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Hamling KR, Harmon K, Kimura Y, Higashijima SI, Schoppik D. The Vestibulospinal Nucleus Is a Locus of Balance Development. J Neurosci 2024; 44:e2315232024. [PMID: 38777599 PMCID: PMC11270517 DOI: 10.1523/jneurosci.2315-23.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
Mature vertebrates maintain posture using vestibulospinal neurons that transform sensed instability into reflexive commands to spinal motor circuits. Postural stability improves across development. However, due to the complexity of terrestrial locomotion, vestibulospinal contributions to postural refinement in early life remain unexplored. Here we leveraged the relative simplicity of underwater locomotion to quantify the postural consequences of losing vestibulospinal neurons during development in larval zebrafish of undifferentiated sex. By comparing posture at two timepoints, we discovered that later lesions of vestibulospinal neurons led to greater instability. Analysis of thousands of individual swim bouts revealed that lesions disrupted movement timing and corrective reflexes without impacting swim kinematics, and that this effect was particularly strong in older larvae. Using a generative model of swimming, we showed how these disruptions could account for the increased postural variability at both timepoints. Finally, late lesions disrupted the fin/trunk coordination observed in older larvae, linking vestibulospinal neurons to postural control schemes used to navigate in depth. Since later lesions were considerably more disruptive to postural stability, we conclude that vestibulospinal contributions to balance increase as larvae mature. Vestibulospinal neurons are highly conserved across vertebrates; we therefore propose that they are a substrate for developmental improvements to postural control.
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Affiliation(s)
- Kyla R Hamling
- Departments of Otolaryngology, Neuroscience & Physiology, and the Neuroscience Institute, New York University Grossman School of Medicine, New York, New York 10016
| | - Katherine Harmon
- Departments of Otolaryngology, Neuroscience & Physiology, and the Neuroscience Institute, New York University Grossman School of Medicine, New York, New York 10016
| | - Yukiko Kimura
- National Institutes of Natural Sciences, Exploratory Research Center on Life and Living Systems (ExCELLS), National Institute for Basic Biology, Okazaki, Aichi 444-8787, Japan
| | - Shin-Ichi Higashijima
- National Institutes of Natural Sciences, Exploratory Research Center on Life and Living Systems (ExCELLS), National Institute for Basic Biology, Okazaki, Aichi 444-8787, Japan
| | - David Schoppik
- Departments of Otolaryngology, Neuroscience & Physiology, and the Neuroscience Institute, New York University Grossman School of Medicine, New York, New York 10016
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Hamling KR, Harmon K, Kimura Y, Higashijima SI, Schoppik D. The vestibulospinal nucleus is a locus of balance development. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.12.06.570482. [PMID: 38105966 PMCID: PMC10723429 DOI: 10.1101/2023.12.06.570482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Mature vertebrates maintain posture using vestibulospinal neurons that transform sensed instability into reflexive commands to spinal motor circuits. Postural stability improves across development. However, due to the complexity of terrestrial locomotion, vestibulospinal contributions to postural refinement in early life remain unexplored. Here we leveraged the relative simplicity of underwater locomotion to quantify the postural consequences of losing vestibulospinal neurons during development in larval zebrafish of undifferentiated sex. By comparing posture at two timepoints, we discovered that later lesions of vestibulospinal neurons led to greater instability. Analysis of thousands of individual swim bouts revealed that lesions disrupted movement timing and corrective reflexes without impacting swim kinematics, and that this effect was particularly strong in older larvae. Using a generative model of swimming, we showed how these disruptions could account for the increased postural variability at both timepoints. Finally, late lesions disrupted the fin/trunk coordination observed in older larvae, linking vestibulospinal neurons to postural control schemes used to navigate in depth. Since later lesions were considerably more disruptive to postural stability, we conclude that vestibulospinal contributions to balance increase as larvae mature. Vestibulospinal neurons are highly conserved across vertebrates; we therefore propose that they are a substrate for developmental improvements to postural control.
