Auditory and visual 3D virtual reality therapy as a new treatment for chronic subjective tinnitus: Results of a randomized controlled trial.

BACKGROUND: Subjective tinnitus (ST) is a frequent audiologic condition that still requires effective treatment. This study aimed at evaluating two therapeutic approaches: Virtual Reality (VR) immersion in auditory and visual 3D environments and Cognitive Behaviour Therapy (CBT). METHODS: This open, randomized and therapeutic equivalence trial used bilateral testing of VR versus CBT. Adult patients displaying unilateral or predominantly unilateral ST, and fulfilling inclusion criteria were included after giving their written informed consent. We measured the different therapeutic effect by comparing the mean scores of validated questionnaires and visual analog scales, pre and post protocol. Equivalence was established if both strategies did not differ for more than a predetermined limit. We used univariate and multivariate analysis adjusted on baseline values to assess treatment efficacy. In addition of this trial, purely exploratory comparison to a waiting list group (WL) was provided. RESULTS: Between August, 2009 and November, 2011, 148 of 162 screened patients were enrolled (VR n = 61, CBT n = 58, WL n = 29). These groups did not differ at baseline for demographic data. Three month after the end of the treatment, we didn't find any difference between VR and CBT groups either for tinnitus severity (p = 0.99) or tinnitus handicap (p = 0.36). CONCLUSION: VR appears to be at least as effective as CBT in unilateral ST patients.

Human side preferences in three different whole-body movement tasks.

Animals turn away from the hemisphere with the more active dopamine (DA) system. For humans, a similar relationship has been assumed. However, results from independent studies were obtained from different tasks and indicated different side preferences. To investigate side preferences between different tasks within the same subject, we assessed in 36 healthy research participants (20 women) (1) long-term spontaneous turning (number of 360 degree turns during 20 h), (2) veering (lateral deviations during walking blindfolded straight forward) and (3) stepping (deviations while stepping blindfolded on a given spot) behavior. We observed a left-sided preference for long-term spontaneous turning behavior and no significant side preference for veering and stepping behavior. The absence of consistent side preferences suggests that DA does not equally control lateralized whole-body movements. We propose that visual control enhanced left-sided movement preferences, probably through an enhanced contribution of the right hemisphere to visuo-spatial behavior. Recently, we reported [Neurosci. Lett. 339 (2003) 115] that levodopa supplementation decreases right-sided veering tendencies, while stepping behavior was unaffected by substance intake. We suggest that veering tendencies, which appeared equally pronounced in either direction, are under dopaminergic control as long as attention is directed towards extrapersonal space. Side preferences in lateralized whole-body movement tasks are thus neither comparable between tasks nor within subjects. We conclude that experimental parameters such as visuo-spatial control and spatial task demands (veering is directed to extrapersonal space and stepping to peripersonal space) determine whether or not the DA system is involved.

Pure imagery hemi-neglect of far space.

Patients with hemispatial neglect restricted to near (within reaching distance) or to far space (beyond reaching distance) have been described. This constitutes a double-dissociation considered by current neurocognitive thinking as compelling evidence for separate networks. However, a similar double-dissociation exists with respect to perceived as opposed to imagined space. If the organization of represented space was similar to that of perceived space, it should contain a far/near dissociation as well. This paper describes a patient with pure representational neglect restricted to far space.

Multisensory integration for spatial orientation in trait anxiety subjects: absence of visual dependence.

Studies suggest a greater reliance on visual information for maintaining balance in anxious subjects. Nevertheless, links between this supposed preferred visual processing and spatial orientation have not yet been evaluated. Two groups of subjects differing in their level of trait anxiety were formed. Equipped with a head-mounted visual display, they learned a virtual corridor using passive translation but active rotation, both with normal and with two different conflicting sensory conditions. After two visual navigation trials in the corridor, they were blindfolded and asked to reproduce the same trajectory from memory. In addition, subjects drew a map of the remembered corridor. Anxious subjects were comparable to non-anxious subjects when asked to reproduce the trajectory from memory, but exhibited a deficit when drawing a map of the corridor they were in. The results do not support the hypothesis that anxious subjects use preferentially one type of sensory cue over another for spatial orientation, but instead manifest difficulties in constructing more global representations of space.

Differential effects of labyrinthine dysfunction on distance and direction during blindfolded walking of a triangular path.

While we walk through the environment, we constantly receive inputs from different sensory systems. For us to accomplish a given task, for example to reach a target location, the sensory information has to be integrated to update our knowledge of self-position and self-orientation with respect to the target so that we can correctly plan and perform the remaining trajectory. As has been shown previously, vestibular information plays a minor role in the performance of linear goal-directed locomotion when walking blindfolded toward a previously seen target within a few meters. The present study extends the question of whether vestibular information is a requirement for goal-directed locomotion by studying a more complex task that also involves rotation: walking a triangular path. Furthermore, studying this task provides information about how we walk a given trajectory, how we move around corners, and whether we are able to return to the starting point. Seven young male, five labyrinthine-defective (LD) and five age- and gender-matched control subjects were asked to walk a previously seen triangular path, which was marked on the ground, first without vision (EC) and then with vision (EO). Each subject performed three clockwise (CW) and three counterclockwise (CCW) walks under the EC condition and one CW and CCW walk under the EO condition. The movement of the subjects was recorded by means of a 3D motion analysis system. Analysis of the data showed that LD subjects had, in the EC condition, a significantly larger final arrival error, which was due to increased directional errors during the turns. However, there was no difference between the groups as regards the overall path length walked. This shows that LD subjects were able to plan and execute the given trajectory without vision, but failed to turn correctly around the corners. Hence, the results demonstrate that vestibular information enhances the ability to perform a planned trajectory incorporating whole body rotations when no visual feedback is available.

