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This report identifies fundamental problems to be addressed in order to build relevant clinical tests of human balance while standing. The stated purpose of these tests is identification of lesion site and/or definition of functional balance deficits in a specific patient. During a recent consensus meeting (ESCEBD), 60 researchers and experienced clinical users of posturography (14 European countries, 9 different disciplines) inventoried and critically analyzed the various methodologies of posturography currently used for clinical evaluation. To complement posturography, alternative methods of assessment of balance control were considered. The indications for the clinical use of posturography were defined as well as recommendations regarding measurement parameters, type of perturbations and signal analysis techniques to improve assessment of balance control. Consensus was reached that a force platform cannot be considered as a technique which is sufficient on its own to perform a clinically relevant test for the assessment of neuro-otological and musculo-skeletal conditions, evaluation of compensation or treatment (rehabilitation) or prediction of falls. It should be supported by complementary methods, such as segment motion analysis, body-fixed 2D or 3D accelerometer-gyroscope or electromyography. At present, no generally applicable posturography test is available with reasonable sensitivity and specificity for the diagnosis of balance disorders. Perturbation techniques are most likely needed to enhance the diagnostic yield of posturography.

The aim of this study was to determine whether the greater medial-lateral (ML) instability observed in patients with compensated unilateral vestibular loss (UVL), tested on a seesaw platform with eyes closed, is task-dependent. UVL patients, categorized into three groups according to time since lesion (1 week, 1 month and 1 year), bilateral vestibular loss patients and age-matched healthy control subjects were tested in three dynamic postural tasks. These tasks involved different supports - a seesaw platform (Satel), a platform generating horizontal linear translations (Synapsys) and foam rubber placed on a static platform - each requiring different somatosensory cues to maintain equilibrium. Displacements of the subjects' center of pressure in both the anterior-posterior (AP) and ML directions were recorded by strain gauges within the platforms. Only tests performed with eyes closed were analyzed. Bilateral vestibular loss patients fell during foam and seesaw trials but not on the platform generating translations. We previously reported that UVL patients had greater postural oscillations on the seesaw platform in the ML compared to AP direction. In this study, we show similar ML/AP differences in patient performance on foam when standing with 'feet close together'. In contrast, these differences were not found when patients were tested on linear translation or on foam standing with feet apart. In conclusion, the postural performance of patients with vestibular loss depends on the exact task used to measure postural stability. UVL patients are less stable when subjected to movement in the ML direction because of the biomechanical constraints of the tasks and/or the availability of proprioceptive information., (2008 S. Karger AG, Basel.)

The postural instability of patients with vestibular loss (11 with bilateral and 101 with unilateral vestibular loss) at different times following the lesion was investigated by means of posturography and compared to healthy subjects. In addition, subjects submitted to galvanic vestibular stimulation were also studied to compare their postural performances with those of patients with complete unilateral vestibular lesion. The platform consisted of a static computerized force platform, on which a seesaw platform could be placed to test the subjects in dynamic conditions. The displacement of the center of foot pressure was measured under different conditions: subjects standing on the fixed platform, eyes open and eyes closed and subjects standing on the seesaw platform, eyes open and eyes closed. In the last condition, balance was tested in the subject's pitch plane by allowing the platform to rotate forwards and backwards only and in the patient's roll plane by allowing the platform to rotate to the left and to the right. The results showed that in static conditions, only bilateral vestibular loss patients had abnormal values compared to controls. In contrast, in dynamic eyes-closed conditions, both bilateral and unilateral patients could be differentiated from controls. Bilateral patients were unable to stand up without falling in both pitch and roll planes. Unilateral patients fell in the first week following the lesion and exhibited increased postural oscillations in both planes from the 2-week up to the 1-year postlesion stage. In addition and more importantly, they fell more often or had higher sway in the roll than in the pitch plane. Therefore, this study suggests that dynamic posturography on a seesaw platform could be a valuable tool for clinical diagnosis and quantitative analysis of imbalance in patients suffering from a unilateral vestibular loss up to 1 year after the lesion., (Copyright (c) 2005 S. Karger AG, Basel.)

