Mechanisms Determining Chronic Vestibular Symptoms

Lead Research Organisation: Imperial College London
Department Name: Dept of Medicine

Abstract

Dizziness and balance disorders are extremely common medical problems. Patients with dizziness are seen by GPs, neurologists, ear specialists, cardiologists and old age physicians. This is so because dizziness can come from the brain, the ear or the heart and it is more common in the elderly. An extremely common from of sudden onset (acute) dizziness is a condition called vestibular neuritis or labyrinthitis, a viral infection of the inner ear. Although initially freightening at least half of the patients recover within weeks. However, the other half go on to develop various degrees of long term (chronic) dizzy symptoms, with considerable impact for the sufferer, his/her family and the economy (working days lost). The main thrust of our research proposals deals with this question: what are the reasons why some patients with vestibular neuritis do well but others don’t? Can we identify different causes interfering with the recovery? Specifically, we are probing the hypothesis that processing of balance relevant signals by the cerebral cortex may be faulty in these chronic patients. We are confident that understanding of such brain processes in dizzy patients will allow us to set up the basis for rational rehabilitation programs and/or preventive measures.

Technical Summary

Patients with diseases of the labyrinth often fail to compensate for the disordered vestibular function and develop chronic symptoms of dizziness, including vertigo, incoordination and nausea, which are provoked particularly in busy environments. These patients are a considerable draw on medical resources as a consequence of their intractability to existing therapies and social costs are also high - 41% of dizzy patients report occupational difficulties and 21% cannot work because of dizziness (Yardley 1998). Although there is some adaptation of reflex vestibular-ocular and spinal functions following labyrinthine lesions, these reflex functions only correlate with dizziness symptoms in the acute stage of vestibular disease and not with chronic symptoms. This suggests the hypothesis that chronically dizzy patients have problems with relearning perceptuo-motor control of spatial functions - using appropriate combinations of other bodily senses and vision to guide balance and orientation. Chronically dizzy patents have not made these compensations adequately because of failures in plasticity of perceptuo-motor control. This hypothesis will be tested in experiments that address the three kinds of symptoms experienced by dizzy patients; comparing symptomatic with well compensated patients to identify how compensation fails. i) The causes of false perceptions of movement and orientation will be studied. Reflex vestibular functions will be compared with patients? ability to use processed vestibular signals to estimate velocity of self-motion and resulting reorientation in space, to identify the nature and level in the CNS of the dysfunction. ii) Patients? perceptuo-motor incoordination will be studied. Firstly by probing how in-appropriate selection of sensory cues, particularly patients? tendency to visual dependence, causes misperceptions of orientation of the self and external objects. Thereafter, the impact of using different sensory cues to control balance and gait on unstable surfaces will be evaluated, with emphasis on how patients may learn to select reliable and relevant sensory cues for movement control. iii) The hypothesis that the malaise many patients experience in busy environments may be an enhanced susceptibility to motion sickness caused by deranged vestibular function will be evaluated. Initially by comparing questionnaire assessments of pre- and post morbid levels of susceptibility, then by measuring patients? actual susceptibility during exposure to provocative motion. Our findings are likely to provide the scientific basis of therapy, in which the identification of an individual patient?s problems with using different senses to control his balance will guide the design of appropriate balance training desensitisation training.

Publications

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Agarwal K (2012) Visual dependence and BPPV. in Journal of neurology

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Anastasopoulos D (2011) Altered eye-to-foot coordination in standing parkinsonian patients during large gaze and whole-body reorientations. in Movement disorders : official journal of the Movement Disorder Society

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Anderson T (2008) Oculomotor function in multiple system atrophy: clinical and laboratory features in 30 patients. in Movement disorders : official journal of the Movement Disorder Society

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Arshad Q (2012) A new device to quantify ocular counterroll using retinal afterimages. in Audiology & neuro-otology

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Arshad Q (2013) Handedness-related cortical modulation of the vestibular-ocular reflex. in The Journal of neuroscience : the official journal of the Society for Neuroscience

 
Description Improved Treatment of Balance Disorders
Geographic Reach Multiple continents/international 
Policy Influence Type Influenced training of practitioners or researchers
Impact This REF impact case collected several lines of evidence showing how the treatments we devised had been adopted worldwide, and were cited in government health policy documents.
URL http://impact.ref.ac.uk/CaseStudies/CaseStudy.aspx?Id=42200
 
Description International diagnostic criteria on PPPD (functional psychogenic dizziness)
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in clinical reviews
Impact Psychogenic dizziness is extremely common and yet no diagnosis guidelines were available until this consensus guidelines
 
Description Rehabilitation treatment of dizziness
Geographic Reach National 
Policy Influence Type Citation in other policy documents
Impact The DOH "Provision of adult balance services: a good practice guide", 2009, recommends the treatment we devised for 'visual vertigo/dizziness' (MRC funded)
 