Pure representational neglect after right thalamic lesion.

After a right thalamic stroke, an 86-year-old man presented an acute pure left representational neglect in the absence of any perceptual neglect. On spatial mental imagery tasks, the patient systematically omitted items located on his left side, but only when a vantage point was given. This suggests that (1) pure representational neglect is not just a residual finding after recovery from global (perceptual and representational) neglect; (2) space representation can be coded by two independent processes: in viewer-centered or world-based (allocentric) coordinates; and (3) the right thalamus serves as a relay in the processing of spatial visual imagery.

Self-motion perception during a sequence of whole-body rotations in darkeness.

The main aim of this study was to examine how postrotatory effects, induced by passive whole-body rotations in darkness, could alter the perception of motion and eye movements during a subsequent rotation. Perception of angle magnitude was assessed in a reproduction task: blindfolded subjects were first submitted to a passive rotation about the earth-vertical axis on a mobile robot. They were then asked to reproduce this angle by controlling the robot with a joystick. Stimulus rotations ranged from 80 degrees to 340 degrees. Subjects were given one of two delay instructions: after the stimulus, they either had to await the end of postrotatory sensations before starting reproduction (condition free delay, FD), or they had to start immediately after the end of the stimulus rotation (no delay, ND). The delay in FD was used as an incidental measure of the subjective duration of these sensations. Eye movements were recorded with an infrared measuring system (IRIS). Results showed that in both conditions subjects accurately reproduced rotation angles, though they did not reproduce the stimulus dynamics. Peak velocities reached in ND were higher than in FD. This difference suggests that postrotatory effects induced a bias in the perception of angular velocity in the ND condition.

Spatial, not temporal cues drive predictive orienting movements during navigation: a virtual reality study.

A fundamental property of the human brain is the ability to make predictions of future sensory and motor events. We have recently found that steering manoeuvres when walking along curvilinear trajectories are controlled by an anticipatory guidance of the direction of head (and eyes). However it is unclear whether a time-related or space-related signal triggers such anticipatory head orienting movements. By simulating navigation along a multi-legged virtual corridor we show that anticipatory orienting movements are triggered (in standing subjects) by reaching specific locations rather than by the time to the approaching corridor's bend. Similar to what happens in car driving, specific spatial features of the route rather than time to collision seem to drive steering.

Lack of anticipatory gaze-orienting responses in patients with right brain damage.

OBJECTIVE: To study eye movements during cervical proprioceptive stimulation by passive body rotation in darkness, with the head held stationary, in patients with right brain damage and hemineglect. BACKGROUND: At very low frequency, this stimulation is reported to produce an illusion of head turning in space and eye deviations directed opposite to trunk rotation (in the direction of the illusory head rotation). METHODS: Ten normal subjects and seven patients with unilateral cerebral lesions (five right brain-damaged patients with mild to moderate visuospatial neglect, two left brain-damaged patients without neglect) were included in the study. Subjects were seated on a rotating chair. Stimuli consisted of slow sinusoidal passive trunk rotations (+/-30 degrees, 0.01 Hz) while the head was fixed in space. RESULTS: Eye movements directed opposite to trunk rotation were typical for normal subjects and for left brain-damaged patients. In contrast, all right brain-damaged patients showed either eye movements in the direction of trunk rotation or no eye deviations at all. CONCLUSION: This result could characterize a lack of anticipatory coordinating gaze behavior in patients with right brain damage.

Eye deviation during rotation in darkness in trait anxiety: an early expression of perceptual avoidance?

BACKGROUND: Patients with dizziness and patients with panic disorder and agoraphobia share a common symptomatology. Numerous studies have investigated a potential link between anxiety and the vestibular system, but few of them have addressed the specific topic of spatial representation. METHODS: Passive whole-body rotations in the horizontal plane were imposed on two groups of subjects who differed in their level of trait anxiety. Subjects were seated on a mobile robot in darkness. After each passive rotation, subjects were asked to reproduce the stimulus by driving the robot with a joystick and to perform a rotation of the same magnitude. Eye movements were recorded and analyzed. RESULTS: No difference in either perception (accuracy in the reproduction task) or in VOR gain was found between the two groups of subjects. Mean eye deviation, caused by fast phases of the nystagmus, differed in the two groups. It was typically in the anticompensatory direction in the non-anxious group, and in the compensatory direction the anxious group. Such compensatory movement may be explained by an egocentric orientation strategy, that may in turn indicate a lack of interest toward the visual surroundings. CONCLUSIONS: An egocentric strategy for self-orientation exhibited at a level below the threshold of awareness could reveal the existence of a physiological mode of processing leading to agoraphobic avoidance.

