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8 Rotational Vestibular Assessment
A B
D E
C
F
FIGURE 1–7. Portraits of prominent vestibular scientists from the eighteenth through the twentieth century. A. Róbert
Bárány (1876–1936). B. Ernst Josef Mach (1838–1916). C. Robert Waring Darwin (1838–1916). D. Alexander
Crum Brown (1838–1922). E. Erasmus Darwin (1731–1802). F. Jan Evangelista Purkyneˇ (1787–1869). continues
notably by Charles Wells, Erasmus Darwin, and
Robert Waring Darwin) (Wade, 2003), it was not
until the work of Flourens in 1824 that Aristotle’s
five senses officially added one more. Flourens’
research involving the extirpation of semicircular
canals in pigeons finally provided the irrefutable
evidence for the vestibular system’s role in the
perception of motion, thus heralding the elusive
sixth sense.
The emergence of the sixth sense struggled for
nearly 2000 years after Aristotle first described the
five principal human senses. Therefore, it was not
surprising that widespread acceptance was not appreciated by all scientists at the time, including Jan
1. Historical Perspective of Human Rotation and Centrifugation 9
G H
FIGURE 1–7.
Breuer (1842–1925).
continued G. Jean Pierre Flourens (1794–1867). H. Josef
Evangelista Purkyneˇ, who continued to remain
hesitant in acknowledging all the available scientific evidence at the time (Wade, 2003).
Despite the quiescence of reports investigating the use of rotational chairs for the clinical
diagnosis and treatment of vertigo throughout
the early and mid-1800s, there were significant
advancements in the understanding of vestibular
physiology in the last quarter of the nineteenth century. Ernst Josef Mach, Alexander Crum Brown,
and Josef Breuer (see Figure 1–7) almost simultaneously proposed the “hydrodynamic theory
of semicircular canal function” in 1874 to 1875.
Ernst Josef Mach, in particular, was instrumental
in this theory. During this time, Mach also published scientific reports investigating the nature
of otolith responses, as well as the first reports
indicating the semicircular canals responded to
acceleration, not velocity (Cohen & Raphan, 2004).
Between the years 1874 and 1875, Ernst Mach constructed a rotational chair that was mounted in a
rotatable frame, and examined the perception of
the visual vertical during static tilt, and also the
visual aftereffects of body rotation (Figure 1–8).
Mach performed such studies after observing the
vertical tilting of telegraph poles when rounding an inappropriately banked curve on a train
(Cohen & Raphan, 2004). For his work on subjective visual vertical, some consider Ernst Mach the
“Father of Otolith Function Testing.” Despite this
otological notoriety, Ernst Josef Mach, being an
Austrian physicist and philosopher, is probably
better known for the Mach principle, which was
the precursor to Einstein’s theory of relativity.
It is also worth noting that during the time
of Mach’s discoveries, Alexander Crum Brown
also devised methods for measuring thresholds
for detecting body movements on a rotating
stool. He determined that thresholds were lowest when the head was positioned so that one of
the semicircular canals was in the plane of rotation; a precursor to Ewald’s laws of semicircular
canal function. Finally, toward the beginning of
the twentieth century, Lorente de Nó (1933) first
described in detail the three-neuron arc that connects the peripheral vestibular end organs to the
ocular muscles, thus detailing the Vestibular Ocular Reflex (VOR) pathways that Charles Wells
eloquently described 140 years earlier (Cohen &
Raphan, 2004).
10 Rotational Vestibular Assessment
A B
FIGURE 1–8.
examined the perception of the visual vertical during static tilt, and also the visual aftereffects of body rotation.
Some consider Ernst Mach the “Father of Otolith Function Testing.” From Grundlinien der Lehre von den Bewe-
gungsempfindungen, by E. Mach, 1875, Leipzig, Verlang von Wilhelm Engelmann.
A. Ernst Mach (1838–1916). B. The rotational chair that was mounted in a rotatable frame, which
ROTATION IN THE EARLY
TWENTIETH CENTURY
day rotational chairs are sometimes referred to as
“Bárány chairs.” Although modern chairs have
come along way in their function, chairs similar
in appearance and function to Bárány’s original
Despite the scientific evidence heralding the emergence of the vestibular system as the sixth sense,
chair are actually still in use today in some aerospace and military motion tolerance labs.
the application of clinical rotation withstood a
slow transition from the psychiatric treatment
of mental disorders to the clinical assessment of
otolaryngological disease. Toward the later part
Introduction of Rotational Testing in
the Assessment of Vestibular Function
of the nineteenth century and the early part of
the twentieth century, the medicinal evidence for
Horn’s “psychiatric centrifuge” finally gave way
to more scientific evidence supporting the use of
rotation as a clinical method for investigating
vestibular function. Nearly a century after the
well-accepted and routine use of patient rotation
for the treatment of psychiatric disorders, Róbert
Bárány (see Figure 1–7) introduced the application of patient rotation in 1907 as a means for
the clinical assessment of the vestibular system.
