Perception of Upright: Multisensory Convergence and the Role of Temporo-Parietal Cortex

Focused Update on Clinical Testing of Otolith Organs

Sensing gravity through the otolith receptors is crucial for bipedal stability and gait. The overall contribution of the otolith organs to eye movements, postural control, and perceptual functions is the basis for clinical testing of otolith function. With such a wide range of contributions, it is important to recognize that the functional outcomes of these tests may vary depending on the specific method employed to stimulate the hair cells. In this article, we review common methods used for clinical evaluation of otolith function and discuss how different aspects of physiology may affect the functional measurements in these tests. We compare the properties and performance of various clinical tests with an emphasis on the newly developed video ocular counter roll (vOCR), measurement of ocular torsion on fundus photography, and subjective visual vertical or horizontal (SVV/SVH) testing.

Focused Update on Migraine and Vertigo Comorbidity

PURPOSE OF REVIEW

To provide an update on comorbidity of vestibular symptoms and migraine.

RECENT FINDINGS

Multisensory processing and integration is a key concept for understanding mixed presentation of migraine and vestibular symptoms. Here, we discuss how vestibular migraine should be distinguished from a secondary migraine phenomenon in which migraine symptoms may coincide with or triggered by another vestibular disorder. We also have some updates on the diagnostic criteria of vestibular migraine, its pathophysiology, and common approaches used for its treatment. As a common clinical presentation of migraine and vestibular symptoms, vestibular migraine should be distinguished from a secondary migraine phenomenon, in which migraine symptoms may be triggered by or coincide with another vestibular disorder. Recent experimental evidence suggests vestibular symptoms in vestibular migraine are linked to multisensory mechanisms that control body motion and orientation in space.

Asymmetry of the Subjective Visual Vertical in Patients With Unilateral Peripheral Vestibular Deficit

BACKGROUND AND OBJECTIVES

Perception of verticality is clinically assessed using the subjective visual vertical (SVV), a test of the otolith system that consists of aligning a bar on the gravitational vertical in darkness. Patients with acute unilateral vestibulopathy (AUVP) show a systematic SVV bias toward the affected side, whichever the side of line orientation. Whether SVV estimates are symmetrical has not been investigated.

SUBJECTS AND METHODS

This study included 10 patients with AUVP (vestibular neuritis) and 10 with BPPV (posterior semicircular canal). SVV measurements were made at two preset angles of line orientation (15° and 30°) toward the ipsilateral and contralateral sides, relative to the affected side.

RESULTS

The results showed asymmetrical SVV estimates in the AUVP group, with significantly greater SVV errors for ipsilateral than contralateral line orientation, as well as for the preset angle of 30° compared to 15°. SVV estimates were significantly lower in patients with BPPV who also exhibited SVV asymmetry. SVV estimates remained unchanged just after the maneuver and were normalized some days later or after supplementary maneuvers.

CONCLUSIONS

SVV asymmetry should be routinely considered in the clinic. We recommend individually assessing ipsilateral and contralateral SVV and using at least two preset angles. This allows for a better assessment and diagnosis of otolith organ imbalance that can trigger chronic instability and dizziness. The contribution of neck afferents related to head position in space seems to be the main source of SVV asymmetry.

Clinical Assessment of Subjective Visual and Haptic Vertical Norms in Healthy Adults

BACKGROUND AND OBJECTIVE

Accurate verticality perception is essential for daily life activities, such as correctly estimating object orientation in space. This study established normative data for the subjective visual vertical (SVV) and subjective haptic vertical (SHV) using the portable and self-constructable modified Bucket test and Rotating-Column test. Additionally, the contribution of age, sex, and starting position of the line/ column on SVV and SHV accuracy were evaluated.

METHOD

This study, part of the PRECISE project (ClinicalTrials.gov ID NCT05978596), was conducted following the STROBE guidelines. Healthy adults without visual/neurological/vestibular disorders were recruited. Subjective visual vertical and SHV accuracy were described in terms of constant errors (i.e., mean deviation from 0° [true vertical] respecting its direction), unsigned errors (i.e., mean deviation from 0° irrespective of direction), and variability (i.e., intra-individual standard deviation).

RESULTS

Sixty participants were evaluated (mean age: 41.14 [SD = 16.74] years). Subjective visual vertical constant errors between -2.82° and 2.90°, unsigned errors up to 2.15°, and variability up to 1.61° are considered normal. Subjective haptic vertical constant errors ranged from -6.94° to 8.18°, unsigned errors up to 6.66° and variability up to 4.25°. Higher ages led to higher SVV unsigned errors and variability. SHV variability was higher in females compared to males. Certain starting positions led to higher SVV and SHV constants and SVV unsigned errors.

DISCUSSION

Normative data are provided for affordable, self-constructable, and portable SVV and SHV tools. These norms are consistent with more sophisticated equipment and can be used to distinguish between normal and abnormal values.

Rod and frame test parameters for neuropsychology studies

BACKGROUND

The rod and frame test (RFT), a measure of field dependence-independence, recently has reemerged as a measure of research interest and potential diagnostic value in neuropsychology. In the standard RFT, the subject experiences offsetting visual cues from a frame surrounding an embedded rod, while the subject's postural/vestibular cues provide the sense of verticality as the subject attempts to set the rod to vertical. The paper shows that RFTs not adhering to RFT parameters can reduce the test's visual framework impact experienced by the subject. Comparisons of neuropsychological studies will highlight that correct adherence to RFT testing conditions can strengthen RFT effects.

METHOD

This review presents the parameters that have been studied which impact on subject performance on the RFT. It identifies how computer administered RFTs have been applied to enhance the study of the RFT parameters and make the RFT more accessible to the study of different diagnostic groups. The article also critiques studies by identifying how the RFT's parameters, study's design and statistical analysis may have diminished identifying the full effects of the RFT experience.

RESULTS

Parameters impacting judgments of verticality of the rod can include: perceived size of rod and frame, the gap between the ends of the rod and surrounding frame, presentation of the rod within an encompassing 3D visual framework that visually blocks out the surrounding environment, a dark room, instructions stressing egocentric vs allocentric strategies, double frame surrounding the rod to assess global perception effects, etc. Details are presented how gap size likely affected results in neuropsychology studies. Potentially, these and other experiments may be studied using computer administered RFTs.

CONCLUSIONS

Based on the descriptions of computer administered RFTs, this article suggested that incorporating these technologies can provide better understanding underlying the RFT, and in turn, understanding neuropsychology processes.

Hypoperfusion in Supramarginal and Orbital Gyrus, Position Discrimination Test, and Microsaccades as a Predictor of Pisa Syndrome in Parkinson's Disease

Patients with Parkinson's disease (PD) experience significantly reduced quality of life when PD is complicated with Pisa syndrome (PS). PS is a postural abnormality associated with a lateral bending of the trunk, causing the patient to lean to one side. Microsaccades during fixation are transmitted to the visual cortex, and this gaze movement may be impaired in PD. We aimed to detect presymptomatic signs of PS. We enrolled 50 patients with PD without dementia and investigated the visual systems in patients with concurrent PD and PS based on a Romberg ratio of<1.0. Gaze analysis, pupil diameter, stabilization tests, neuropsychological tests, and cerebral perfusion scintigraphy were reviewed and statistically analyzed. Two years later, we divided the patients into three groups as follows: PISA++ (patients who had PS at enrollment), PISA-+ (patients without PS that developed PS during the 2-year period), and PISA-- (patients without PS that did not develop PS during the 2-year period). The PISA-+ group exhibited a significantly higher daily levodopa dose and longer fixations, as well as lower position discrimination, Wechsler Adult Intelligence Scale-Third Edition blocking, and blood flow in the left supramarginal and orbital gyri than that in the PISA-- group. The PISA++ group showed a significantly longer fixation time and lower Mini-Mental State Examination score, Romberg ratio of area, amplitude, velocity of microsaccades, and blood flow in the left precuneus and cuneus than that in the PISA-+ group. Before the onset of PS, hypoperfusion occurred in the correlative visual cortex and the position discrimination test. Patients with PS have reduced saccades and slow microsaccades.

Assessments of Subjective Visual Gravity and Spontaneous Nystagmus in Patients With Vestibular Neuritis

OBJECTIVE

This study aimed to assess the correlation between the spontaneous nystagmus (SN) and the subjective visual vertical/horizontal (SVV/SVH) among patients with vestibular neuritis (VN) at the different head positions.