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Affiliation(s)
- Kyla R Hamling
- Departments of Otolaryngology, Neuroscience & Physiology, and the Neuroscience Institute, New York University Grossman School of Medicine
| | - Katherine Harmon
- Departments of Otolaryngology, Neuroscience & Physiology, and the Neuroscience Institute, New York University Grossman School of Medicine
| | - Yukiko Kimura
- National Institutes of Natural Sciences, Exploratory Research Center on Life and Living Systems (ExCELLS), National Institute for Basic Biology, Okazaki 444-8787, Aichi, Japan
| | - Shin-Ichi Higashijima
- National Institutes of Natural Sciences, Exploratory Research Center on Life and Living Systems (ExCELLS), National Institute for Basic Biology, Okazaki 444-8787, Aichi, Japan
| | - David Schoppik
- Departments of Otolaryngology, Neuroscience & Physiology, and the Neuroscience Institute, New York University Grossman School of Medicine
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Olechowski-Bessaguet A, Grandemange R, Cardoit L, Courty E, Lambert FM, Le Ray D. Functional organization of vestibulospinal inputs on thoracic motoneurons responsible for trunk postural control in Xenopus. J Physiol 2019; 598:817-838. [PMID: 31834949 DOI: 10.1113/jp278599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/08/2019] [Indexed: 12/15/2022] Open
Abstract
KEY POINTS Vestibulospinal reflexes participate in postural control. How this is achieved has not been investigated fully. We combined electrophysiological, neuroanatomical and imaging techniques to decipher the vestibulospinal network controlling the activation of back and limb muscles responsible for postural adjustments. We describe two distinct pathways activating either thoracic postural motoneurons alone or thoracic and lumbar motoneurons together, with the latter co-ordinating specifically hindlimb extensors and postural back muscles. ABSTRACT In vertebrates, trunk postural stabilization is known to rely mainly on direct vestibulospinal inputs on spinal axial motoneurons. However, a substantial role of central spinal commands ascending from lumbar segments is not excluded during active locomotion. In the adult Xenopus, a lumbar drive dramatically overwhelms the descending inputs onto thoracic postural motoneurons during swimming. Given that vestibulospinal fibres also project onto the lumbar segments that shelter the locomotor generators, we investigated whether such a lumbo-thoracic pathway may relay vestibular information and consequently, also be involved in the control of posture at rest. We show that thoracic postural motoneurons exhibit particular dendritic spatial organization allowing them to gather information from both sides of the cord. In response to passive head motion, these motoneurons display both early and delayed discharges, with the latter occurring in phase with ipsilateral hindlimb extensor bursts. We demonstrate that both vestibulospinal and lumbar ascending fibres converge onto postural motoneurons, and that thoracic motoneurons monosynaptically respond to the electrical stimulation of either pathway. Finally, we show that vestibulospinal fibres project to and activate lumbar interneurons with thoracic projections. Taken together, our results complete the scheme of the vestibulospinal control of posture by illustrating the existence of a novel, indirect pathway, which implicates lumbar interneurons relaying vestibular inputs to thoracic motoneurons, and participating in global body postural stabilization in the absence of active locomotion.
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Affiliation(s)
- Anne Olechowski-Bessaguet
- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA, CNRS UMR 5287), Université de Bordeaux, Bordeaux cedex, France
| | - Raphaël Grandemange
- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA, CNRS UMR 5287), Université de Bordeaux, Bordeaux cedex, France
| | - Laura Cardoit
- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA, CNRS UMR 5287), Université de Bordeaux, Bordeaux cedex, France
| | - Elric Courty
- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA, CNRS UMR 5287), Université de Bordeaux, Bordeaux cedex, France
| | - François M Lambert
- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA, CNRS UMR 5287), Université de Bordeaux, Bordeaux cedex, France
| | - Didier Le Ray
- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA, CNRS UMR 5287), Université de Bordeaux, Bordeaux cedex, France
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Yakushin SB, Martinelli GP, Raphan T, Xiang Y, Holstein GR, Cohen B. Vasovagal oscillations and vasovagal responses produced by the vestibulo-sympathetic reflex in the rat. Front Neurol 2014; 5:37. [PMID: 24772102 PMCID: PMC3983498 DOI: 10.3389/fneur.2014.00037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 03/14/2014] [Indexed: 12/17/2022] Open
Abstract
Sinusoidal galvanic vestibular stimulation (sGVS) induces oscillations in blood pressure (BP) and heart rate (HR), i.e., vasovagal oscillations, as well as transient decreases in BP and HR, i.e., vasovagal responses, in isoflurane-anesthetized rats. We determined the characteristics of the vasovagal oscillations, assessed their role in the generation of vasovagal responses, and determined whether they could be induced by monaural as well as by binaural sGVS and by oscillation in pitch. Wavelet analyses were used to determine the power distributions of the waveforms. Monaural and binaural sGVS and pitch generated vasovagal oscillations at the frequency and at twice the frequency of stimulation. Vasovagal oscillations and vasovagal responses were maximally induced at low stimulus frequencies (0.025-0.05 Hz). The oscillations were attenuated and the responses were rarely induced at higher stimulus frequencies. Vasovagal oscillations could occur without induction of vasovagal responses, but vasovagal responses were always associated with a vasovagal oscillation. We posit that the vasovagal oscillations originate in a low frequency band that, when appropriately activated by strong sympathetic stimulation, can generate vasovagal oscillations as a precursor for vasovagal responses and syncope. We further suggest that the activity responsible for the vasovagal oscillations arises in low frequency, otolith neurons with orientation vectors close to the vertical axis of the head. These neurons are likely to provide critical input to the vestibulo-sympathetic reflex to increase BP and HR upon changes in head position relative to gravity, and to contribute to the production of vasovagal oscillations and vasovagal responses and syncope when the baroreflex is inactivated.
