Vestibular Rehabilitation in Isolated Otolith Dysfunction After Covid-19: A Case Report

A 56-year-old female with dizziness, imbalance, and a slight floating sensation was evaluated. Her symptoms started after infection with the novel coronavirus (SARS-CoV-2). Routine auditory test (pure tone audiometry), vestibular assessment (videonystagmography), and neurologic test results were in the normal range, but the otolith evaluations, such as cervical vestibular evoked myogenic potentials (cVEMP) and subjective visual vertical tests, showed abnormal findings. The patient underwent a ten-session individualized vestibular rehabilitation program (one session per week). After completing rehabilitation sessions, her chief complaints were alleviated, the performance on computerized posturography was improved, and the abnormal cVEMP amplitude asymmetry between ears disappeared. In conclusion, vestibular disorders can happen after COVID-19 infection, presenting exclusively with isolated otolith dysfunction. In these patients, functional integrity assessment of the whole vestibular system is crucial, and vestibular rehabilitation may be beneficial.

Manifestations of Aging in Virtual Reality Implementation of Rod and Frame Test

Senior adults’ reliance on the visual frame of reference for spatial orientation is a manifestation of an age-related shift in cognitive style from field independence to field dependence. We implemented a virtual reality rod and frame test (VR-RFT) to assess visual field dependence (VFD) in n=39 young adults (20-30 years old) and n=43 seniors (60 years old and above). The subjects were asked to determine subjective visual vertical (SVV) for 19 angles of frame tilt (running from -45 degrees to 45 degrees in steps of 5 degrees). The strong VFD of seniors was manifested not only by the increased error in the determination of SVV (SVVE) but also in its distribution. For small and large frame tilt angles, seniors’ SVVE skewness and kurtosis were greater than those of young adults. The SVVE median dependence on frame tilt may be accounted for with a phenomenological model whose two parameters describe the strengths of primary (P) and secondary (S) visual attractors which subjects use to infer SVV: the edges of the frame and its imaginary diagonals. For young adults, these parameters were: PY=14.91 and SY=12.51. For seniors, we observed an over 50% increase in the strength of the primary attractor PS=26.31 while the strength of the secondary one was only weakly affected by aging: SS=13.74. We demonstrate that the asymmetry between the strength of attractors significantly contributes to SVVE made by seniors at large frame tilts. We hypothesize that a variant VR-RFT may be used in rehabilitation to reduce excessive VFD.

Bilateral Asymmetry in Ocular Counter-Rolling Reflex Is Associated With Individual Motion Sickness Susceptibility

Accumulating evidence suggests that individual variations in vestibular functions are associated with motion sickness (MS) susceptibility. We investigated whether vestibular functions in the reflex and cortical pathways could predict the susceptibility of individuals to MS. MS-susceptible and control adults were recruited according to the Motion Sickness Susceptibility Questionnaire (MSSQ) score. Otolith reflex and cortical functions were assessed using the ocular counter rolling test and the head-tilt subjective visual vertical (HT-SVV) test, respectively. The bilateral asymmetry of each function was compared between the MS-susceptible and the control groups. Although the two tests for otolith functions were conducted using the same stimulation (lateral head tilt), bilateral asymmetry of otolith reflex rather than cortical function was significantly associated with MS susceptibility. Our data suggests that bilateral asymmetry in the otolith reflex pathway is capable of predicting susceptibility to MS to some extent. Our data also suggest that the association between vestibular function and MS susceptibility can vary based on the vehicle types. Future vehicles, such as self-driving cars, will make us aware of other vestibular functions associated with MS susceptibility.

Postural adjustment as a function of scene orientation

Visual orientation plays an important role in postural control, but the specific characteristics of postural response to orientation remain unknown. In this study, we investigated the relationship between postural response and the subjective visual vertical (SVV) as a function of scene orientation. We presented a virtual room including everyday objects through a head mounted display and measured head tilt. The room orientation varied from 165° left to 180° right in 15° increments. In a separate session, we also conducted a rod adjustment task to record the participant’s SVV in the tilted room. We applied a weighted vector sum model to head tilt and SVV error, and obtained the weight of three visual cues to orientation: frame, horizon and polarity cues. We found substantial contributions of all visual cues to head tilt and SVV error. For SVV error, frame cues made the largest contribution, whereas polarity contribution made the smallest. Head tilt tended to follow a similar pattern to SVV error, but the pattern was unclear. These findings suggest that multiple visual cues to orientation are involved in postural control, and imply different representations of environmental coordinates across postural control and verticality perception.