STUDY DESIGN

Case-control study.

SETTING

Affiliated Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine.

METHODS

This study evaluated the SVV/SVH in both healthy subjects and patients with VN. These evaluations were performed in 5 different head positions: upright, 45° tilt to the left, 90° tilt to the left, 45° tilt to the right, and 90° tilt to the right. Additionally, the intensity of SN, as measured by slow-phase velocity, was recorded.

RESULTS

In patients with VN, a significant correlation was observed between SN and SVV/SVH in an upright position. The intensity of SN was higher when the head was tilted 90° toward the affected side compared to other positions. The SVV/SVH displayed an ipsiversive shift, when the head was tilted toward both the lesion and unaffected sides, exhibiting a contraversive direction. Furthermore, the changes in position-induced SN were consistent with the displacements of SVV and SVH caused by head tilt.

CONCLUSION

The presence of SN in patients with VN was observed to vary across different head position. These variations could potentially be attributed to the diverse activation patterns of the mechanical properties of otolith organs that are induced by head tilts.

Representational horizon and visual space orientation: An investigation into the role of visual contextual cues on spatial mislocalisations

The perceived offset position of a moving target has been found to be displaced forward, in the direction of motion (Representational Momentum; RM), downward, in the direction of gravity (Representational Gravity; RG), and, recently, further displaced along the horizon implied by the visual context (Representational Horizon; RH). The latter, while still underexplored, offers the prospect to clarify the role of visual contextual cues in spatial orientation and in the perception of dynamic events. As such, the present work sets forth to ascertain the robustness of Representational Horizon across varying types of visual contexts, particularly between interior and exterior scenes, and to clarify to what degree it reflects a perceptual or response phenomenon. To that end, participants were shown targets, moving along one out of several possible trajectories, overlaid on a randomly chosen background depicting either an interior or exterior scene rotated -22.5º, 0º, or 22.5º in relation to the actual vertical. Upon the vanishing of the target, participants were required to indicate its last seen location with a computer mouse. For half the participants, the background vanished with the target while for the remaining it was kept visible until a response was provided. Spatial localisations were subjected to a discrete Fourier decomposition procedure to obtain independent estimates of RM, RG, and RH. Outcomes showed that RH's direction was biased towards the horizon implied by the visual context, but solely for exterior scenes, and irrespective of its presence or absence during the spatial localisation response, supporting its perceptual/representational nature.

What visuospatial perception has taught us about the pathophysiology of vestibular migraine

PURPOSE OF REVIEW

A decade has passed since vestibular migraine (VM) was formally established as a clinical entity. During this time, VM has emerged amongst the most common cause of episodic vertigo. Like all forms of migraine, VM symptoms are most prominent during individual attacks, however many patients may also develop persistent symptoms that are less prominent and can still interfere with daily activities.

RECENT FINDINGS

Vestibular inputs are strongly multimodal, and because of extensive convergence with other sensory information, they do not result in a distinct conscious sensation. Here we review experimental evidence that supports VM symptoms are linked to multisensory mechanisms that control body motion and position in space.

SUMMARY

Multisensory integration is a key concept for understanding migraine. In this context, VM pathophysiology may involve multisensory processes critical for motion perception, spatial orientation, visuospatial attention, and spatial awareness.

Nonhuman primates exploit the prior assumption that the visual world is vertical

When human subjects tilt their heads in dark surroundings, the noisiness of vestibular information impedes precise reports on objects' orientation with respect to Earth's vertical axis. This difficulty is mitigated if a vertical visual background is available. Tilted visual backgrounds induce feelings of head tilt in subjects who are in fact upright. This is often explained as a result of the brain resorting to the prior assumption that natural visual backgrounds are vertical. Here, we tested whether monkeys show comparable perceptual mechanisms. To this end we trained two monkeys to align a visual arrow to a vertical reference line that had variable luminance across trials, while including a large, clearly visible background square whose orientation changed from trial to trial. On ∼20% of all trials, the vertical reference line was left out to measure the subjective visual vertical (SVV). When the frame was upright, the monkeys' SVV was aligned with the gravitational vertical. In accordance with the perceptual reports of humans, however, when the frame was tilted it induced an illusion of head tilt as indicated by a bias in SVV toward the frame orientation. Thus all primates exploit the prior assumption that the visual world is vertical.NEW & NOTEWORTHY Here we show that the principles that characterize the human perception of the vertical are shared by another old world primate species, the rhesus monkey, suggesting phylogenetic continuity. In both species the integration of visual and vestibular information on the orientation of the head relative to the world is similarly constrained by the prior assumption that the visual world is vertical in the sense of having an orientation that is congruent with the gravity vector.

Transcranial Direct Current Stimulation over the Temporoparietal Junction Modulates Posture Control in Unfamiliar Environments

The temporoparietal junction (TPJ), which integrates visual, somatosensory, and vestibular information to form body schema, is involved in human postural control. We evaluated whether or not the transcranial direct current stimulation (tDCS) of the TPJ can modulate postural control on an unstable surface with eyes closed, during which the updating of body schema is needed to maintain balance. Sixteen healthy subjects participated in this study. The order of the three types of tDCS (anodal, cathodal, and sham) over the right TPJ was counterbalanced across the participants. We evaluated dynamic posture control while the participants were standing on a stable surface with eyes open and an unstable surface with eyes closed. Anodal tDCS enhanced postural control on an unstable surface with eyes closed during and after stimulation, but cathodal tDCS deteriorated postural control during stimulation. Neither anodal nor cathodal tDCS altered postural control while the participants were on a stable surface with eyes open. Anodal tDCS may enhance postural control with non-vision and altered tactile perception by activating the TPJ, which integrates multisensory inputs to update the body schema, whereas cathodal tDCS has the opposite effect. tDCS over the TPJ may facilitate the updating of body schemas to accommodate changes in sensory inputs and help develop novel approaches to prevent falls.

Neuroanatomy of reduced distortion of body-centred spatial coding during body tilt in stroke patients

Awareness of the direction of the body's (longitudinal) axis is fundamental for action and perception. The perceived body axis orientation is strongly biased during body tilt; however, the neural substrates underlying this phenomenon remain largely unknown. Here, we tackled this issue using a neuropsychological approach in patients with hemispheric stroke. Thirty-seven stroke patients and 20 age-matched healthy controls adjusted a visual line with the perceived body longitudinal axis when the body was upright or laterally tilted by 10 degrees. The bias of the perceived body axis caused by body tilt, termed tilt-dependent error (TDE), was compared between the groups. The TDE was significantly smaller (i.e., less affected performance by body tilt) in the stroke group (15.9 ± 15.9°) than in the control group (25.7 ± 17.1°). Lesion subtraction analysis and Bayesian lesion-symptom inference revealed that the abnormally reduced TDEs were associated with lesions in the right occipitotemporal cortex, such as the superior and middle temporal gyri. Our findings contribute to a better understanding of the neuroanatomy of body-centred spatial coding during whole-body tilt.

Psychophysical evidence for the involvement of head/body-centered reference frames in egocentric visuospatial memory: A whole-body roll tilt paradigm

Accurate memory regarding the location of an object with respect to one's own body, termed egocentric visuospatial memory, is essential for action directed toward the object. Although researchers have suggested that the brain stores information related to egocentric visuospatial memory not only in the eye-centered reference frame but also in the other egocentric (i.e., head- or body-centered or both) reference frames, experimental evidence is scarce. Here, we tested this possibility by exploiting the perceptual distortion of head/body-centered coordinates via whole-body tilt relative to gravity. We hypothesized that if the head/body-centered reference frames are involved in storing the egocentric representation of a target in memory, then reproduction would be affected by this perceptual distortion. In two experiments, we asked participants to reproduce the remembered location of a visual target relative to their head/body. Using intervening whole-body roll rotations, we manipulated the initial (target presentation) and final (reproduction of the remembered location) body orientations in space and evaluated the effect on the reproduced location. Our results showed significant biases of the reproduced target location and perceived head/body longitudinal axis in the direction of the intervening body rotation. Importantly, the amount of error was correlated across participants. These results provide experimental evidence for the neural encoding and storage of information related to egocentric visuospatial memory in the head/body-centered reference frames.

