSPV) was measured before and 30 minutes after randomized ingestion of 20 mg of 3,4-DAP or placebo orally; at least 1 week later, the treatments were switched.

RESULTS

3,4-DAP reduced mean PSPV of DBN from 7.2 +/- 4.2 degrees /s (mean +/- SD) before treatment to 3.1 +/- 2.5 degrees/s 30 minutes after ingestion of the 3,4-DAP (p < 0.001, two-way analysis of variance). Placebo had no measurable effect. In 10 of 17 subjects, the mean PSPV decreased by >50% and in 12 of 17 by >40%. In parallel, the subjects had less oscillopsia and felt more stable while standing and walking. Nine of the subjects continued to take the drug with success. Except for transient minor perioral or digital paresthesia reported by three subjects and nausea and headache reported by one, no other side effects were observed.

CONCLUSIONS

In this study, the authors demonstrated that a single dose of 3,4-DAP significantly improved DBN. In view of animal studies reporting that micromolar concentrations of 4-aminopyridine increased the excitability of Purkinje cells, it is suggested that the efficacy of 3,4-DAP may be due to an increase of the physiologic inhibitory influence of the vestibulocerebellum on the vestibular nuclei.

Postural reflexes evoked by tapping forehead and chest

We investigated whether a tap with a reflex hammer to the forehead can elicit responses in the leg muscles and whether vestibular stimulation is the crucial prerequisite for eliciting these responses. We also measured the postural changes caused by the tap and by the compensatory, presumably reflex-like reactions of the subject. Tap-evoked activity of leg muscles was easily elicited during upright stance in normal subjects and was also seen in two subjects without vestibular function. The pattern of muscle activation clearly showed a counteraction to the tap-evoked perturbation of stance. Taps applied to the chest elicited similar reflexes. Since these two conditions imply a different activation of the vestibular apparatus, the vestibular input alone cannot account for the observed leg muscle reflexes. We suggest that multisensory reflex pathways that integrate vestibular and proprioceptive inputs account for these reflexes.

Patients with somatoform phobic postural vertigo: the more difficult the balance task, the better the balance performance

The objective was to test, whether the increased body sway activity, shown in patients with phobic postural vertigo (PPV) in a previous posturographic study, impairs postural balance during demanding balance tasks. In 17 patients with PPV and 15 normal subjects body sway was analyzed for two standing positions on a foam rubber-padded posturographic platform with the eyes open or closed: (a) normal upright stance, (b) tandem stance. During normal upright stance patients showed an increase in body sway activity between 0.1 and 19 Hz and in sway path values for lateral and fore/aft directions. During the most difficult balance task, i.e. tandem stance with the eyes closed, body sway activity and sway path values did not differ between patients and controls. Objective balance skills were not impaired in patients with PPV during balance tasks at the limits of postural control.

Increased body sway at 3.5-8 Hz in patients with phobic postural vertigo

Postural sway during upright stance was analyzed in 12 patients with phobic postural vertigo (PPV) and in 12 age-matched healthy volunteers. Recordings were made under different conditions (with the eyes open or closed): when standing on a foam rubber pad with the head upright, turned 30 degrees to the right or left, or during 1 Hz horizontal head oscillations. Sway analysis included calculation of sway path, of root mean square values of sway and of the power spectrum of sway in fore/aft and lateral directions. There was a significant increase in sway activity in the 3.53-8 Hz frequency band in patients with PPV. This did not impair objective postural stability. Increase in higher frequency sway activity may simply reflect a change in postural strategy rather than a sensorimotor dysfunction. The patients' conscious control of stance may augment co-activation of anti-gravity muscles, a strategy applied by normal subjects when performing demanding balancing tasks.

Can short-latency vestibulospinal reflexes in lower leg muscles be elicited by tapping the head?