The aim of this study was to determine how context and on-line sensory information are combined to control posture in seated subjects submitted to high-jerk, passive linear accelerations. Subjects were seated with eyes closed on a servo-controlled linear sled. They were asked to relax and received brief accelerations either sideways or in the fore-aft direction. The stimuli had an abrupt onset, comparable to the jerk experienced during a minor car collision. Rotation and translation of the head and body were measured using an Optotrak system. In some of the subjects, surface electromyographic (EMG) responses of selected neck and/or back muscles were recorded simultaneously. For each subject, responses were highly stereotyped from the first trial, and showed little sign of habituation or sensitisation. Comparable results were obtained with sideways and fore-aft accelerations. During each impulse, the head lagged behind the trunk for several tens of milliseconds. The subjects' head movement responses were distributed as a continuum in between two extreme categories. The 'stiff' subjects showed little rotation or translation of the head relative to the trunk for the whole duration of the impulse. In contrast, the 'floppy' subjects showed a large roll or pitch of the head relative to the trunk in the direction opposite to the sled movement. This response appeared as an exaggerated 'inertial' response to the impulse. Surface EMG recordings showed that most of the stiff subjects were not contracting their superficial neck or back muscles. We think they relied on bilateral contractions of their deep, axial musculature to keep the head-neck ensemble in line with the trunk during the movement. About half of the floppy subjects displayed reflex activation of the neck muscles on the side opposite to the direction of acceleration, which occurred before or during the head movement and tended to exaggerate it. The other floppy subjects seemed to rely on only the passive biomechanical properties of their head-neck ensemble to compensate for the perturbation. In our study, proprioception was the sole source of sensory information as long as the head did not move. We therefore presume that the EMG responses and head movements we observed were mainly triggered by the activation of stretch receptors in the hips, trunk and/or neck. The visualisation of an imaginary reference in space during sideways impulses significantly reduced the head roll exhibited by floppy subjects. This suggests that the adoption by the central nervous system of an extrinsic, 'allocentric' frame of reference instead of an intrinsic, 'egocentric' one may be instrumental for the selection of the stiff strategy. The response of floppy subjects appeared to be maladaptive and likely to increase the risk of whiplash injury during motor vehicle accidents. Evolution of postural control may not have taken into account the implications of passive, high-acceleration perturbations affecting seated subjects.

The waltzing behavior is usually attributed to vestibular dysfunction. However, the vestibular control of gaze and posture has not yet been measured quantitatively in any waltzing mutant. Therefore, this study was aimed at investigating the relationship between inner-ear morphology, the circling behavior, and the vestibular control of gaze and posture in a new strain of waltzing rats. Light- and electron-microscopy studies of these mutants did not reveal any structural abnormalities of the vestibular neural epithelia. In addition, the expression of Calretinin and 200-kD phosphorylated and non-phosphorylated neurofilaments was also found to be normal in the vestibular neural epithelia and ganglion cells. In contrast, the mutants showed severe dysfunctions of the vestibular control of gaze and posture. The skeletal geometry of the alert unrestrained animals was studied using cineradiography. At rest, waltzing rats held their heads tilted down: the horizontal semicircular-canal's plane was near the earth-horizontal's plane, instead of being tilted up as in Long Evans control rats. In addition, their cervical column was pitched more forward (33.6 degrees) than in the control group (6.9 degrees). The circling behavior was observed frequently, and the rats had episodes of circling in both directions. The episodes of circling amounted to an average of 17 turns, and the average angular velocity of the circling was 645 degrees/s. Unilateral labyrinthectomy induced the same postural and oculomotor syndromes in the waltzing and control groups. This indicates that the mutant vestibular nerve had a significant resting discharge before the lesion. Eye movements were recorded using acutely implanted search coils. Although waltzing rats were able to perform normal spontaneous eye movements, they showed a complete deficit of the horizontal vestibulo-ocular reflex (HVOR) and an impairment of the maculo-ocular reflex (MOR) during constant velocity, off-vertical axis rotation (OVAR). These results show, for the first time, that deficient transduction and/or processing of the horizontal-canal- and macular-related information can be causally related to the circling behavior and abnormal posture, respectively.

Previously we demonstrated a stereotyped resting posture of the head-neck arrangement in a number of vertebrates: the cervical vertebral column is oriented vertically to form one portion of the partial S-shaped configuration of the entire spine. The present investigation quantified the various strategies of head-neck movements employed by different mammalian species (human, monkeys, cats, rabbits and guinea pigs) using cineradiography. At rest, bipeds and quadrupeds hold their heads at the extreme point of flexion of the passive atlanto-occipital range of motion. In this posture, the horizontal semicircular canals are tilted upward from earth horizontal by 5 to 10 degrees and roughly parallel the plane determined by the two obliquus capitis posterior muscles. Furthermore, at this head position, the utricular maculae become oriented earth-horizontally. In quadrupedal animals, head-neck movements in the sagittal plane result from movement at the atlanto-occipital articulation (head/C1) and at the multi-articular cervico-thoracic junction (C6-Th3). Only very small flexion/extension movements occur within the body of the cervical vertebral column (C2-C5). Lowering the head from the resting position is only possible by flexion at the C6-Th3 vertebrae. Raising of gaze from the resting position is only possible by extension of the head at the atlanto-occipital articulation. By contrast, sagittal plane head movements in bipeds are largely confined to the cervico-thoracic junction. This is related to a significantly reduced range of motion of the atlanto-occipital articulation. In monkeys and humans, it range of motion is about 13 and 8-11 degrees, respectively, compared to 105 degrees in rabbits. Our cineradiographic data demonstrated different strategies for head movements in the sagittal plane between quadrupeds and bipeds. At one end of the spectrum, in the case of rabbits, there was no systematic relationship between head and neck orientation. Rabbits stabilized head posture by using the head-neck structure in a parallelogram fashion, which resulted in head posture being largely independent of cervical vertebral column orientation. In monkeys and humans, however, orientation of the head depended almost entirely on the orientation of the cervical vertebral column. In such case, head movements in the sagittal plane almost exclusively relied on the positioning of the cervico-thoracic junction. These different strategies again correlate with the different ranges of motion of the atlanto-occipital articulation. We suggest that vertebrates use mechanical constraints and preferred planes of action for head-neck movement control to simplify sensory-motor transformations subserving motor control and plasticity and to minimize neuronal operations.