Gravity perception disturbance in patients with unilateral Meniere disease

Objective

To investigate gravity perception disturbance (GPD) in patients with Meniere disease (MD), we classified GPD type based on the results of the head-tilt perception gain (HTPG) and the head-upright subjective visual vertical (HU-SVV) evaluated by the head-tilt SVV (HT-SVV) test in patients with unilateral MD.

Methods

We conducted the HT-SVV test on 115 patients with unilateral MD and 115 healthy controls. Among the 115 patients, the period from the first vertigo episode to the examination (PFVE) was known for 91 patients.

Results

The HT-SVV test classified 60.9% and 39.1% of patients with unilateral MD as GPD and non-GPD, respectively. GPD was classified according to HTPG/HU-SVV combinations as follows: Type A GPD (21.7%, normal HTPG/abnormal HU-SVV), Type B GPD (23.5%, abnormal HTPG/normal HU-SVV), and Type C GPD (15.7%, abnormal HTPG/abnormal HU-SVV). As the PFVE became longer, patients with non-GPD and Type A GPD decreased; however, those with Types B and C GPD increased.

Conclusion

This study provides novel information on unilateral MD from the perspective of gravity perception by classifying GPD based on the results of the HT-SVV test. This study's findings suggest that overcompensation for vestibular dysfunction in patients with unilateral MD exhibited by large HTPG abnormalities may be strongly associated with persistent postural-perceptual dizziness.

Level of Evidence

3b.

Subjective visual vertical and head position in patients with idiopathic scoliosis

BACKGROUND

Idiopathic scoliosis (IS) is a structural spinal deformity that can affect the position of the head. One of the etiological hypotheses is that it can be caused by dysfunction of the vestibular system, which can cause abnormal perception of subjective visual vertical (SVV).

OBJECTIVE

This study aimed to evaluate the differences in head position and its possible correlation with the perception of SVV in children with IS.

METHODS

We examined 37 patients with IS and 37 healthy individuals. The position of the head was evaluated from digital photographs, where we compared the coronal head tilt and the coronal shoulder angle. Measurement of SVV perception was performed using the Bucket method.

RESULTS

Coronal head tilt values were significantly different between the groups (median 2.3° [interquartile range 1.8-4.2] vs 1.3° [0.9-2.3], p = 0.001; patients vs. controls). There was a significant difference in SVV between the groups (2.33° [1.40-3.25] vs 0.50° [0.41-1.10], p < 0.001; patients vs controls). There was a correlation between the side of head tilt and the side of SVV in patients with IS (χ2 = 5.6, p = 0.02).

CONCLUSIONS

Patients with IS had a greater head tilt in the coronal plane and impaired SVV perception.

Comparing the impact of the method of adjustment and forced-choice methodologies on subjective visual vertical bias and variability

BACKGROUND

Previous research suggested that the method of adjustment and forced choice variants of the subjective visual vertical (SVV) produce comparable estimates of both bias and variability. However, variants of the SVV that utilize a method of adjustment procedure are known to be heavily influenced by task parameters, including the stimulus rotation speed, which was not accounted for in previous SVV research comparing the method of adjustment to forced-choice.

OBJECTIVE

The aim of the present study was to determine if (1) the SVV with a forced-choice procedure produces both bias and variability estimates that are comparable to those obtained using a method of adjustment procedure, (2) to see if rotation speed impacts the comparability of estimates and (3) quantify correlations between the estimates produced by different procedures.

METHODS

Participants completed a variant of the SVV which utilized a forced-choice procedure as well as two variants of the SVV using a method of adjustment procedure with two different rotation speeds (6°/s and 12°/s).

RESULTS

We found that the bias estimates were similar across all three conditions tested and that the variability estimates were greater in the SVV variants that utilized a method of adjustment procedure. This difference was more pronounced when the rotation speed was slower (6°/s).

CONCLUSIONS

The results of this study suggest that forced-choice and method of adjustment methodologies yield similar bias estimates and different variability estimates. Given these results, we recommend utilizing forced-choice procedures unless (a) forced-choice is not feasible or (b) response variability is unimportant. We also recommend that clinicians consider the SVV methods when interpreting a patient's test results, especially for variability metrics.

The diagnostic value of the ocular tilt reaction plus head tilt subjective visual vertical (±45°) in patients with acute central vascular vertigo

Objectives

To investigate the localization diagnostic value of the ocular tilt reaction (OTR) plus head tilt subjective visual vertical (SVV) in patients with acute central vascular vertigo (ACVV).

Methods

We enrolled 40 patients with acute infarction, 20 with unilateral brainstem infarction (BI) and 20 with unilateral cerebellar infarction (CI). We also included 20 patients with unilateral peripheral vestibular disorders (UPVD) as the control group. The participants completed the OTR and SVV during head tilt (±45°) within 1 week of symptom onset.

Results

In patients with ACVV, including that caused by lateral medullary infarction (100%, 2/2), partial pontine infarction (21%, 3/14), and cerebellum infarction (35%, 7/20), we observed ipsiversive OTR, similar to that seen in UPVD patients (80.0%, 16/20). Some of the patients with medial medullary infarction (50%, 1/2), partial pons infarction (42%, 6/14), midbrain infarction (100%, 2/2), and partial cerebellum infarction (30.0%, 6/20) showed contraversive OTR. The skew deviation (SD) of the BI group with ACVV was significantly greater than that of the UPVD group (6.60 ± 2.70° vs. 1.80 ± 1.30°, Z = −2.50, P = 0.012), such that the mean SD of the patients with a pons infarction was 9.50° and that of patients with medulla infarction was 5.00°. In ACVV patients with no cerebellar damage, the area under the curve of the receiver operating characteristic curve corresponding to the use of SD to predict brainstem damage was 0.92 (95%CI: 0.73–1.00), with a sensitivity of 100% and a specificity of 80% when SD ≥ 3°. We found no statistical difference in SD between the UPVD and CI groups (1.33 ± 0.58° vs. 1.80 ± 1.30°, Z = −0.344, P = 0.73). Compared with the UPVD patients, the ACVV patients with a partial pons infarction (43%, 6/14, χ2 = 13.68, P = 0.002) or medulla infarction (25%, 1/4, χ2 = 4.94, P = 0.103) exhibited signs of the ipsiversive E-effect with the contraversive A-effect, while those with a partial medulla infarction (50%, 2/4), pons infarction (43%, 6/14), or cerebellar infarction (60%, 12/20) exhibited a pathological symmetrical increase in the E-effect.

Conclusions

The evaluation of OTR plus head tilt SVV (±45°) in vertigo patients is helpful for identifying and diagnosing ACVV, especially when SD is ≥ 3° or the E-effect is symmetrically increased.

Static Subjective Visual Vertical (SVV) in Patients with Vestibular Migraine

BACKGROUND

 Vestibular migraine (VM) is one of the common causes of episodic dizziness, but it is underdiagnosed and poorly understood. Previous research suggests that otolith reflex pathway performance is often impaired in this patient group, leading to altered perception of roll plane stimuli. Clinically, this perception can be measured with subjective visual vertical (SVV) testing.

PURPOSE

 The aim of this study is to compare static SVV performance (absolute mean SVV tilt, variance) in a cohort of patients diagnosed with VM to results obtained from clinically derived normative data.

STUDY DESIGN

 Retrospective case review.

STUDY SAMPLE

 Ninety-four consecutive patients between 18 and 65 years of age diagnosed with VM were included in this comparison to clinically derived normative data.

DATA COLLECTION AND ANALYSIS

 Retrospective chart review was completed. Demographic data, symptom report, and vestibular laboratory results were documented. SVV performance was documented in terms of absolute mean SVV tilt and response variance.

RESULTS

 Abnormal mean SVV tilt was described in 54% (n = 51) of patients with VM. Including abnormal response variance increased those identified with abnormal presentation to 67% (n = 63). Laboratory findings were insignificant for semicircular canal function, but of those with abnormal ocular vestibular myogenic potential results (n = 30), 77% (n = 23) demonstrated both abnormal SVV and utriculo-ocular reflex performance. There were no associations noted for SVV performance and demographic or other self-report variables.

CONCLUSION

 Absolute mean SVV tilt and response variance are often abnormal in patients diagnosed with VM. These findings support theories suggesting atypical intralabyrinthine integration within the vestibular nuclei and cerebellar nodular pathways.