A gentle tap on the forehead evoked short-latency motor responses in the sternocleidomastoid muscle, which may be vestibulocollic reflexes with characteristics similar to those elicited by clicks. We tested this paradigm in subjects standing upright, in order to determine the differential effects of taps on the forehead on the patterns and latencies of spinal stretch and vestibulospinal reflexes, which are important for postural control. Taps on the forehead elicited short-latency inhibitory electromyographic responses in both gastrocnemius muscles with a mean latency of 48.3 +/- 3.1 ms (onset) to 98.3 +/- 6.3 ms (end). Taps on the sternum elicited similar responses from the gastrocnemius muscles, indicating that vestibular stimulation is not essential for eliciting these responses. Both responses may play a role in predetermining the strategy for correcting body perturbations. The actual reflex is probably elicited by somatosensory input from the neck, which converges with vestibular input for the multisensory control of posture.

Postural stability differentiates "lower body" from idiopathic parkinsonism

INTRODUCTION

Patients with an akinetic Parkinson syndrome of the lower extremities and a poor response to L-DOPA have been described as "lower body Parkinsonism" (LBP). These patients are characterized by frequent fallings and poor balance.

METHODS

We have studied body sway with static (force platform) and dynamic (Equitest) posturography in 11 LBP patients, 6 of them revealing deep white matter lesions on MRI and 10 patients with advanced Parkinson's disease (PD) and compared performance with 30 age-matched controls.

RESULTS

When standing on a fixed support the postural performance of both patient groups lay within the normal range. The balance of LBP patients worsened in the static testing in the conditions "eyes open on foam" (p < 0.05) and "eyes closed on foam" (p < 0.0006, of 11 patients falling), whereas the balance of PD patients deteriorated only with "eyes closed on foam" (p < 0.05). Dynamic posturography confirmed these results in 6 different sensory conditions, clearly distinguishing the more unstable LBP patients from PD patients during "standing, eyes closed, foot support sway referenced" (p < 0.005).

CONCLUSION

We conclude, that postural adjustments in LBP patients are more disturbed than those in PD patients and posturography can be an additional tool for the differential diagnosis of Parkinson syndromes with gait disorders.

Dependence of visual stabilization of postural sway on the cortical magnification factor of restricted visual fields

Monocular visual stabilization of fore-aft and lateral body sway was tested posturographically in normal subjects (wearing visual field blinds) as a function of visual field size and location of the visual field on the central or peripheral retina. Body sway applied to a force- measuring platform is less with central (foveal) vision when central and peripheral visual fields have the same area. If, however, the peripheral field size is corrected by the cortical magnification factor of the retina in the primary cortex, body sway is stabilized by the peripheral retina to the same extent. Thus, there is no functional specialization of central and peripheral retina with respect to balance control. Visual stabilization of upright stance is a function of field size and cortical representation of the retina. The central and the peripheral retina have different thresholds to detect motion; this was surprisingly not reflected in measurements of normal fore-aft and lateral body sway.

Postural imbalance: an early sign in HIV-1 infected patients

We have recorded postural performance in 50 HIV-infected patients in different stages of the disease (Walter Reed (WR) stages I-VI) by means of a force measuring platform. The results were compared with 50 age-matched controls. A significant instability was particularly evident when standing on an unstable foot support. In patients standing with "eyes closed", postural sway was significantly higher in every patient group (WR I-II: P less than 0.02, WR III-V: P less than 0.001, WR VI: P less than 0.001). Patients in stage WR I-II showed no relevant neurological abnormalities. In agreement with other neurophysiological data in the literature we suggest that postural imbalance could be an early sign of central nervous system penetration of HIV. No correlation with electromyographic or cerebrospinal fluid findings could be found.