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Affiliation(s)
- Sergei B Yakushin
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Giorgio P Martinelli
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Theodore Raphan
- Department of Computer and Information Sciences, Brooklyn College of the City University of New York , Brooklyn, NY , USA
| | - Yongqing Xiang
- Department of Computer and Information Sciences, Brooklyn College of the City University of New York , Brooklyn, NY , USA
| | - Gay R Holstein
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, NY , USA ; Department of Neuroscience, Icahn School of Medicine at Mount Sinai , New York, NY , USA
| | - Bernard Cohen
- Department of Neurology, Icahn School of Medicine at Mount Sinai , New York, NY , USA
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Catanzaro MF, Miller DJ, Cotter LA, McCall AA, Yates BJ. Integration of vestibular and gastrointestinal inputs by cerebellar fastigial nucleus neurons: multisensory influences on motion sickness. Exp Brain Res 2014; 232:2581-9. [PMID: 24677139 DOI: 10.1007/s00221-014-3898-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/25/2014] [Indexed: 12/14/2022]
Abstract
Previous studies demonstrated that ingestion of the emetic compound copper sulfate (CuSO4) alters the responses to vestibular stimulation of a large fraction of neurons in brainstem regions that mediate nausea and vomiting, thereby affecting motion sickness susceptibility. Other studies suggested that the processing of vestibular inputs by cerebellar neurons plays a critical role in generating motion sickness and that neurons in the cerebellar fastigial nucleus receive visceral inputs. These findings raised the hypothesis that stimulation of gastrointestinal receptors by a nauseogenic compound affects the processing of labyrinthine signals by fastigial nucleus neurons. We tested this hypothesis in decerebrate cats by determining the effects of intragastric injection of CuSO4 on the responses of rostral fastigial nucleus to whole-body rotations that activate labyrinthine receptors. Responses to vestibular stimulation of fastigial nucleus neurons were more complex in decerebrate cats than reported previously in conscious felines. In particular, spatiotemporal convergence responses, which reflect the convergence of vestibular inputs with different spatial and temporal properties, were more common in decerebrate than in conscious felines. The firing rate of a small percentage of fastigial nucleus neurons (15%) was altered over 50% by the administration of CuSO4; the firing rate of the majority of these cells decreased. The responses to vestibular stimulation of a majority of these cells were attenuated after the compound was provided. Although these data support our hypothesis, the low fraction of fastigial nucleus neurons whose firing rate and responses to vestibular stimulation were affected by the administration of CuSO4 casts doubt on the notion that nauseogenic visceral inputs modulate motion sickness susceptibility principally through neural pathways that include the cerebellar fastigial nucleus. Instead, it appears that convergence of gastrointestinal and vestibular inputs occurs mainly in the brainstem.