Evaluation of subjective vertical perception among stroke patients: a systematic review

Background: Verticality misperception is relatively common among patients after stroke, and it may be evaluated in terms of (a) subjective visual vertical (SVV), (b) subjective haptic vertical (SHV) and (c) subjective postural vertical (SPV). To better understand these assessment methods, we conducted a systematic review of the methodological characteristics of different protocols for evaluating SVV, SHV and SPV among individuals after stroke. Objective: To standardize the methodological characteristics of protocols for evaluating verticality perception after stroke. Methods: We searched the following databases: PUBMED, regional BVS portal (MEDLINE, LILACS, IBECS, CUBMED, Psychology Index and LIS), CINAHL, SCOPUS, Web of Science, Science Direct, Cochrane Library and PEDro. Two review authors independently used the QUADAS method (Quality Assessment of Diagnostic Accuracy Studies) and extracted data. Results: We included 21 studies in the review: most (80.9%) used SVV, eight (38.1%) used SPV and four (19.0%) used SHV. We observed high variability in assessments of verticality perception, due to patient positions, devices used, numbers of repetitions and angle of inclination for starting the tests. Conclusion: This systematic review was one of the first to explore all the methods of assessing verticality perception after stroke, and it provides crucial information on how to perform the tests, in order to guide future researchers/clinicians.

Pupil responses associated with the perception of gravitational vertical under directional optic flows

This study assessed the pupil responses in the sensory integration of various directional optic flows during the perception of gravitational vertical. A total of 30 healthy participants were enrolled with normal responses to conventional subjective visual vertical (SVV) which was determined by measuring the difference (error angles) between the luminous line adjusted by the participants and the true vertical. SVV was performed under various types of rotational (5°/s, 10°/s, and 50°/s) and straight (5°/s and 10°/s) optic flows presented via a head-mounted display. Error angles (°) of the SVV and changes in pupil diameters (mm) were measured to evaluate the changes in the visually assessed subjective verticality and related cognitive demands. Significantly larger error angles were measured under rotational optic flows than under straight flows (p < 0.001). The error angles also significantly increased as the velocity of the rotational optic flow increased. The pupil diameter increased after starting the test, demonstrating the largest diameter during the final fine-tuning around the vertical. Significantly larger pupil changes were identified under rotational flows than in straight flows. Pupil changes were significantly correlated with error angles and the visual analog scale representing subjective difficulties during each test. These results suggest increased pupil changes for integrating more challenging visual sensory inputs in the process of gravity perception.

Long-duration head down bed rest as an analog of microgravity: Effects on the static perception of upright

BACKGROUND: Humans demonstrate many physiological changes in microgravity for which long-duration head down bed rest (HDBR) is a reliable analog. However, information on how HDBR affects sensory processing is lacking. OBJECTIVE: We previously showed (25) that microgravity alters the weighting applied to visual cues in determining the perceptual upright (PU), an effect that lasts long after return. Does long-duration HDBR have comparable effects? METHODS: We assessed static spatial orientation using the luminous line test (subjective visual vertical, SVV) and the oriented character recognition test (PU) before, during and after 21 days of 6° HDBR in 10 participants. Methods were essentially identical as previously used in orbit (25). RESULTS: Overall, HDBR had no effect on the reliance on visual relative to body cues in determining the PU. However, when considering the three critical time points (pre-bed rest, end of bed rest, and 14 days post-bed rest) there was a significant decrease in reliance on visual relative to body cues, as found in microgravity. The ratio had an average time constant of 7.28 days and returned to pre-bed-rest levels within 14 days. The SVV was unaffected. CONCLUSIONS: We conclude that bed rest can be a useful analog for the study of the perception of static self-orientation during long-term exposure to microgravity. More detailed work on the precise time course of our effects is needed in both bed rest and microgravity conditions.

Cochlear implant surgery and perioperative dizziness is associated with utricular hyperfunction

BACKGROUND: Dizziness is a common perioperative complication after cochlear implantation (CI). To date, the exact cause behind this phenomenon remains unclear. There is recent evidence to suggest that otolith function, specifically utricular, may be affected shortly after CI surgery, however whether these changes are related to patient symptoms has not yet been investigated. OBJECTIVE: To determine whether CI surgery and perioperative dizziness is associated with changes on utricular function. METHODS: We performed an observational study on patients undergoing routine CI surgery. Utricular function was assessed using the Subjective Visual Vertical (SVV), and perioperative dizziness was determined using a questionnaire. The study followed patients before surgery and then again 1-day, 1-week and 6-weeks after implantation. RESULTS: Forty-one adult CI recipients participated in the study. The SVV deviated away from the operated ear by an average of 2.17° a day after implantation, 0.889° 1 week and –0.25° 6 weeks after surgery. Dizziness contributed to a tilt of 0.5° away from the implanted ear. These deviations were statistically significant. CONCLUSIONS: CI surgery causes utricular hyperfunction in the operated ear that resolves over 6 weeks. SVV tilts were greater in participants experiencing dizziness, suggesting that utricular hyperfunction may contribute to the dizziness.