Influence of magnetic resonance imaging on evoked potentials and nerve conduction velocities in humans

The authors investigated the influence of a 1.0-T magnetic field of a magnetic resonance (MR) imaging device, as well as the possible effects of the changing magnetic field and the RF field, on somatosensory, visual, and auditory evoked potentials and on peripheral nerve conduction velocities. The neural potentials outside and inside the static magnetic field were recorded before and after MR imaging. The measured latencies before and after MR imaging were within the normal range for healthy volunteers. The magnetic field did not significantly alter central or peripheral conduction velocities.

Differential effects of retinal target displacement, changing size and changing disparity in the control of anterior/posterior and lateral body sway

When visual information is provided in addition to input from other sensory systems, normal body sway can be attenuated by about 50%. The essential visual cue is retinal target displacement, which increases as eye-target distance is reduced. As a result, both lateral and anterior/posterior (A-P) sway decrease as eye/target distance decreases. We have investigated the geometrical basis of lateral and fore-aft sway detection by vision, the latter provided by detection of change in disparity of the visual axis of both eyes and change in target size. Using known movement detection thresholds the largest possible distance for visual stabilization of posture can be calculated to be 34 m for lateral sway, and for fore-aft sway 1.50 m for change in disparity and 3.20 m for change in size. Visual stimuli were designed to selectively stabilize fore-aft sway either by change in size or by change in disparity. The experiments revealed that the theoretical prediction overestimates the efficacy of visual stabilization of lateral sway and underestimates the efficacy of fore-aft sway stabilization. It is proposed that microoscillations of the eye increase the threshold for detection of retinal target displacements, leading to less efficient lateral sway stabilization than expected, and that the threshold for detection of self motion in the A-P direction is lower than the threshold for object motion detection used in the calculations, leading to more efficient stabilization of A-P sway.

Postural sway during retinal image stabilisation

Posturographic measurements using a piezoelectric platform were made in normal subjects while wearing a combination of spectacle and contact lens providing partial stabilisation of the retinal image (RIS). The amount of postural sway seen while wearing the device at rest is intermediate between the "normal vision" and "eyes closed" conditions, and increases with increasing amounts of RIS. However, when large active head-and-eye movements are performed, postural sway is dramatically increased when using RIS, and is then worse than while performing the same task in the "eyes closed" condition. It is concluded that patients who use the partial-RIS device for the treatment of severe oscillopsia may benefit only when performing tasks in which the head is relatively still, such as reading, writing or watching TV. It is also proposed that the partial-RIS device can serve as a model in normal free-standing subjects for the postural effects of oculomotor disorders.

Spatial dissociation of early and late colour evoked components

Evoked potentials to the primary colours red, green, yellow and blue were recorded and compared with those evoked by white. The unpatterned 10 degrees X13 degrees stimuli were generated with the aid of a colour monitor. Activity was depicted with 5 electrodes, the central electrode 5 cm above the inion and two on each side 5 and 10 cm apart from the central electrode. With equally bright colour stimuli a previously described early negative colour-dominated component N87 was localized in all subjects at the central occipital electrode while the following positivity P100 was clearly more lateralized to the peripheral electrodes. With half-field stimulation N87 showed a similar--paradoxical--lateralization to the ipsilateral electrodes as has been demonstrated for pattern reversal. The existence and localization of N87 could be confirmed also for blue colours, its amplitude independent of the blue luminance, its latency decreasing for definite additional brightness increments and decrements. The N87 to blue was of the same latency as the N87 components to other colours. N87 is mainly generated foveally and parafoveally, its amplitude saturates with stimuli larger than 6-8 degrees in diameter.

[Effect of in vivo nuclear magnetic resonance tomography on somatosensory and visual evoked potentials in the human]

By means of registration of somatosensory (SSEP) and visual (VEP) evoked potentials under the influence of different magnetic and electromagnetic fields of Magnetic Resonance we investigated the influence of Magnetic Resonance Imaging (MRI) on human nervous system (all measurements with an 1.0 T MR imager are performed outside and inside the static magnetic field, before and after MR imaging). In vivo experiments on 20 healthy volunteers show in SSEP registrations as well as in VEP-registrations no measurable influence on nerve conduction. The measured latencies before and after MR imaging are found inside the standard values which are valid for healthy volunteers. In vivo experiments at field-strengthens up to 1.0 Tesla show no significant changes of the central and peripheral conduction velocity with human beings.