Adaptation as a sensorial profile in trait anxiety: a study with virtual reality.

Twenty-four volunteers were recruited on the basis of their trait anxiety scores (low trait anxiety [LTA] and high trait anxiety [HTA]) as assessed by the State-Trait Anxiety Inventory. Adaptation to conflicting visual-vestibular stimulation (VVS) was used to study integration of space-related multi-sensory information in trait anxiety. First, vestibular perception was assessed by rotating the blindfolded subjects about the vertical axis (horizontal plane rotations) on a remote-controlled mobile robot. The subjects were asked to indicate the perceived rotation by use of an angular pointer. Subjects were then immersed into the center of a visual virtual square room by means of a head-mounted display. They were asked to control the robot with a joystick in order to perform 90 degrees rotations in the virtual room. However, a gain of 0.5 was introduced between visual scene and robot rotation so that the subjects were submitted to a conflict situation in which the 90 degrees rotational visual input was concurrent with a 180 degrees vestibular input. After 45 min of training with the virtual reality display, subjects were tested again in total darkness in order to determine whether their vestibular system had been reset by the conflicting visual signals. We found significant differences in adaptation to VVS between HTA and LTA groups as well as between males and females. Subjects of the HTA group demonstrated larger adaptation than that of the LTA group. Males also showed a greater level of adaptation compared to females. Our results suggest greater visual dependence in HTA subjects. This might be important for understanding the mechanisms underlying pathological anxiety and particularly agoraphobia.

Multisensory integration in spatial orientation.

Recent psychophysical studies on normal subjects, as well as brain imaging studies, have revised the concepts concerning the mechanisms underlying spatial orientation during navigation tasks. The emphasis has been put on internal models that allow the prediction of a planned trajectory and are essential in the steering of locomotion. Cognitive factors such as strategies and emotional parameters are now starting to be included in the research on spatial orientation. It is obvious that important individual and gender differences exist in the brain operations underlying spatial orientation in humans, which may help to understand the construction of a coherent perception and the organic neural disorders related to the internal representation of space.

Non-specific directional adaptation to asymmetrical visual-vestibular stimulation.

Subjective estimates of passive whole-body rotations in darkness were evaluated before and after exposure to asymmetrical incoherent visual-vestibular stimulation (VVS). Two subjects who showed large capacity for adaptation to symmetrical incoherent VVS were enrolled in the study. Strikingly, after 45 min of asymmetrical left-right VVS, perception of rotation decreased equally for rotations to the right and to the left indicating that the calibration of vestibular sensory input for spatial orientation did not undergo a directional specific control.

Eye movements during torso rotations in labyrinthine-defective subjects.

The aim of this study was to examine whether the chronic loss of vestibular function modifies perceptual and oculomotor responses during torso rotations in darkness. Subjects (4 patients with complete vestibular loss and 7 healthy volunteers) were seated on a rotating chair. Stimuli consisted of sinusoidal chair rotations (+/-30 degrees, 0.1 Hz and 0.011 Hz). We used 2 conditions: space stationary head (neck stimulation) and space stationary head and shoulders (torso stimulation). Horizontal eye deviations and slow component of eye movements were analysed. The results showed that eye movements and perception of head motion in space during neck stimulation were similar to those during torso stimulation both in normal and labyrinthine-defective (LD) subjects. During low-frequency chair rotations (0.011 Hz) all subjects perceived illusory head or head and shoulder rotation in space (as if the lower part of the body was stationary relative to the room) and shifted their gaze in the direction of illusory head rotation. In these conditions there was no significant difference in eye movements between normal and LD subjects. During higher frequency chair rotations (0.1 Hz), LD subjects had significantly larger eye deviations as well as increases in the gain of the slow component of eye movements relative to normals. In these conditions patients mostly perceived illusory head or head and shoulder rotation in space while normal subjects mainly perceived the head as stationary in space. The results indicate that 1) neck and torso rotations can evoke similar ocular responses in LD subjects, 2) the chronic loss of vestibular function modifies the representation of axial body segment motion relative to space.

The vestibulo-ocular reflex and angular displacement perception in darkness in humans: adaptation to a virtual environment.

The vestibulo-ocular reflex (VOR) and angular displacement perception were measured in 25 healthy humans in darkness before and after exposure to incoherent visual-vestibular stimulation (VVS): 45 min of repeated passive 180 degrees whole-body rotations around the vertical axis concurrent with only 90 degrees rotation in a visual virtual square room. Large inter-individual variability was observed for both VOR gain and turning estimates. The individual VOR gains were not correlated with perceived angles of rotation either before or after VVS. After VVS, the angular displacement perception decreased by 24+/-16% while the VOR gain did not change significantly. The results suggest that adaptive plasticity in turning perception and adaptive plasticity in VOR might be independent of one another.