High Definition tDCS Effect on Postural Control in Healthy Individuals: Entropy Analysis of a Crossover Clinical Trial

Objective: Converging evidence supporting an effect of transcranial direct current stimulation (tDCS) on postural control and human verticality perception highlights this strategy as promising for post-stroke rehabilitation. We have previously demonstrated polarity-dependent effects of high-definition tDCS (HD-tDCS) on weight-bearing asymmetry. However, there is no investigation regarding the time-course of effects on postural control induced by HD-tDCS protocols. Thus, we performed a nonlinear time series analysis focusing on the entropy of the ground reaction force as a secondary investigation of our randomized, double-blind, placebo-controlled, crossover clinical trial. Materials and Methods: Twenty healthy right-handed young adults received the following conditions (random order, separate days); anode center HD-tDCS, cathode center HD-tDCS or sham HD-tDCS at 1, 2, and 3 mA over the right temporo-parietal junction (TPJ). Using summarized time series of transfer entropy, we evaluated the exchanging information (causal direction) between both force plates and compared the dose-response across the healthy subjects with a Generalized Linear Hierarchical/Mixed Model (GLMM). Results: We found significant variation during the dynamic information flow (p < 0.001) among the dominant bodyside (and across time). A greater force transfer entropy was observed from the right to the left side during the cathode-center HD-tDCS up to 2 mA, with a causal relationship in the information flow (equilibrium force transfer) from right to left that decreased over time. Conclusions: HD-tDCS intervention induced a dynamic influence over time on postural control entropy. Right hemisphere TPJ stimulation using cathode-center HD-tDCS can induce an asymmetry of body weight distribution towards the ipsilateral side of stimulation. These results support the clinical potential of HD-tDCS for post-stroke rehabilitation.

Postural adjustment as a function of scene orientation

Visual orientation plays an important role in postural control, but the specific characteristics of postural response to orientation remain unknown. In this study, we investigated the relationship between postural response and the subjective visual vertical (SVV) as a function of scene orientation. We presented a virtual room including everyday objects through a head-mounted display and measured head tilt around the naso-occipital axis. The room orientation varied from 165° counterclockwise to 180° clockwise around the center of display in 15° increments. In a separate session, we also conducted a rod adjustment task to record the participant's SVV in the tilted room. We applied a weighted vector sum model to head tilt and SVV error and obtained the weight of three visual cues to orientation: frame, horizon, and polarity. We found significant contributions for all visual cues to head tilt and SVV error. For SVV error, frame cues made the largest contribution, whereas polarity contribution made the smallest. For head tilt, there was no clear difference across visual cue types, although the order of contribution was similar to the SVV. These findings suggest that multiple visual cues to orientation are involved in postural control and imply different representations of vertical orientation across postural control and perception.

Visuospatial orientation: Differential effects of head and body positions

To orientate in space, the brain must integrate sensory information that encodes the position of the body with the visual cues from the surrounding environment. In this process, the extent of reliance on visual information is known as the visual dependence. Here, we asked whether the relative positions of the head and body can modulate such visual dependence (VD). We used the effect of optokinetic stimulation (30°/s) on subjective visual vertical (SVV) to quantify VD as the average optokinetic-induced SVV bias in clockwise and counter-clockwise directions. The VD bias was measured in eight subjects with a head-on-body tilt (HBT) where only the head was tilted on the body, and also with a whole-body tilt (WBT) where the head and body were tilted together. The VD bias with HBT of 20° was in the same direction of the head tilt position (left tilt VD -1.35 ± 0.1.2°; right VD 1.60 ± 0.9°), whereas the VD bias with WBT of 20° was in a direction away from the body tilt position (left tilt VD 2.5 ± 1.1°; right tilt VD -2.1 ± 0.9°). These findings show differential effects of relative head and body positions on visual cue integration, a process which could facilitate optimal interaction with the surrounding environment for spatial orientation.

Psychophysical Haptic Measurement of Vertical Perception: Elucidating a Hand Sensory Bias

The primary sensory modality for probing spatial perception can vary among psychophysical paradigms. In the subjective visual vertical (SVV) task, the brain must account for the position of the eye within the orbit to generate an estimate of a visual line orientation, whereas in the subjective haptic vertical (SHV) task, the position of the hand is used to sense the orientation of a haptic bar. Here we investigated whether a hand sensory bias can affect SHV measurement. We measured SHV in 12 subjects (6 left-handed and 6 right-handed) with a forced-choice paradigm using their left and right hands separately. The SHV measurement was less accurate than the SVV measurements (-0.6 ± 0.7) and it was biased in the direction of the hand used in the task but was not affected by handedness; SHV left hand -6.8 ± 2.1° (left-handed -7.9 ± 3.6°, right-handed -5.8 ± 2.5°) and right hand 9.8 ± 1.5° (left-handed 7.4 ± 2.2°, right-handed 12.3 ± 1.8°). SHV measurement with the same hand was also affected by the haptic bar placement on the left or right side versus midline, showing a side effect (left vs midline -2.0 ± 1.3°, right vs midline 3.8 ± 1.7°). Midline SHV measures using the left and right hands were different, confirming a laterality effect (left hand -4.5 ± 1.7°, right hand 6.4 ± 2.0°). These results demonstrate a sensory bias in SHV measurement related to the effects of both hand-in-body (i.e., right vs left hand) and hand-in-space positions. Such modality-specific bias may result in disparity between SHV and SVV measurements, and therefore cannot be generalized to vertical or spatial perception.

Human movements do not look the same in a tilted world: Gravitational constraints influence the perception of biological motion

We investigated whether gravitational constraints influence the interaction of visual, proprioceptive and vestibular cues for Biological Motion Perception (BMP). Participants were asked to distinguish between plausible and random point-light movements, while passively placed in either an upright or a tilted body orientation. Manipulating the body orientation with respect to gravity leads to different gravitational signals transmitted by the visual, proprioceptive, and vestibular systems. Participants were overall faster in distinguishing plausible point-light movements than random movements. Critically, response times for biologically plausible point-light movements - but not for random movements - were significantly prolonged in the tilted body orientation. Our results suggest that BMP depends not only on the spatial-temporal cues embedded in point-light movements but also rely on the congruency between current gravitational signals detected by the sensory systems and our previous knowledge of terrestrial gravity. STATEMENT OF RELEVANCE: As humankind is preparing for a new space age, understanding how gravity influences behaviour and cognition has never been more pressing. All living organisms have evolved to survive in a terrestrial gravitational field. Although we cannot consciously feel gravity, it has an impact in our life: it affects how we move and interact with the external environment. The sensory signals from the vestibular system are continuously combined with visual and proprioceptive cues to help us in maintaining a stable representation of the world. Here we placed participants in a tilted body orientation and were able to determine that a conflict between prior gravitational knowledge and what was actively sensed about gravity affected human Biological Movement Perception. Humans suffer changes in perception under non-terrestrial gravity conditions that may potentially compromise performance during space exploration.

Novel Cognitive Functions Arise at the Convergence of Macroscale Gradients

Functions in higher-order brain regions are the source of extensive debate. Although past trends have been to describe the brain-especially posterior cortical areas-in terms of a set of functional modules, a new emerging paradigm focuses on the integration of proximal functions. In this review, we synthesize emerging evidence that a variety of novel functions in the higher-order brain regions are due to convergence: convergence of macroscale gradients brings feature-rich representations into close proximity, presenting an opportunity for novel functions to arise. Using the TPJ as an example, we demonstrate that convergence is enabled via three properties of the brain: (1) hierarchical organization, (2) abstraction, and (3) equidistance. As gradients travel from primary sensory cortices to higher-order brain regions, information becomes abstracted and hierarchical, and eventually, gradients meet at a point maximally and equally distant from their sensory origins. This convergence, which produces multifaceted combinations, such as mentalizing another person's thought or projecting into a future space, parallels evolutionary and developmental characteristics in such regions, resulting in new cognitive and affective faculties.

Panoramic Uncertainty in Vertical Perception

Judgments of the orientation of a visual line with respect to earth vertical are affected by panoramic visual cues. This is illustrated by the rod-and-frame effect (RFE), the finding that the perceived orientation of a luminous rod is biased by the orientation of a surrounding squared frame. In this study, we tested how the uncertainty of frame orientation affects the RFE by asking upright or tilted participants to psychometrically judge the orientation of a briefly flashed rod contained within either a circular frame, a squared frame, or either of two intermediate frame forms, called squircles, presented in various orientations. Results showed a cyclical modulation of frame-induced bias across the range of the square and squircular frame orientations. The magnitude of this bias increased with increasing squaredness of the frame, as if the more unequivocal the orientation cues of the frame, the larger the reliance on them for rod orientation judgments. These findings are explained with a Bayesian optimal integration model in which participants flexibly weigh visual panoramic cues, depending on their orientation reliability, and non-visual cues in the perception of vertical.

