Balance in Virtual Reality: Effect of Age and Bilateral Vestibular Loss.

BACKGROUND: Quantitative balance measurement is used in clinical practice to prevent falls. The conditions of the test were limited to eyes open, eyes closed, and sway-referenced vision. We developed a new visual perturbation to challenge balance using virtual reality (VR), measuring postural stability by a Wii Balance Board (WBB). METHODS: In this study, we recorded balance performance of 116 healthy subjects and of 10 bilateral vestibular loss patients using VR to assess the effect of age and the effect of total loss of vestibular function. We used several conditions: eyes open (normal visual inputs), eyes closed (no visual inputs), stable visual world (vision referenced), and perturbed visual world (visual perturbation) at different amplitudes of perturbation. Balance under these visual conditions was assessed on the WBB (stable support surface) and on the WBB plus foam rubber (unstable support surface). RESULTS: In healthy subjects, we found that the percentage of falls increased with age and with the amplitude of perturbation for both conditions: WBB or WBB + foam. Moreover, we can define a threshold for falls in each age group as the amplitude of perturbation which induced falls. For bilateral vestibular loss patients, on the WBB + foam, all of them failed with eyes closed and with perturbed visual world even at the minimal amplitude of perturbation. Finally, we observed that stable visual world induced fewer falls than eyes closed whatever the subject's group (healthy or bilateral vestibular loss) and whatever the age decade. CONCLUSION: VR allowed us to develop a useful new tool with a wide range of visual perturbations. Rather than only two levels of visual condition (eyes open and eyes closed), the VR stimulus can be continuously adjusted to produce a visual perturbation powerful enough to induce falls even in young healthy subjects and which has allowed us to determine a threshold for falls.

A new saccadic indicator of peripheral vestibular function based on the video head impulse test.

OBJECTIVE: While compensatory saccades indicate vestibular loss in the conventional head impulse test paradigm (HIMP), in which the participant fixates an earth-fixed target, we investigated a complementary suppression head impulse paradigm (SHIMP), in which the participant is fixating a head-fixed target to elicit anticompensatory saccades as a sign of vestibular function. METHODS: HIMP and SHIMP eye movement responses were measured with the horizontal video head impulse test in patients with unilateral vestibular loss, patients with bilateral vestibular loss, and in healthy controls. RESULTS: Vestibulo-ocular reflex gains showed close correlation (R(2) = 0.97) with slightly lower SHIMP than HIMP gains (mean gain difference 0.06 ± 0.05 SD, p < 0.001). However, the 2 paradigms produced complementary catch-up saccade patterns: HIMP elicited compensatory saccades in patients but rarely in controls, whereas SHIMP elicited large anticompensatory saccades in controls, but smaller or no saccades in bilateral vestibular loss. Unilateral vestibular loss produced covert saccades in HIMP, but later and smaller saccades in SHIMP toward the affected side. Cumulative HIMP and SHIMP saccade amplitude differentiated patients from controls with high sensitivity and specificity. CONCLUSIONS: While compensatory saccades indicate vestibular loss in conventional HIMP, anticompensatory saccades in SHIMP using a head-fixed target indicate vestibular function. SHIMP saccades usually appear later than HIMP saccades, therefore being more salient to the naked eye and facilitating vestibulo-ocular reflex gain measurements. The new paradigm is intuitive and easy to explain to patients, and the SHIMP results complement those from the standard video head impulse test. CLASSIFICATION OF EVIDENCE: This case-control study provides Class III evidence that SHIMP accurately identifies patients with unilateral or bilateral vestibulopathies.

Maintaining Balance when Looking at a Virtual Reality Three-Dimensional Display of a Field of Moving Dots or at a Virtual Reality Scene.

EXPERIMENTAL OBJECTIVE: To provide a safe, simple, relatively inexpensive, fast, accurate way of quantifying balance performance either in isolation, or in the face of challenges provided by 3D high definition moving visual stimuli as well as by the proprioceptive challenge from standing on a foam pad. This method uses the new technology of the Wii balance board to measure postural stability during powerful, realistic visual challenges from immersive virtual reality. LIMITATIONS OF CURRENT TECHNIQUES: Present computerized methods for measuring postural stability are large, complex, slow, and expensive, and do not allow for testing the response to realistic visual challenges. PROTOCOL: Subjects stand on a 6 cm thick, firm, foam pad on a Wii balance board. They wear a fast, high resolution, low persistence, virtual reality head set (Oculus Rift DK2). This allows displays of varying speed, direction, depth, and complexity to be delivered. The subject experiences a visual illusion of real objects fixed relative to the world, and any of these displays can be perturbed in an unpredictable fashion. A special app (BalanceRite) used the same procedures for analyzing postural analysis as used by the Equitest. POWER OF THE TECHNIQUE: Four simple "proof of concept" experiments demonstrate that this technique matches the gold standard Equitest in terms of the measurement of postural stability but goes beyond the Equitest by measuring stability in the face of visual challenges, which are so powerful that even healthy subjects fall. The response to these challenges presents an opportunity for predicting falls and for rehabilitation of seniors and patients with poor postural stability. SIGNIFICANCE FOR THE FIELD: This new method provides a simpler, quicker, cheaper method of measurement than the Equitest. It may provide a new mode of training to prevent falls, by maintaining postural stability in the face of visual and proprioceptive challenges similar to those encountered in life.

Driving on ice: impaired driving skills in current methamphetamine users.

RATIONALE: Previous research indicates a complex link between methamphetamine (METH) and driving performance. Acute dosing with amphetamines has improved driving-related performance in some laboratory studies, while epidemiological studies suggest an association between METH use, impaired driving, and accident culpability. METHODS: Current METH users were compared to a control group of nonusers on driving simulator performance. Groups were matched for age, gender, and driving experience. Subjects were assessed for current drug use, drug dependence, and drug levels in saliva/blood as well as personality variables, sleepiness, and driving performance. RESULTS: METH users, most of whom met the criteria for METH dependence, were significantly more likely to speed and to weave from side to side when driving. They also left less distance between their vehicle and oncoming vehicles when making a right-hand turn. This risky driving was not associated with current blood levels of METH or its principal metabolite, amphetamine, which varied widely within the METH group. Other drugs were detected (principally low levels of THC or MDMA) in some METH users, but at levels that were unlikely to impair driving performance. There were higher levels of impulsivity and antisocial personality disorder in the METH-using cohort. CONCLUSIONS: These findings confirm indications from epidemiological studies of an association between METH use and impaired driving ability and provide a platform for future research to further explore the factors contributing to increased accident risk in this population.