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What do I need to know about
multisensory interactions?
Adolfo M. Bronstein
Neuro-otology Unit
Centre for Neuroscience
Imperial College London
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Vest.
Nuclei
Cortex: Conscious Perception
Vertigo
Brainstem: III/IV/VI nerves- VOR
Nystagmus & Oscillopsia
Brainstem - Autonomic centres
Nausea, Sweating, Heart Pounding
Spinal: Vestibular Spinal Tract
Unsteadiness
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The Components of the Balance
System
Three inputs:
• Vestibular
• Visual
• Proprioceptive
• (+ cognition)
Four outputs:
• Conscious perception
• Eye movements
• Body movements
• Autonomic (visceral)
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An example of
Vestibulo-
Proprioceptive
interaction:
The COR
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Labyrinthine Defective Subjects (LDS)
0
0.2
0.4
0.6
Whole body VOR Head re. Trunk Trunk re. Head (COR)
ga
inAn example of ‘proprioceptive – cognitive’ interaction:
Context dependent modulation of the COR
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Visual interactions in balance control
• Visuo-vestibular interaction
• Visuo-proprioceptive interaction (postural)
• Visual input in vestibular compensation
– Visual dependency
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Bus
Bus
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Visuo-Vestibular interaction:
1st: VOR + OKN
2nd: VOR Suppression
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Visual input for the suppression of ocular instability (nystagmus)
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Visual input for the supression of postural instability
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Fixating on an object in the foreground (parallax) can reverse
the direction of visuo-postural sway - no trivial ‘reflex’!
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Eye-in-head and head-on-trunk
position is taken into account
a function of ocular and
cervical proprioceptors?
Exp Brain Res.
1996;111:283-8.
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Cognitive control: Action & Expectation
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Head-drop technique for vestibulo-spinal reflexes
10 cm
Accelerometer
Release
Sling
Surface electrodes
The concept of short and long latency loops
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‘Head drop technique’
• Passive drop: ‘relax and let the head fall’
• Active drop: ‘relax but stop the drop as soon as you can’
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Time (ms)
0 500
0.5 g
1 mV
active
passive
100
Early
act.
P
R SCM, EMG
Acceleration traces
25ms
66 ms
160 ms
Normal head drop
active
passive
Munchau et al, ‘Brain’, 2001
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The Motor System
and its
Multiple Levels
Birnbaumer 1991
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Vestibular compensation
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Factors delaying vestibular compensation
• Fluctuating vestibular disorder
• Additional disorder:
– CNS
– Peripheral nerve
– Cervical spine
– Visual
• Lack of mobility
• Drugs
• Psychosocial
• Visual dependence
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The Concept of
VISUAL DEPENDENCE
in the normal population
Witkin 1959
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Peripheral Vestibular Symptoms
• Vertigo and nausea
• Dizziness
• Motion intolerance:
– Head motion
– Visual motion
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Peripheral Vestibular Symptoms
• Vertigo and nausea
• Dizziness
• Motion intolerance:
– Head motion
– Visual motion VISUAL VERTIGO
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Dizziness worsened by visual stimulation
• One of the ‘Underrated neuro-otological symptoms’
(Hoffman and Brookler 1978).
• ‘Motorist's vestibular disorientation syndrome’
(Page and Gresty 1985).
• ‘Space and motion discomfort’
(Jacob et al 1993).
• ‘Visual vertigo syndrome’
(Bronstein 1995).
• ‘Visual vestibular mismatch’
(Longridge et al 2002).
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Visually disorienting surroundings:
- Supermarkets, repetitive fences
- Ironing striped shirts, drawing curtains
- Disco lights, movies
- Traffic, driving, crowds
- Flowing rivers, clouds
…beware of panic attacks, agoraphobia and psychosomatic dizziness
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Visual Vertigo PatientsPostural Tests: static and dynamic visual stimuli
Fastrack Fastrack
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Stabilising and Destabilising effects of Vision
1
1.5
2
2.5
3
3.5
4
4.5
5
EC / E O D isk / EO
Qu
oti
en
t
N orm al con trols
V isua l Ver tigo
LD S
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Optokinetic treatment
Eyetrek
Optokinetic drum
Optokinetic disc
J Neurol.
2004;251:983-95.
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Do I need posturography to
see which patients have visual
dependence?
NO! Talking to your patients
is actually better--->
Computerised Dynamic Posturography
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What do I need to know about
multisensory interactions?
- Balance is a function of the brain, not the ear
- The brain uses all possible sensory resources available for balance
- Even the simplest head or body movements involve multiple sensory inputs
- Any input may be missing or ‘unreliable’, both in health and disease but the brain
will continue to balance you by means of:
---> sensory reweighting
---> central compensation
- These processes are, to some extent, idiosyncratic (vary from person to person)
- As clinicians we must be aware of these issues when treating our patients
this is the basis of good, customised rehabilitation