Watching the Effects of Gravity. Vestibular Cortex and the Neural Representation of "Visual" Gravity

Gravity is a physical constraint all terrestrial species have adapted to through evolution. Indeed, gravity effects are taken into account in many forms of interaction with the environment, from the seemingly simple task of maintaining balance to the complex motor skills performed by athletes and dancers. Graviceptors, primarily located in the vestibular otolith organs, feed the Central Nervous System with information related to the gravity acceleration vector. This information is integrated with signals from semicircular canals, vision, and proprioception in an ensemble of interconnected brain areas, including the vestibular nuclei, cerebellum, thalamus, insula, retroinsula, parietal operculum, and temporo-parietal junction, in the so-called vestibular network. Classical views consider this stage of multisensory integration as instrumental to sort out conflicting and/or ambiguous information from the incoming sensory signals. However, there is compelling evidence that it also contributes to an internal representation of gravity effects based on prior experience with the environment. This a priori knowledge could be engaged by various types of information, including sensory signals like the visual ones, which lack a direct correspondence with physical gravity. Indeed, the retinal accelerations elicited by gravitational motion in a visual scene are not invariant, but scale with viewing distance. Moreover, the "visual" gravity vector may not be aligned with physical gravity, as when we watch a scene on a tilted monitor or in weightlessness. This review will discuss experimental evidence from behavioral, neuroimaging (connectomics, fMRI, TMS), and patients' studies, supporting the idea that the internal model estimating the effects of gravity on visual objects is constructed by transforming the vestibular estimates of physical gravity, which are computed in the brainstem and cerebellum, into internalized estimates of virtual gravity, stored in the vestibular cortex. The integration of the internal model of gravity with visual and non-visual signals would take place at multiple levels in the cortex and might involve recurrent connections between early visual areas engaged in the analysis of spatio-temporal features of the visual stimuli and higher visual areas in temporo-parietal-insular regions.

Subjective visual vertical imprecision during lateral head tilt in patients with chronic dizziness

Most prior studies of the subjective visual vertical (SVV) focus on inaccuracy of subjects' SVV responses with the head in an upright position. Here we investigated SVV imprecision during lateral head tilt in patients with chronic dizziness compared to healthy controls. Forty-five dizzy patients and 45 healthy controls underwent SVV testing wearing virtual reality (VR) goggles, sitting upright (0°) and during head tilt in the roll plane (± 30°). Ten trials were completed in each of three static head positions. The SVV inaccuracy and SVV imprecision were analyzed and compared between groups, along with systematic errors during head tilt, i.e., A-effect and E-effect (E-effect is a typical SVV response during head tilts of ± 30°). The SVV imprecision was found to be affected by head position (upright/right head tilt/left head tilt, p < 0.001) and underlying dizziness (dizzy patients/healthy controls, p = 0.005). The SVV imprecision during left head tilt was greater in dizzy patients compared to healthy controls (p = 0.04). With right head tilt, there was a trend towards greater SVV imprecision in dizzy patients (p = 0.08). Dizzy patients were more likely to have bilateral (6.7%) or unilateral (22.2%) A-effect during lateral head tilt than healthy controls (bilateral (0%) or unilateral (6.7%) A-effect, p < 0.01). Greater SVV imprecision in chronically dizzy patients during head tilts may be attributable to increased noise of vestibular sensory afferents or disturbances of multisensory integration. Our findings suggest that SVV imprecision may be a useful clinical parameter of underlying dizziness measurable with bedside SVV testing in VR.

Results of subjective visual vertical tests in patients with vertigo/dizziness

OBJECTIVE

We previously established the head-tilt subjective visual vertical (HT-SVV) test to evaluate head-tilt perception gain (HTPG) in addition to the original head-upright SVV (HU-SVV) test (Wada-Y et al.: Laryngoscope Investig Otolaryngol, 2020). In this study, we aimed to investigate the HU-SVV and HT-SVV abnormality rates among patients with vertigo/dizziness.

METHODS

Between July 2014 and December 2020, 357 patients were hospitalized for examining the HU-SVV and HT-SVV at our vertigo/dizziness center. Among these patients, 120 had Meniere's disease (MD), 99 had unilateral vestibular disease (UVD), 76 had benign paroxysmal positional vertigo (BPPV), 14 had vestibular migraine (VM), 13 had orthostatic dysfunction (OD), 12 had bilateral vestibular disease (BVD), 12 had central dizziness (CD), 7 had vestibular schwannoma (VS), and 4 had psychogenic dizziness (PD). We determined the reference values of the absolute HU-SVV (<2.5°) and HTPG (0.80-1.25) for the sitting position and used these for calculating the HU-SVV and HT-SVV abnormality rates in each type of vertigo/dizziness.

RESULTS

Among the 357 patients, 111 had abnormal HU-SVV results (31.1%), 132 had abnormal HT-SVV results (37.0%), and 185 had abnormal HU-SVV and/or HT-SVV results (51.8%). The modified HT-SVV test in combination with the original HU-SVV test could detect gravity perception disturbance in patients with vertigo/dizziness significantly better than the original test alone (chi-square: p=0.00019). The HU-SVV, HT-SVV, and HU-SVV and/or HT-SVV abnormality rates were significantly higher in patients with peripheral vestibular diseases, i.e., MD, UVD, BPPV, and BVD than in those with other types of vertigo/dizziness, i.e., VM, OD, CD, VS, and PD (chi-square: p=0.010, p=0.020, and p=0.0025, respectively).

CONCLUSION

These findings suggest that the combined HT-SVV and HU-SVV test could be a powerful neuro-otologic examination for detecting pathologies in the vestibular otolithic pathway.

Evaluation of the Video Ocular Counter-Roll (vOCR) as a New Clinical Test of Otolith Function in Peripheral Vestibulopathy

Importance

Video-oculography (VOG) goggles have been integrated into the assessment of semicircular canal function in patients with vestibular disorders. However, a similar bedside VOG method for testing otolith function is lacking.

Objective

To evaluate the use of VOG-based measurement of ocular counter-roll (vOCR) as a clinical test of otolith function.

Design, Setting, and Participants

A case-control study was conducted to compare vOCR measurement among patients at various stages of unilateral loss of vestibular function with healthy controls. The receiver operating characteristic curve method was used to determine the diagnostic accuracy of the vOCR test in detecting loss of otolith function. Participants were recruited at a tertiary center including the Johns Hopkins outpatient clinic and Johns Hopkins Hospital, Baltimore, Maryland. Participants included 56 individuals with acute (≤4 weeks after surgery), subacute (4 weeks-6 months after surgery), and chronic (>6 months after surgery) unilateral vestibular loss as well as healthy controls. A simple bedside maneuver with en bloc, 30° lateral tilt of the head and trunk was used for vOCR measurement. The study was conducted from February 2, 2017, to March 10, 2019.

Intervention

In each participant vOCR was measured during static tilts of the head and trunk en bloc.

Main Outcomes and Measures

The vOCR measurements and diagnostic accuracy of vOCR in detecting patients with loss of vestibular function from healthy controls.

Results

Of the 56 participants, 28 (50.0%) were men; mean (SD) age was 53.5 (11.4) years. The mean (SD) time of acute unilateral vestibular loss was 9 (7) days (range, 2-17 days) in the acute group, 61 (39) days (range, 28-172 days) in the subacute group, and 985 (1066) days (range 185-4200 days) in the chronic group. The vOCR test showed reduction on the side of vestibular loss, and the deficit was greater in patients with acute and subacute vestibular loss than in patients with chronic loss and healthy controls (acute vs chronic: -1.81°; 95% CI, -3.45° to -0.17°; acute vs control: -3.18°; 95% CI, -4.83° to -1.54°; subacute vs chronic: -0.63°; 95% CI, -2.28° to 1.01°; subacute vs control: -2.01°; 95% CI, -3.65° to -0.36°; acute vs subacute: -1.17°; 95% CI, -2.88° to 0.52°; and chronic vs control: -1.37°; 95% CI, -2.96° to 0.21°). The asymmetry in vOCR between the side of vestibular loss and healthy side was significantly higher in patients with acute vs chronic loss (0.28; 95% CI, 0.06-0.51). Overall, the performance of the vOCR test in discriminating between patients with vestibular loss and healthy controls was 0.83 (area under the receiver operating characteristic curve). The best vOCR threshold to detect vestibular loss at the 30° tilt was 4.5°, with a sensitivity of 80% (95% CI, 0.62%-0.88%) and specificity of 82% (95% CI, 0.57%-1.00%).