Description Revised European guidelines on nystagmus and oscillopsia treatment
Geographic Reach Asia 
Policy Influence Type Membership of a guidance committee
 
Description AMS Clinician Scientist Fellowship
Amount £700,000 (GBP)
Organisation Academy of Medical Sciences (AMS) 
Sector Charity/Non Profit
Country United Kingdom
Start  
 
Description MRC Project Grant
Amount £384,712 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 10/2008 
End 09/2011
 
Description P18036 - Meniere's Society Project Grant
Amount £284,406 (GBP)
Funding ID P18036 
Organisation Ménière’s Society 
Sector Charity/Non Profit
Country United Kingdom
Start 07/2008 
End 12/2015
 
Title Vestibular perceptual 'wheel' test 
Description We developed a way of quantitating a subject's perception of turning and have applied this to patients with dizziness and visual problems/ 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2008 
Provided To Others? Yes  
Impact We have identified with this technique that a traditional 'motor organ' like the cerebellum actually participates in movement perception as well. 
 
Description Cardio-respiratory function during travelling (KCL) 
Organisation King's College London
Department School of Biomedical Sciences KCL
Country United Kingdom 
Sector Academic/University 
PI Contribution We concieved the research based upon clinical observations of patients' distress during vehiclar travelling
Collaborator Contribution They provided research fellow
Impact 18791658
Start Year 2006
 
Description Cortical processing of rotational stimuli (Perugia) 
Organisation University of Perugia
Country Italy 
Sector Academic/University 
PI Contribution Provided clinical ideas. Data analysis and manuscript writing.
Collaborator Contribution Large scale testing of patients. Provided us with a new valuble vestibular stimlus (asymetric rotation)
Impact see papers together with V.E. Pettorossi
Start Year 2011
 
Description Depersonalization in vestibular disease (IMSS) 
Organisation Mexican Social Security Insitute (IMSS)
Department Medical Research Unit in Otoneurology
Country Mexico 
Sector Public 
PI Contribution We've provided technical, scientific and personnel support
Collaborator Contribution They've contributed the research protocol
Impact 17578858
 
Description Human spatial orientation (Marseille) 
Organisation Aix-Marseille University
Country France 
Sector Academic/University 
PI Contribution Provided research concepts and infrastructure
Collaborator Contribution Research fellows
Impact PMID:14663543 PMID:17101157 PMID:23206549
 
Description Long term vestibular compensation (Zurich) 
Organisation University of Zurich
Department Neurology Department Zurich
Country Switzerland 
Sector Academic/University 
PI Contribution We've provided the research concept
Collaborator Contribution The Swiss team allowed access to their patient database and adapted our research tools to their environment
Impact 18604466
Start Year 2007
 
Description Mutisegmental gaze-led body movements (Athens) 
Organisation University of Athens
Country Greece 
Sector Academic/University 
PI Contribution We've provided teh experimental protocol
Collaborator Contribution They provided novel maths-based analysis
Impact 18718325 19002676
Start Year 2008
 
Description Normal and abnormal motion sickness (Westminster) 
Organisation University of Westminster
Country United Kingdom 
Sector Academic/University 
PI Contribution We have provided our laboratory and research students to sevral projects in common
Collaborator Contribution Prof Golding, from the Univ of Westminster is a top researcher in motion sickness and a proficient statistician. His skills are used in many of our projects.
Impact 19522361 18619124
 
Description Scientific basis of neuro-rehabilitation of balance (KCL) 
Organisation King's College London
Department School of Medicine KCL
Country United Kingdom 
Sector Academic/University 
PI Contribution We provided the research concept/question and the apparatus required
Collaborator Contribution 17538212
Impact 17538212
 
Description Verticality perception in hemisphere stroke (Grenoble) 
Organisation University of Grenoble
Country France 
Sector Academic/University 
PI Contribution This projected was executed in our lab, where the visiting professor examined stroke patients with our experimental facilities
Collaborator Contribution Brought stroke/rehab research skills we did not have
Impact Pubmed # 18678565 Pubmed # 17498956 16721607 18703811
 
Description Vestibular cortical processing (UCL Sobell) 
Organisation University College London
Department Institute of Neurology
Country United Kingdom 
Sector Academic/University 
PI Contribution We've provided the research question
Collaborator Contribution They provided top experts in TMS brain stimulation for our research
Impact 18718324 18440143
Start Year 2006
 
Description Visual aspects of motion sickness (Maastricht) 
Organisation Maastricht University (UM)
Country Netherlands 
Sector Academic/University 
PI Contribution We identified the reserch question and provided the technology
Collaborator Contribution Provided research fellow
Impact 18619124
Start Year 2007
 