Motor control of different segments of the body with multiple degrees of freedom appears to be coordinated by utilizing preferred axes of motor activity. This hypothesis may also be applied to vestibular control of posture. To explore this question we studied the anatomical relationship between the head and the cervical vertebral column by taking radiographs of the head-neck region in unrestrained alert guinea pigs. We determined that biomechanical constraints contribute to the stereotypical skeletal geometry observed in the resting animal and to a functional segmentation of the head-neck movement apparatus. Subsequent lesion studies of vestibular end organs with quantification of the resulting postural syndromes suggest that the functional segmentation of the cervical vertebral column corresponds to a functional partitioning of vestibular afferents. Our findings also indicate that the sensorimotor transformation mechanisms necessary to convert a given head velocity signal into the appropriate neck motor frame are already embedded in the networks provided by second-order vestibular neurons. Good trim of postural control will be the end result of an appropriate internal representation of the objective vertical.

X-ray photography was employed to analyse the postural syndromes following unilateral global and selective lesions of the vestibular apparatus in guinea pigs. Following hemilabyrinthectomy, head rotation in the horizontal plane resulted mainly from rotation of the cervical vertebrae whereas lateral head tilt was due to the rotation of thoracic vertebrae about the longitudinal axis. These results support our previous conclusion that because of both resting posture and intrinsic biomechanical constraints, the number of degrees of freedom of the cervical column is reduced and the cervical vertebrae are functionally specialized. Selective lesions of the vestibular apparatus have aided in determining the origin of the different components of the hemilabyrinthectomy syndrome: rotation of thoracic vertebrae was caused by unilateral lesion of the otolithic system whereas rotation of the head in the horizontal plane resulted from unilateral lesion of the horizontal semicircular canal system. We conclude that the functional segmentation of the cervical column corresponds to a differential distribution of vestibular afferents.

There is considerable evidence from studies on cats and monkeys that several cortical areas such as area 2v at the tip of the intraparietal sulcus, area 3av in the sulcus centralis, the parietoinsular vestibular cortex adjacent to the posterior insula (PIVC) and area 7 in the inferior parietal lobule are involved in the processing of vestibular information. Microelectrode recordings from these areas have shown that: (1) most of these cortical neurons are connected trisynaptically to the labyrinthine endorgans and (2) they receive converging vestibular, visual and somatosensory inputs. These data suggest that a multimodal cortical system is involved in postural and gaze control. In humans, recent positron emission tomography (PET) scans and functional magnetic resonance imaging (fMRI) studies have largely confirmed these data. However, because of the limited temporal resolution of these two methods, the minimum time of arrival of labyrinthine inputs from the vestibular hair cells to these cortical areas has not yet been determined. In this study, we used the evoked potential method to attempt to answer this question. Due to its excellent temporal resolution, this method is ideal for the investigation of the tri- or polysynaptic nature of the vestibulocortical pathways. Eleven volunteer patients, who underwent a vestibular neurectomy due to intractable Meniere's disease (MD) or acoustic neurinoma resection, were included in this experiment. Patients were anesthetized and the vestibular nerve was electrically stimulated. The evoked potentials were recorded by 30 subcutaneous active electrodes located on the scalp. The brain electrical source imaging (BESA) program (version 2.0, 1995) was used to calculate dipole sources. The latency period for the activation of five distinct cortical zones, including the prefrontal and/or the frontal lobe, the ipsilateral temporoparietal cortex, the anterior portion of the supplementary motor area (SMA) and the contralateral parietal cortex, was 6 ms. The short latency period recorded for each of these areas indicates that several trisynaptic pathways, passing through the vestibular nuclei and the thalamic neurons, link the primary vestibular afferents to the cortex. We suggest that all these areas, including the prefrontal area, process egomotion information and may be involved in planning motor synergies to counteract loss of equilibrium. [ABSTRACT FROM AUTHOR]