Factors Responsible for The Development of Chronic Vertigo and Imbalance

Lead Research Organisation: Imperial College London

Abstract

Many patients who suffer disease of the inner ear fail to compensate and develop chronic symptoms of dizziness which are disabling. Such patients draw on medical resources since they peregrinate for years between GP and various specialists without adequate treatment since current therapies for dizzy patients, which emphasise relearning reflex balance functions are ineffective. Our research investigates: i) The impact of chronic dizziness on the patients life and functions in society; ii) failure to compensate for imbalance at a higher level of brain function involving cognition and perception; iii) the possibility that chronically dizzy patients may have an inability to both plan and control movement and balance at the same time as performing other tasks so that balance does not become automatic; iv) the possibility that certain medical conditions, for example migraine, and environmental factors, such as the psychological and physical challenges of public transport including motion sickness, may impede the patients ability to participate in the activities of everyday life; v) the effect of psycho-social context on a patients activities of daily life including the ability to work and comparing the widely differing communities of Sienna and London.

Technical Summary

This programme seeks to identify and develop treatment for factors which impede the ability to adapt to disorders of balance and vestibular function with the consequence that the patient becomes chronically dizzy.|The main components which have been the focus of attention over the 2007-2008 cycle are:|A. Chronically dizzy patients have a deficit in High order (cortical) control of balance and orientation. ||In an attempt to identify the functional localisation of vestibular cortical signals in humans we have pioneered the use of TMS (transcranial magnetic stimulation) to stimulate cortical areas and disrupt vestibular function. ||We have given the first quantitative description of vestibular function in the congenitally blind and its use in spatial navigation. Continuing studies seek to identify the mechanism for navigation in local space and how it depends on vestibular function.||To determine the effect of vestibular disorder on spatial attention we are studying Vestibular function in patients with cortical lesions with and without spatial neglect.||Adaptation to balance disorder implies that the patient is capable of locomotor learning and prediction. To determine what locomotor mechanisms might be disordered in chronic dizziness we have studied disorienting situations such as walking on a broken escalator. These studies have investigated illusory motion and inappropriate sway and are continuing to identify the neural bases of inappropriate motor behaviour: viz, frontal Lobes, basal ganglia and cerebellum and the contribution of vestibular and proprioceptive sensory control mechanisms by comparing normal subjects with patients with neurological and neurosensory disorders including cerebellar disorders and Parkinsons disease.||B. The chronically dizzy patient has a hyperplastic perceptual system so that brief experiences of dizziness provoke long term susceptibility.|Psychophysical studies are being conducted to establish if patients have different perceptual thresholds for motion and perception of orientation in comparison with matched normal subjects and how these relate to pathophysiology in terms of quantitative deficits in balance mechanisms such as degree of loss of vestibular function. ||In these studies we have introduced provocative stimulation which gives a patient (eg with positional vertigo) or normal subject a brief experience of dizziness. Thereafter changes in perception of orientation in the environment and ability to manage misleading cues (such as tilted visual surrounds) may be probed. We have identified subjects whose ability to establish veridical perception of the orientation of the environment is significantly impaired after experience of vertigo. Studies are continuing to establish the nature of this mechanism to see how it might be rehabilitated. ||C: The chronically dizzy patient is particularly susceptible to environmental challenges: vehicle motion and visual disorientation. ||Studies of environmental challenges have identified autonomic responses to buffeting motion in vehicles such as ambulances and jerky bus rides showing that young healthy adults may develop hyperventilation due to mechanical shocks and be come hypocapnic. We have also shown how people may adapt their respiration to withstand mechanical buffeting. The results will be used to study the particular vulnerability of patients with balance disorders and how they may be rehabilitated. ||Motion sickness is a frequent consequence of vehicle motion and we have developed behavioural regimes to suppress motion sickness that approach a comparable effectiveness of medication.||Visual moving scenes provoke sickness instability and dizziness in normal subjects and vestibular patients have a particular susceptibility to visual motion. We have studied normal responses to moving visual scenes characterising the particular types of motion that provoke dizziness and malaise in order to understand the visual-vestibular mechanisms that may be ren

Publications

10 25 50
publication icon
Acheson JF (2001) Elevated visual motion detection thresholds in adults with acquired ophthalmoplegia. in The British journal of ophthalmology

publication icon
Albuquerque W (2004) "Doctor, I can hear my eyes": report of two cases with different mechanisms. in Journal of neurology, neurosurgery, and psychiatry

publication icon
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

publication icon
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

publication icon
Balaratnam MS (2010) Amyotrophic lateral sclerosis and ocular flutter. in Amyotrophic lateral sclerosis : official publication of the World Federation of Neurology Research Group on Motor Neuron Diseases

 
Description Citation in a Cochrane review
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in systematic reviews
Impact The new techniques devised by our research have been adopted worldwide, eg see below from the American Physical Therapy Association: The American Physical Therapy Association "Patient Fact Sheet" on "Visual Vertigo and Motion Sensitivity": http://www.neuropt.org/docs/vsig-physician-fact-sheets/visual-vertigo-motion-sensitivity.pdf?sfvrsn=2 Podcasts: http://www.neuropt.org/special-interest-groups/vestibular-rehabilitation/podcasts (podcast #2 - "Visual vertigo" and podcast #6: High Tech Vestibular and Balance Gadgets mins. 26-36).
 
Description European guidelines on nystagmus and oscillopsia treatment
Geographic Reach Asia 
Policy Influence Type Membership of a guidance committee
 
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 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 MRC COOG - Evaluation of vibrotactile prothesis for indicating spatial orientation in patients with balance disorders and sensory deficits
Amount £182,916 (GBP)
Funding ID G0300405 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 01/2005 
End 01/2008
 
Description PhD Studentships - Dix Foundation
Amount £128,000 (GBP)
Funding ID DMMCA RC0167 
Organisation Otto Dix Foundation 
Sector Public
Country Germany
Start 03/2003 
End 02/2006
 
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 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 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 Short-latency eye movements evoked by near-threshold galvanic vestibular stimulation. (Russia) 
Organisation Russian Institute of Information Transmssion
Country Russian Federation 
Sector Academic/University 
PI Contribution Provided the concept and eye movement expertise and techniques
Collaborator Contribution Expertise on proprioceotive vibration stimuli
Impact Clarified the origin of a long standing visual illusion
 
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 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 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 Articles in Evening Standard 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact Article featured in the Evening Standard on the research we produced on the 'broken escalator effect' including large photograph (ES Monday 15/11/2004, page 17)

see above
Year(s) Of Engagement Activity Pre-2006
 
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 Radio Scotland - Live Interview 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Promoted our research across the border

Scottish researcher contacted us about this project
Year(s) Of Engagement Activity Pre-2006
 
Description BBC TV Series - The Dancers Body 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Our laboratotries featured in a BBC tv series - The Dancers Body

Inspired further research
Year(s) Of Engagement Activity Pre-2006
 
Description BBC World Service 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Health professionals
Results and Impact Teaching basic rehabilitation techniques to medical services in developing countries

N/C
Year(s) Of Engagement Activity Pre-2006
 
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