Description Visual control of posture (CNRS) 
Organisation National Center for Scientific Research (Centre National de la Recherche Scientifique CNRS)
Department Laboratory of Psychology and Neurocognition, University of Savoy
Country France 
Sector Public 
PI Contribution We've provided the lab and technology
Collaborator Contribution They contributed the research question and manpower
Impact 18672020 19026959
Start Year 2007
 
Description visuo-vestibular verticality perception (Provence) 
Organisation Aix-Marseille University
Country France 
Sector Academic/University 
PI Contribution Provided research equipment and appropriate patients
Collaborator Contribution Provided research fellow and research concept
Impact 17101157
Start Year 2006
 
Title DVD home-based treatment of 'visual vertigo' and difficult dizziness 
Description A collection of visual motion images designed for patients to treat their dizziness, either at home or with a physiotherapist 
IP Reference  
Protection Copyrighted (e.g. software)
Year Protection Granted 2013
Licensed Yes
Impact Most physiotherapist want to employ this treatment (www.bsno.org.uk)
 
Title Device measuring binocular disparities 
Description A head mounted device has been developed which measures eye position and visual image disorientation with facilities for testing the influence of balance organs on such eye movements. This rationalises and simplifies ENT-Ophthalmic examination. It is under trial in clinics to assess its utility and possible commercial development. 
Type Diagnostic Tool - Non-Imaging
Current Stage Of Development Refinement. Clinical
Year Development Stage Completed 2011
Development Status Under active development/distribution
Impact The instrument rationalises and simplifies ENT-Ophthalmic examination. It is currently under trial in clinics to assess its utility with a view to possible commercial development. 
 
Title Software for clinical and testing and analysis of eye movements for vestibular balance test 
Description ftware for clinical and testing and analysis of eye movements for vestibular balance test. 
Type Of Technology Software 
Open Source License? Yes  
Impact Clinical service at UCL and Imperial can now routinely analyse eye movements for vestibular testing. 
 
Description Article in 360 - the Imperial NHS newspaper 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact News item centred on our equipment, trials, diseases we see (in particular Meniere's disease)

Led to subsequent news items
Year(s) Of Engagement Activity 2009
 
Description Articles in national newspapers 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Approximately once a year the media visit our labs for one reason or another, or contact us re. publications that may catch the public's imagination (eg the 'broken escalator effect; clinical trials). This has included Daily Mail, Metro, a local West London Newspaper, Evening Standard, The Times (16/11/2004) and others.

These caused increased patient referrals to our clinical services and follow up letters in the newspapers.
Year(s) Of Engagement Activity Pre-2006,2006,2007,2008,
 
Description Articles in the 'Metro' 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Replying to letters posted by members of the public

n/c
Year(s) Of Engagement Activity Pre-2006,2009
 
Description BBC TV - Bang Goes The Theory - Series 3 Episode 2 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact It was a section, 10mins or so, in the BBC 'Bang goes the Theory'. Our eqipment was featured and our input acknowledged

No direct response as far as we could see.
Year(s) Of Engagement Activity 2010
URL http://www.bbc.co.uk/programmes/p00ccqqw
 
Description Brain awareness week. Natural history museum, London 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact Doing simple experiments in front of public

N/C
Year(s) Of Engagement Activity Pre-2006,2006,2007
 
Description Daily Mail and Daily Mail online 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Treatment of Meniere's disease by intratympanic injection for joint centre randomised, double-blind, clinical trial on unilateral refractory Meniere's disease at Charing Cross Hospital and Leicester Royal Infirmary.

Advertised new treatments for Meniere's disease trialled at Charing Cross Hospital between the Neuro-Otology department and Ear Nose and Throat.
Year(s) Of Engagement Activity 2012
URL http://www.dailymail.co.uk/health/article-2224996/Dizzy-spells-The-jab-INSIDE-ear-stop-head-spinning...
 
Description Int Sailing Magazine 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Article advising the public on managing motion sickness was published in Europe's largest sailing magazine, 'Yacht'.

Have been approached by travel companies requesting information on advising travellers and awaiting decision on whether they are willing to fund this service.
Year(s) Of Engagement Activity 2011
 
Description National newspaper article 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Newspaper article Daily Mail of differential diagnosis on acute vertigo.
Year(s) Of Engagement Activity 2013
URL http://www.dailymail.co.uk/health/article-2513427/Doctors-told-John-ear-infection-In-fact-hidden-str...
 
Description Visual vestibular rehab 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Describes a DVD for Vestibular Rehab and Stimulation by Dr Bronstein and Pavlou.
Year(s) Of Engagement Activity 2016
URL http://www.neuropt.org/docs/default-source/vsig-abstract-of-the-week-archives/vr-sig-abstracts-of-th...