Conclusions and Relevance

The findings of this case-control study suggest that the vOCR test can be performed with a simple bedside maneuver and may be used to detect or track loss of otolith function.

Neuroanatomical correlates of the perception of body axis orientation during body tilt: a voxel-based morphometry study

Accurate perception of the orientations of the body axis and gravity is essential for actions. The ability to perceive these orientations during head and body tilt varies across individuals, and its underlying neural basis is unknown. To address this, we investigated the association between inter-individual differences in local gray matter (GM) volume and inter-individual differences in the ability to estimate the directions of body longitudinal axis or gravity during whole-body tilt using voxel-based morphometry (VBM) analysis in 50 healthy adults (20–46 years, 25 men and 25 women). Although no anatomical regions were identified relating to performance requiring estimates of gravitational direction, we found a significant correlation between the GM volume in the right middle occipital gyrus and the ability to estimate the body axis orientation. This finding provides the first evidence on neuroanatomical substrates of the perception of body axis orientation during body tilt.

Does somatosensory feedback from the plantar foot sole contribute to verticality perception?

AIM OF THE STUDY

In upright standing, the human foot sole is the only point of contact with the ground conveying information about the pressure distribution under the feet. We examined how the altered somatosensory input from the plantar foot receptors, when standing on a soft surface, affects the subjective estimation of the earth vertical in different sensory contexts.

MATERIALS AND METHODS

Twelve (12) healthy young females (mean age: 21.8 ± 2.4 years) adjusted the orientation of a visual line (35 × 1.5 cm) representing the roll orientation of a hand-held (attached on a 24.9 × 4 cm cylinder) or head-attached electromagnetic tracking sensor (Nest of Birds, Ascension Technologies Inc., VT. USA, 60 Hz) under two visual conditions (eyes open, eyes closed) while standing on a soft or firm surface. The mean absolute (accuracy) and variable (precision) error in the verticality estimate was depicted in the sensor's roll deviation from the gravitational vertical.

RESULTS

The accuracy and the precision of the estimate decreased in the absence of vision, while standing on the soft surface and when the estimate was provided by an active hand rather than head rotation. The surface effect was significant only in the absence of vision and when the estimate was provided by the hand.

CONCLUSIONS

The contribution of the plantar foot mechanoreceptors to gravity perception is sensory context dependent. Perception of the earth vertical is more accurate when estimated by active head rotation due to the integration of the vestibular and neck proprioceptive afferents.

Haptic awareness changes when lying down

Accurate localization of touch requires the integration of two reference frames-an internal (e.g., anatomical) and an external (e.g., spatial). Using a tactile temporal order judgement task with the hands crossed over the midline, we investigated the integration of these two reference frames. We manipulated the reliability of the visual and vestibular information, both of which contribute to the external reference frame. Visual information was manipulated between experiments (Experiment 1 was done with full vision and Experiment 2 was done while wearing a blindfold). Vestibular information was manipulated in both experiments by having the two groups of participants complete the task in both an upright posture and one where they were lying down on their side. Using a Bayesian hierarchical model, we estimated the perceptual weight applied to these reference frames. Lying participants on their side reduced the weight applied to the external reference frame and produced a smaller deficit; blindfolding resulted in similar reductions. These findings reinforce the importance of the visual system when weighting tactile reference frames, and highlight the importance of the vestibular system in this integration.

Multisensory contribution in visuospatial orientation: an interaction between neck and trunk proprioception

A coherent perception of spatial orientation is key in maintaining postural control. To achieve this the brain must access sensory inputs encoding both the body and the head position and integrate them with incoming visual information. Here we isolated the contribution of proprioception to verticality perception and further investigated whether changing the body position without moving the head can modulate visual dependence-the extent to which an individual relies on visual cues for spatial orientation. Spatial orientation was measured in ten healthy individuals [6 female; 25-47 years (SD 7.8 years)] using a virtual reality based subjective visual vertical (SVV) task. Individuals aligned an arrow to their perceived gravitational vertical, initially against a static black background (10 trials), and then in other conditions with clockwise and counterclockwise background rotations (each 10 trials). In all conditions, subjects were seated first in the upright position, then with trunk tilted 20° to the right, followed by 20° to the left while the head was always aligned vertically. The SVV error was modulated by the trunk position, and it was greater when the trunk was tilted to the left compared to right or upright trunk positions (p < 0.001). Likewise, background rotation had an effect on SVV errors as these were greater with counterclockwise visual rotation compared to static background and clockwise roll motion (p < 0.001). Our results show that the interaction between neck and trunk proprioception can modulate how visual inputs affect spatial orientation.

Is Lateropulsion Really Related with a Specific Lesion of the Brain?

Lateropulsion (pusher syndrome) is an important barrier to standing and gait after stroke. Although several studies have attempted to elucidate the relationship between brain lesions and lateropulsion, the effects of specific brain lesions on the development of lateropulsion remain unclear. Thus, the present study investigated the effects of stroke lesion location and size on lateropulsion in right hemisphere stroke patients. The present retrospective cross-sectional observational study assessed 50 right hemisphere stroke patients. Lateropulsion was diagnosed and evaluated using the Scale for Contraversive Pushing (SCP). Voxel-based lesion symptom mapping (VLSM) analysis with 3T-MRI was used to identify the culprit lesion for SCP. We also performed VLSM controlling for lesion volume as a nuisance covariate, in a multivariate model that also controlled for other factors contributing to pusher behavior. VLSM, combined with statistical non-parametric mapping (SnPM), identified the specific region with SCP. Lesion size was associated with lateropulsion. The precentral gyrus, postcentral gyrus, inferior frontal gyrus, insula and subgyral parietal lobe of the right hemisphere seemed to be associated with the lateropulsion; however, after adjusting for lesion volume as a nuisance covariate, no lesion areas were associated with the SCP scores. The size of the right hemisphere lesion was the only factor most strongly associated with lateropulsion in patients with stroke. These results may be useful for planning rehabilitation strategies of restoring vertical posture and understanding the pathophysiology of lateropulsion in stroke patients.

Inter-rater and test-retest reliability of computerized clinical vestibular tools

BACKGROUND

Clinical vestibular technology is rapidly evolving to improve objective assessments of vestibular function. Understanding the reliability and expected score ranges of emerging clinical vestibular tools is important to gauge how these tools should be used as clinical endpoints.

OBJECTIVE

The objective of this study was to evaluate inter-rater and test-retest reliability intraclass correlation coefficients (ICCs) of four vestibular tools and to determine expected ranges of scores through smallest real difference (SRD) measures.

METHODS

Sixty healthy graduate students completed two 1-hour sessions, at most a week apart, consisting of two video head-impulse tests (vHIT), computerized dynamic visual acuity (cDVA) tests, and a smartphone-assisted bucket test (SA-SVV). Thirty students were tested by different testers at each session (inter-rater) and 30 by the same tester (test-retest). ICCs and SRDs were calculated for both conditions.

RESULTS

Most measures fell within the moderate ICC range (0.50-0.75). ICCs were higher for cDVA in the inter-rater subgroup and higher for vHITs in the test-retest subgroup.

CONCLUSIONS

Measures from the four tools evaluated were moderately reliable. There may be a tester effect on reliabilities, specifically vHITs. Further research should repeat these analyses in a patient population and explore methodological differences between vHIT systems.

Test-retest reliability of subjective visual vertical measurements with lateral head tilt in virtual reality goggles

Objective:

The objective is to investigate the test-retest reliability of subjective visual vertical (SVV) in the upright position and with lateral head tilts through a computerized SVV measuring system using virtual reality (VR) goggles.