Interaction between perceived self-motion and object-motion impairs vehicle guidance

When one is riding in a vehicle, perceptual thresholds for motion of objects are significantly elevated above those determined under corresponding but simulated conditions in the laboratory without concurrent self-motion perception. Authorities on road traffic accidents should thus consider an additional perceptual time of at least 300 milliseconds for detecting critical changes in headway beyond the usual reaction time. Detection times thus corrected consequently lead to an alteration of our conception of safe intervehicle distances in a convoy. This elevation of thresholds for object-motion during self-motion, with its consequences for visual control of vehicle guidance, can be seen as a disadvantageous side effect of an otherwise beneficial space-constancy mechanism, which provides us with a stable world during locomotion.

Oscillopsia and retinal slip. Evidence supporting a clinical test

A clinical bedside test for oscillopsia is described for patients suffering from an acute deficiency of compensatory eye movements due either to inappropriate pursuit eye movements or a defective vestibulo-ocular reflex (VOR). This test involves quantitative measurement of the amplitude of apparent image motion (oscillopsia) during head oscillations with frequencies of 1 or 2 Hz, +/- 20 deg amplitude. It was found that normals show no oscillopsia at 1 Hz whereas patients with acute disorders do. In subacute diseases of eye-head co-ordination, however, recordings of head and eye movements revealed a dissociation between net retinal slip and oscillopsia, with the magnitude of the latter being appreciably smaller than the former. This was interpreted as indicating a central suppression mechanism initiated by the acute eye movement deficiency. The results are discussed in terms of an inhibitory interaction between self and object motion perception which produces elevated thresholds for the detection of image motion.

[Visual prevention from motion sickness in cars]

The differential effects of vision on motion sickness in cars were tested under real road conditions using linear accelerations, in order to confirm earlier laboratory results on visual modulation of vestibular nausea induced by angular accelerations of the body. The 18 voluntary subjects were exposed to repetitive braking maneuvers (linear accelerations: 0.1-1.2 g) on a highway. The simultaneous visual stimulus conditions for the 3 separate days were: I) eyes open, visual control of car motion; II) eyes closed; III) eyes open, artificial stationary visual field (reading). The severity of motion sickness (magnitude estimation 1-10) was a function of the visual stimulus condition with significant differences among these conditions: I) moderate nausea (less than 1) with adequate visual motion perception; II) medium nausea (approximately equal to 2) with eyes closed and somatosensory-vestibular excitation only; III) strong nausea (greater than 5) with conflicting sensory input, when vestibular acceleration is in disagreement with the visual information of no movement. Providing ample peripheral vision of the relatively moving surround is the best strategy to alleviate car sickness.

Postural imbalance with head extension: improvement by training as a model for ataxia therapy

Head extension may cause a physiological vertigo and postural imbalance separate and distinct from basilar insufficiency. This physiological imbalance mainly is due to a vestibular sensory deficiency when the utricular otoliths are beyond their working range because of the change in head position. Since the intact visual and somatosensory control hope widely compensate for the vestibular deficiency, head-extension vertigo is of particular concern only in certain stimulus situations or diseases in which the stabilizing input from the eyes or joint receptors is reduced. Balance training on foam rubber with head extension and closed eyes improved postural-sway activity up to 50% within five days. A daily short-term training effect and a long-term training effect together form a typical exponential sawtooth curve of postural stability over time. After termination of training, learned balance skill exponentially returns to the pretraining values within weeks. The percentage of improvement through training depends on the amount of initial instability. Clinicians should treat ataxia by exposing patients to stimulus situations producing increasing body instability in order to activate sensorimotor rearrangement.