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Affiliation(s)
- Michael F Catanzaro
- Department of Otolaryngology, University of Pittsburgh, Room 519, Eye and Ear Institute, Pittsburgh, PA, 15213, USA
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Kasumacic N, Glover JC, Perreault MC. Vestibular-mediated synaptic inputs and pathways to sympathetic preganglionic neurons in the neonatal mouse. J Physiol 2012; 590:5809-26. [PMID: 22946097 PMCID: PMC3528993 DOI: 10.1113/jphysiol.2012.234609] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 08/29/2012] [Indexed: 12/17/2022] Open
Abstract
To assess when vestibulosympathetic projections become functional postnatally, and to establish a preparation in which vestibulosympathetic circuitry can be characterized more precisely, we used an optical approach to record VIIIth nerve-evoked synaptic inputs to thoracic sympathetic preganglionic neurons (SPNs) in newborn mice. Stimulation of the VIIIth nerve was performed in an isolated brainstem-spinal cord preparation after retrogradely labelling with the fluorescent calcium indicator Calcium Green 1-conjugated dextran amine, the SPNs and the somatic motoneurons (MNs) in the thoracic (T) segments T2, 4, 6, 8, 10 and 12. Synaptically mediated calcium responses could be visualized and recorded in individual SPNs and MNs, and analysed with respect to latency, temporal pattern, magnitude and synaptic pharmacology. VIIIth nerve stimulation evoked responses in all SPNs and MNs investigated. The SPN responses had onset latencies from 90 to 200 ms, compared with much shorter latencies in MNs, and were completely abolished by mephenesin, a drug that preferentially reduces polysynaptic over monosynaptic transmission. Bicuculline and picrotoxin, but not strychnine, increased the magnitudes of the SPN responses without changing the onset latencies, suggesting a convergence of concomitant excitatory and inhibitory synaptic inputs. Lesions strategically placed to test the involvement of direct vestibulospinal pathways versus indirect pathways within the brainstem showed that vestibulosympathetic inputs in the neonate are mediated predominantly, if not exclusively, by the latter. Thus, already at birth, synaptic connections in the vestibulosympathetic reflex are functional and require the involvement of the ventrolateral medulla as in adult mammals.
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Affiliation(s)
- Nedim Kasumacic
- Laboratory of Neural Development and Optical Recording (NDEVOR), Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, N-0317 Oslo, Norway
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Highstein SM, Holstein GR. The anatomical and physiological framework for vestibular prostheses. Anat Rec (Hoboken) 2012; 295:2000-9. [PMID: 23044714 PMCID: PMC4039022 DOI: 10.1002/ar.22582] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 07/24/2012] [Indexed: 12/14/2022]
Abstract
This article reviews the structure function of the vestibular system and its pathology with respect to requirements for the design and construction of a functional vestibular prosthesis. The ultimate goal of a vestibular prosthesis is to restore balance and equilibrium through direct activation of vestibular nerve fibers. An overview of the peripheral and central vestibular systems that highlights their most important functional aspects re: the design of a prosthesis is provided. Namely, the peripheral labyrinth faithfully transduces head motion and gravity in both the time and frequency domains. These signals are described in hopes that they may be prosthetically replicated. The peripheral and central connections of the vestibular nerve are also discussed in detail, as are the vestibular nuclei in the brainstem that receive VIIIth nerve innervation. Lastly, the functional effector pathways of the vestibular system, including the vestibulo-ocular, vestibulo-spinal, vestibulo-colic, vestibulo-autonomic, and vestibular efferent innervation of the labyrinth are reviewed.
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Sugiyama Y, Suzuki T, DeStefino VJ, Yates BJ. Integrative responses of neurons in nucleus tractus solitarius to visceral afferent stimulation and vestibular stimulation in vertical planes. Am J Physiol Regul Integr Comp Physiol 2011; 301:R1380-90. [PMID: 21832211 DOI: 10.1152/ajpregu.00361.2011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Anatomical studies have demonstrated that the vestibular nuclei project to nucleus tractus solitarius (NTS), but little is known about the effects of vestibular inputs on NTS neuronal activity. Furthermore, lesions of NTS abolish vomiting elicited by a variety of different triggering mechanisms, including vestibular stimulation, suggesting that emetic inputs may converge on the same NTS neurons. As such, an emetic stimulus that activates gastrointestinal (GI) receptors could alter the responses of NTS neurons to vestibular inputs. In the present study, we examined in decerebrate cats the responses of NTS neurons to rotations of the body in vertical planes before and after the intragastric administration of the emetic compound copper sulfate. The activity of more than one-third of NTS neurons was modulated by vertical vestibular stimulation, with most of the responsive cells having their firing rate altered by rotations in the head-up or head-down directions. These responses were aligned with head position in space, as opposed to the velocity of head movements. The activity of NTS neurons with baroreceptor, pulmonary, and GI inputs could be modulated by vertical plane rotations. However, injection of copper sulfate into the stomach did not alter the responses to vestibular stimulation of NTS neurons that received GI inputs, suggesting that the stimuli did not have additive effects. These findings show that the detection and processing of visceral inputs by NTS neurons can be altered in accordance with the direction of ongoing movements.