Materials and Methods:

Thirty healthy controls underwent SVV test in upright position, with the head tilted to the right 30°, and with the head tilted to the left 30°. Subjects wore SVV VR goggles, which contained a gyroscope for monitoring the angle of head tilt. Each subject completed 10 adjustments in each head position. The mean value of SVV deviations and SVV imprecision (the intra-individual variability of SVV deviations from the 10 adjustments) were recorded and compared across different head positions. The participants then repeated the same SVV protocol at least 1 week later. The test-retest reliability of SVV deviation and SVV imprecision were analyzed.

Results:

The SVV deviation (mean ± standard deviation) was 0.22° ± 1.56° in upright position, −9.64° ± 5.91° in right head tilt, and 7.20° ± 6.36° in left head tilt. The test-retest reliability of SVV deviation was excellent in upright position (intra-class correlation coefficient [ICC] = 0.77, P < 0.001), right head tilt (ICC = 0.83, P < 0.001) and left head tilt (ICC = 0.84, P < 0.001). The SVV values from the 10 adjustments made during right and left head tilts were less precise than when measured at upright (P < 0.001). The test-retest reliability of SVV imprecision was poor at upright (ICC = 0.21, P = 0.26) but fair-to-good in right head tilt (ICC = 0.72, P < 0.001) and left head tilt (ICC = 0.44, P = 0.04).

Conclusion:

The test-retest reliability of SVV deviation during lateral head tilts via VR goggles is excellent, which supports further research into the diagnostic value of head-tilt SVV in various vestibular disorders. In addition, the degree of SVV imprecision during head tilt has fair-to-good test-retest reliability, which suggests SVV imprecision may have clinical applicability.

Multisensory Interactions in Head and Body Centered Perception of Verticality

Percepts of verticality are thought to be constructed as a weighted average of multisensory inputs, but the observed weights differ considerably between studies. In the present study, we evaluate whether this can be explained by differences in how visual, somatosensory and proprioceptive cues contribute to representations of the Head In Space (HIS) and Body In Space (BIS). Participants (10) were standing on a force plate on top of a motion platform while wearing a visualization device that allowed us to artificially tilt their visual surroundings. They were presented with (in)congruent combinations of visual, platform, and head tilt, and performed Rod & Frame Test (RFT) and Subjective Postural Vertical (SPV) tasks. We also recorded postural responses to evaluate the relation between perception and balance. The perception data shows that body tilt, head tilt, and visual tilt affect the HIS and BIS in both experimental tasks. For the RFT task, visual tilt induced considerable biases (≈ 10° for 36° visual tilt) in the direction of the vertical expressed in the visual scene; for the SPV task, participants also adjusted platform tilt to correct for illusory body tilt induced by the visual stimuli, but effects were much smaller (≈ 0.25°). Likewise, postural data from the SPV task indicate participants slightly shifted their weight to counteract visual tilt (0.3° for 36° visual tilt). The data reveal a striking dissociation of visual effects between the two tasks. We find that the data can be explained well using a model where percepts of the HIS and BIS are constructed from direct signals from head and body sensors, respectively, and indirect signals based on body and head signals but corrected for perceived neck tilt. These findings show that perception of the HIS and BIS derive from the same sensory signals, but see profoundly different weighting factors. We conclude that observations of different weightings between studies likely result from querying of distinct latent constructs referenced to the body or head in space.

Structural connectome and connectivity lateralization of the multimodal vestibular cortical network

Unlike other sensory systems, the structural connectivity patterns of the human vestibular cortex remain a matter of debate. Based on their functional properties and hypothesized centrality within the vestibular network, the ‘core’ cortical regions of this network are thought to be areas in the posterior peri-sylvian cortex, in particular the retro-insula (previously named the posterior insular cortex-PIC), and the subregion OP2 of the parietal operculum.

To study the vestibular network, structural connectivity matrices from n=974 healthy individuals drawn from the public Human Connectome Project (HCP) repository were estimated using multi-shell diffusion-weighted data followed by probabilistic tractography and spherical-deconvolution informed filtering of tractograms in combination with subject-specific grey-matter parcellations. Weighted graph-theoretical measures, modularity, and ‘hubness’ of the multimodal vestibular network were then estimated, and a structural lateralization index was defined in order to assess the difference in fiber density of homonym regions in the right and left hemisphere. Differences in connectivity patterns between OP2 and PIC were also estimated.

We found that the bilateral intraparietal sulcus, PIC, and to a lesser degree OP2, are key ‘hub’ regions within the multimodal vestibular network. PIC and OP2 structural connectivity patterns were lateralized to the left hemisphere, while structural connectivity patterns of the posterior peri-sylvian supramarginal and superior temporal gyri were lateralized to the right hemisphere. These lateralization patterns were independent of handedness.

We also found that the structural connectivity pattern of PIC is consistent with a key role of PIC in visuo-vestibular processing and that the structural connectivity pattern of OP2 is consistent with integration of mainly vestibular somato-sensory and motor information. These results suggest an analogy between PIC and the simian visual posterior sylvian (VPS) area and OP2 and the simian parieto-insular vestibular cortex (PIVC).

Overall, these findings may provide novel insights to the current models of vestibular function, as well as to the understanding of the complexity and lateralized signs of vestibular syndromes.

A Bird's eye view from below: Activity in the temporo-parietal junction predicts from-above Necker Cube percepts

The temporo-parietal junction (TPJ) consistently emerges in other-regarding behavior, including tasks probing affective phenomena such as morality and empathy. Yet the TPJ is also recruited in processes with no affective or social component, such as visuo-spatial processing and mathematical cognition. We present serendipitous findings from a perceptual decision-making task on a bistable stimulus, the Necker Cube, performed in an MRI scanner. The stimulus in question is a transparent, wire-frame cube that evokes spontaneous switches in perception. Individuals can view the cube from below or from above, though a consistent bias is shown towards seeing the cube from above. We replicate this bias, finding participants spend more time in the from-above percept. However, in testing for BOLD differences between percept orientations, we found robust responses in bilateral TPJ for the from-above > from-below perceptual state. We speculate that this neural response comes from the sensory incongruence of viewing an object from above while lying supine in the scanner. We further speculate that the TPJ resolves this incongruence by facilitating an egocentric projection. Such a function would explain the TPJ's ubiquitous response to other-regarding, visuo-spatial and mathematical cognition, as all these phenomena demand an ability to ambulate through the coordinate space. Our findings suggest the TPJ may not play a specific role in social or moral components of other-regarding behavior, such as altruism, and further indirectly suggest that "pure", allocentric altruism may not correlate with the TPJ. Results further have implications on how the TPJ may be modulated by activities such as flight or drone operation. Finally, this study highlights the possible need for congruence between stimuli and body position in neuroimaging studies.

New Mobile Device to Measure Verticality Perception: Results in Young Subjects with Headaches

The subjective visual vertical (SVV) test has been frequently used to measure vestibular contribution to the perception of verticality. Recently, mobile devices have been used to efficiently perform this measurement. The aim of this study was to analyze the perception of verticality in subjects with migraines and headaches. A cross-sectional study was conducted that included 28 patients with migraine, 74 with tension-type headache (TTH), and 93 healthy subjects. The SVV test was used through a new virtual reality system. The mean absolute error (MAE) of degrees deviation was also measured to qualify subjects as positive when it was greater than 2.5°. No differences in the prevalence of misperception in verticality was found among healthy subjects (31.18%), migraineurs (21.43%), or those with TTH (33.78%) (p = 0.480). The MAE was not significantly different between the three groups (migraine = 1.36°, TTH = 1.61°, and healthy = 1.68°) (F = 1.097, p = 0.336, and η2 = 0.011). The perception of verticality could not be explained by any variable usually related to headaches. No significant differences exist in the vestibular contribution to the perception of verticality between patients with headaches and healthy subjects. New tests measuring visual and somatosensory contribution should be used to analyze the link between the perception of verticality and headaches.

Effect of head roll-tilt on the subjective visual vertical in healthy participants: Towards better clinical measurement of gravity perception

OBJECTIVE

Gravity perception is an essential function for spatial orientation and postural stability; however, its assessment is not easy. We evaluated the head-tilt perception gain (HTPG, that is, mean perceptual gain [perceived/actual tilt angle] during left or right head roll-tilt conditions) and head-upright subjective visual vertical (SVV) using a simple method developed by us to investigate the characteristics of gravity perception in healthy participants.