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Affiliation(s)
- Yoichiro Sugiyama
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Destefino VJ, Reighard DA, Sugiyama Y, Suzuki T, Cotter LA, Larson MG, Gandhi NJ, Barman SM, Yates BJ. Responses of neurons in the rostral ventrolateral medulla to whole body rotations: comparisons in decerebrate and conscious cats. J Appl Physiol (1985) 2011; 110:1699-707. [PMID: 21493724 DOI: 10.1152/japplphysiol.00180.2011] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The responses to vestibular stimulation of brain stem neurons that regulate sympathetic outflow and blood flow have been studied extensively in decerebrate preparations, but not in conscious animals. In the present study, we compared the responses of neurons in the rostral ventrolateral medulla (RVLM), a principal region of the brain stem involved in the regulation of blood pressure, to whole body rotations of conscious and decerebrate cats. In both preparations, RVLM neurons exhibited similar levels of spontaneous activity (median of ∼17 spikes/s). The firing of about half of the RVLM neurons recorded in decerebrate cats was modulated by rotations; these cells were activated by vertical tilts in a variety of directions, with response characteristics suggesting that their labyrinthine inputs originated in otolith organs. The activity of over one-third of RVLM neurons in decerebrate animals was altered by stimulation of baroreceptors; RVLM units with and without baroreceptor signals had similar responses to rotations. In contrast, only 6% of RVLM neurons studied in conscious cats exhibited cardiac-related activity, and the firing of just 1% of the cells was modulated by rotations. These data suggest that the brain stem circuitry mediating vestibulosympathetic reflexes is highly sensitive to changes in body position in space but that the responses to vestibular stimuli of neurons in the pathway are suppressed by higher brain centers in conscious animals. The findings also raise the possibility that autonomic responses to a variety of inputs, including those from the inner ear, could be gated according to behavioral context and attenuated when they are not necessary.
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Affiliation(s)
- V J Destefino
- Univ. of Pittsburgh School of Medicine, Dept. of Otolaryngology, Eye and Ear Institute, Rm. 519, Pittsburgh, PA 15213, USA
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Review of first trial responses in balance control: influence of vestibular loss and Parkinson's disease. Hum Mov Sci 2011; 30:279-95. [PMID: 21435732 DOI: 10.1016/j.humov.2010.11.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 11/16/2010] [Accepted: 11/20/2010] [Indexed: 11/20/2022]
Abstract
The reaction to an unexpected balance disturbance is unpracticed, often startling and frequently associated with falls. This everyday situation can be reproduced in an experimental setting by exposing standing humans to sudden, unexpected and controlled movements of a support surface. In this review, we focus on the responses to the very first balance perturbation, the so-called first trial reactions (FTRs). Detailed analysis of FTRs may have important implications, both for clinical practice (providing new insights into the pathophysiological mechanisms underlying accidental falls in real life) and for understanding human physiology (what triggers and mediates these FTRs, and what is the relation to startle responses?). Several aspects of the FTRs have become clear. FTRs are characterized by an exaggerated postural reaction, with large EMG responses and co-contracting muscles in multiple body segments. This balance reaction is associated with marked postural instability (greater body sway to the perturbation). When the same perturbation is repeated, the size of the postural response habituates and the instability disappears. Other issues about FTRs remain largely unresolved, and these are addressed here. First, the functional role of FTRs is discussed. It appears that FTRs produce primarily increased trunk flexion during the multi-segmental response to postural perturbations, thus producing instability. Second, we consider which sensory signals trigger and modulate FTRs, placing specific emphasis on the role of vestibular signals. Surprisingly, vestibular signals appear to have no triggering role, but vestibular loss leads to excessive upper body FTRs due to loss of the normal modulatory influence. Third, we address the question whether startle-like responses are contributing to FTRs triggered by proprioceptive signals. We explain why this issue is still unresolved, mainly because of methodological difficulties involved in separating FTRs from 'pure' startle responses. Fourth, we review new work about the influence of perturbation direction on FTRs. Recent work from our group shows that the largest FTRs are obtained for toe-up support surface rotations which perturb the COM in the posterior direction. This direction corresponds to the directional preponderance for falls seen both in the balance laboratory and in daily life. Finally, we briefly touch upon clinical diagnostic issues, addressing whether FTRs (as opposed to habituated responses) could provide a more ecologically valid perspective of postural instability in patients compared to healthy subjects. We conclude that FTRs are an important source of information about human balance performance, both in health and disease. Future studies should no longer discard FTRs, but routinely include these in their analyses. Particular emphasis should be placed on the link between FTRs and everyday balance performance (including falls), and on the possible role played by startle reactions in triggering or modulating FTRs.
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