METHODS

We measured the SVV and head roll-tilt angle during head roll-tilt within ±30° of vertical in the sitting and standing positions while the participant maintained an upright trunk (sitting, 434 participants; standing, 263 participants). We evaluated the head-upright SVV, HTPG, and laterality of the HTPG.

RESULTS

We determined the reference ranges of the absolute head-upright SVV (<2.5°), HTPG (0.80-1.25), and HTPG laterality (<10%) for the sitting position. The head-upright SVV and HTPG laterality were not influenced by sex or age. However, the HTPG was significantly greater in women than in men and in middle-aged (30-64 years) and elderly (65-88 years) participants than in young participants (18-29 years). The HTPG, but not the head-upright SVV or HTPG laterality, was significantly higher in the standing vs sitting position.

CONCLUSION

The HTPG is a novel parameter of gravity perception involving functions of the peripheral otolith and neck somatosensory systems to the central nervous system. The HTPG in healthy participants is influenced by age and sex in the sitting position and immediately increases after standing to reinforce the righting reflex for unstable posture, which was not seen in the head-upright SVV, previously considered the only parameter.

LEVEL OF EVIDENCE

4.

Misperception of Visual Verticality in Patients with Primary Headache Disorders: A Systematic Review with Meta-Analysis

Migraine and tension-type headache (TTH) are the two most prevalent primary headache disorders (PHDs) that may involve visual and vestibular impairments, neck pain, and postural unsteadiness. The perception of visual verticality (VV) has been studied in patients diagnosed with PHD to assess balance disorders showing varying findings. Our study aimed to assess the VV perception in patients diagnosed with PHD in comparison to healthy controls. A systematic review with meta-analysis was carried out in PubMed MEDLINE, Scopus, WOS, CINAHL, and SciELO. The Cohen standardized mean difference (SMD) was used to estimate the differences between exposed and healthy controls. Seven studies with 816 participants were included. The quality of included studies, according to the Newcastle–Ottawa Scale (NOS), was moderate (mean score of 5.2). Patients diagnosed with PHD showed a moderate misperception of VV as assessed with the subjective visual vertical (SVV) test (SMD = 0.530; 95% CI = 0.225, 0.836; p < 0.001). Specifically, a misperception of the SVV was found in patients with migraine (SMD = 0.369; 95% CI = 0.1, 0.638; p = 0.007) and with TTH (SMD = 1.122; 95% CI = 0.540, 1.704; p < 0.001). This review shows a misperception of VV in patients with migraine and TTH when assessed with the SVV test, being higher in patients with TTH, although the THH sample size was low.

Time Course of Sensory Substitution for Gravity Sensing in Visual Vertical Orientation Perception following Complete Vestibular Loss

Loss of vestibular function causes severe acute symptoms of dizziness and disorientation, yet the brain can adapt and regain near to normal locomotor and orientation function through sensory substitution. Animal studies quantifying functional recovery have yet been limited to reflexive eye movements. Here, we studied the interplay between vestibular and proprioceptive graviception in macaque monkeys trained in an earth-vertical visual orientation (subjective visual vertical; SVV) task and measured the time course of sensory substitution for gravity perception following complete bilateral vestibular loss (BVL). Graviceptive gain, defined as the ratio of perceived versus actual tilt angle, decreased to 20% immediately following labyrinthectomy, and recovered to nearly prelesion levels with a time constant of approximately three weeks of postsurgery testing. We conclude that proprioception accounts for up to 20% of gravity sensing in normal animals, and is re-weighted to substitute completely perceptual graviception after vestibular loss. We show that these results can be accounted for by an optimal sensory fusion model.

No handedness effect on spatial orientation or ocular counter-roll during lateral head tilts

Although vestibular inputs are bilaterally represented within the cerebral hemispheres, the higher level vestibular functions exhibit hemispheric asymmetries. Previous studies have suggested that such asymmetries are associated with handedness. Here, we studied the impact of handedness (i.e., hemispheric lateralization) on spatial orientation using a subjective visual vertical (SVV) task. We tested 22 right‐handed and 22 left‐handed subjects in upright position, during prolonged lateral head tilts of 20° (~15 min), and after the head returned to upright position. The corresponding changes in torsional eye position were measured simultaneously using video‐oculography. During lateral head tilts, both right‐ and left‐handers had initial SVV biases in the opposite direction of the head tilt (right‐handers: left tilt 3.0 ± 1.3°, right tilt −4.7 ± 1.5°; left‐handers: left tilt 3.4 ± 1.1°, right tilt −4.1 ± 1.0°). The SVV subsequently drifted in the direction of the head tilt, and there was an aftereffect in the same direction when the head was brought back upright. The ocular torsion initially changed in the opposite direction of the head tilt (right‐handers: left tilt 3.8 ± 0.4°, right tilt −3.8 ± 0.4°; left‐handers: left tilt 4.2 ± 0.5°, right tilt −4.5 ± 0.5°), and there were also drift and aftereffect in the same direction as the head tilt. The changes in upright perception and ocular torsion did not differ between right‐ and left‐handers. These findings show no functional laterality, neither in the higher level neural mechanisms that maintain spatial orientation, nor in the lower level mechanisms that generate the ocular torsion response during lateral head tilt.

The gravitational imprint on sensorimotor planning and control

Humans excel at learning complex tasks, and elite performers such as musicians or athletes develop motor skills that defy biomechanical constraints. All actions require the movement of massive bodies. Of particular interest in the process of sensorimotor learning and control is the impact of gravitational forces on the body. Indeed, efficient control and accurate internal representations of the body configuration in space depend on our ability to feel and anticipate the action of gravity. Here we review studies on perception and sensorimotor control in both normal and altered gravity. Behavioral and modeling studies together suggested that the nervous system develops efficient strategies to take advantage of gravitational forces across a wide variety of tasks. However, when the body was exposed to altered gravity, the rate and amount of adaptation exhibited substantial variation from one experiment to another and sometimes led to partial adjustment only. Overall, these results support the hypothesis that the brain uses a multimodal and flexible representation of the effect of gravity on our body and movements. Future work is necessary to better characterize the nature of this internal representation and the extent to which it can adapt to novel contexts.

Hypogravity reduces trunk admittance and lumbar muscle activation in response to external perturbations

Reduced paraspinal muscle size and flattening of spinal curvatures have been documented after spaceflight. Assessment of trunk adaptations to hypogravity can contribute to development of specific countermeasures. In this study, parabolic flights were used to investigate spinal curvature and muscle responses to hypogravity. Data from five trials at 0.25 g, 0.50 g, and 0.75 g were recorded from six participants positioned in a kneeling-seated position. During the first two trials, participants maintained a normal, upright posture. In the last three trials, small-amplitude perturbations were delivered in the anterior direction at the T₁₀ level. Spinal curvature was estimated with motion capture cameras. Trunk displacement and contact force between the actuator and participant were recorded. Muscle activity responses were collected by intramuscular electromyography (iEMG) of the deep and superficial lumbar multifidus, iliocostalis lumborum, longissimus thoracis, quadratus lumborum, transversus abdominis, obliquus internus, and obliquus externus muscles. The root mean square iEMG and the average spinal angles were calculated. Trunk admittance and muscle responses to perturbations were calculated as closed-loop frequency-response functions. Compared with 0.75 g, 0.25 g resulted in lower activation of the longissimus thoracis (P = 0.002); lower responses of the superficial multifidus at low frequencies (P = 0.043); lower responses of the superficial multifidus (P = 0.029) and iliocostalis lumborum (P = 0.043); lower trunk admittance (P = 0.037) at intermediate frequencies; and stronger responses of the transversus abdominis at higher frequencies (P = 0.032). These findings indicate that exposure to hypogravity reduces trunk admittance, partially compensated by weaker stabilizing contributions of the paraspinal muscles and coinciding with an apparent increase of deep abdominal muscle activity.NEW & NOTEWORTHY This study presents for the first time novel insights into the adaptations to hypogravity of spinal curvatures, trunk stiffness, and paraspinal muscle activity. We showed that exposure to hypogravity reduces the displacement of the trunk by an applied perturbation, partially compensated by weaker stabilizing contributions of the paraspinal muscles and concomitant increase in abdominal muscle responses. These findings may have relevance for future recommendations for planetary surface explorations.

Neurological update: dizziness

The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this 'update' I will review how our understanding of previously "unexplained" dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term 'persistent postural perceptual dizziness', and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.