Bárány developed the first rotational chair that
was universally adopted in otolaryngology clinics
at the time (Figure 1–9). For this reason, modern
Róbert Bárány first introduced the idea of rotational testing in routine clinical assessment of
the vestibular system in 1907. Bárány devised a
method of impulse stimulation whereby an abrupt
acceleration was applied to a rotational “Bárány
chair,” with the patient being given 10 rotations
in 20 seconds, which was then followed by an
abrupt cessation of rotation applied by a manual
foot brake. Immediately following cessation of
rotation, the presence of post-rotary nystagmus
was visualized and timed by the examiner. It
was believed that the slow decay of nystagmus
reflected activity of the horizontal cupulae. The
1. Historical Perspective of Human Rotation and Centrifugation 11
A B
FIGURE 1–9. A. Bárány chair. From Background and Introduction to Whole-Body Rotational Testing by A. M.
Goulson, J. H. McPherson, and N. T. Shepard, 2016. In G. P. Jacobson and N. T. Shepard (Eds.), Balance Function Assessment and Management, (pp. 347–364). San Diego, CA, Plural Publishing. Reprinted with permission.
B. Use of a Bárány chair applying the past-pointing procedure following cessation of rotation. Reprinted with kind
permission from http://www.goflightmedicine.com
test was then repeated in the opposite direction
and the results were often compared. Although the
principles of the test were believed by many early
twentieth century neurologists to be very insightful into the function of the vestibular system, the
administration and subsequent interpretation of
this test was also recognized as problematic, as
control of stimulus delivery was often inconsistent, particularly between different patients.
A few years later in 1931, Veits suggested that
Bárány’s method of impulse stimulation over a
20 second period was, in fact, too short to allow
for the cupulae to return to their original position
after having received such brisk accelerations.
Therefore, Veits suggested that the cessation of
rotation during Bárány’s impulse protocol likely
occurred while the cupulae were still deviated.
In an attempt to remedy this problem, Veits suggested delivering extremely slow accelerations
until reaching a constant velocity of 180°/sec. At
this velocity, Veits proposed maintaining a constant level of rotation until resetting of the cupulae
were assured. He determined this by an absence
of nystagmus and cessation of vertigo. Only after
12 Rotational Vestibular Assessment
these criteria were met, was the brake applied
to the Bárány chair and the duration of the postrotary nystagmus recorded.
In 1948, another attempt to improve upon
Bárány’s impulse stimulation test was proposed by
van Egmond, Groen, and Jongkees. These authors
described a method similar to Veits involving the
use of slow accelerations. However, van Egmond,
Groen, and Jongkees slowly accelerated patients
to a number of predetermined target velocities, at
which time the chair was abruptly stopped and
the post-rotary nystagmus and subjective vertigo
was again timed. van Egmond, Groen, and Jongkees plotted each nystagmus response against
the various target velocities and coined the term
“cupulometry” to describe the vestibular response
over a broader range of frequencies.
During the 1940s, vestibular scientists were
also beginning to investigate the effects of linear
acceleration on the vestibular system. Modified
human centrifuges were used by various researchers during the mid-1900s. Graybiel and Hupp
(1946), and Graybiel, Niven, and Walsh (1952)
devised a method to apply centripetal force to
study the effects of linear acceleration on the utricle. Aside from Ernst Mach’s experiments, these
are perhaps some of the earliest vestibular studies
using “modern” human centrifuges and eccentric
rotation. However, detailed ocular measures of
nystagmus were lacking, and reports were often
confined to patient reports of apparent subjective
tilting of the body, as well as the ostensible visual
tilting of surrounding objects in space.
Some of the earlier successor chairs to the
Bárány chair were the Hallpike, Hood, and Byford
chair (1952) (Figure 1–10), the Tönnies apparatus
(1955) (Figure 1–11), the Frenckner and Preber
chair (1956) (Figure 1–12), the Fluur chair (1960)
(Figure 1–13), the Johnson and Taylor table (1961)
(Figure 1–14), the “Girograph of Montandon”
(Geneva, Switzerland, 1955; Montandon & Russbach, 1955), the Stille-LKB Rotating chair (StilleWerner, Stockholm), and the Heidelberg chair (Ey
& Feldman, 1964; Figure 1–15) (McNally & Stuart,
1967). For an excellent review of the rotational
chairs used during the mid-twentieth century
from military institutions, domestic hospitals and
laboratories, as well as foreign laboratories, the
FIGURE 1–10. Hallpike, Dix, and Byford rotational
chair, 1952. From “The Design, Construction and Performance of a New Type of Revolving Chair Some Experimental Results and Their Application to the Physical
Theory of the Cupular Mechanism” by C. S. Hallpike, J. D.
Hood, and G. H. Byford, 1952, Acta Oto-Laryngologica,
42(6), 511–538. Reprinted with permission.
reader is encouraged to read Guedry and Graybiel’s (1961) report entitled Rotation Devices, Other
Than Centrifuges and Motion Stimulators: The Rationale for the Special Characteristics and Use. In general,
from 1907 until the 1960s, rotational assessments
using the Bárány chair and its successors were
essentially confined to impulse stimulation and
cupulometry protocols. Early attempts were frequently proposed in an attempt to improve testing
and provide better outcome measures; however,
results were plagued with unreliability and poor
sensitivity at identifying vestibular pathology.
A
B C
FIGURE 1–11. Early model of Tönnies apparatus rotational chair. Chair orientation could be modified to study
horizontal nystagmus (A), vertical nystagmus (B), and torsional nystagmus (C). From “On Acceleratory Stimulation,” 1955, Acta Oto-Laryngologica, 45(Suppl. 122), 22–44. Reprinted with permission.
13
A
B C
FIGURE 1–12. Frenckner and Preber chair. Rotational chair (A), computer console (B), and nystagmus printout
(C). From “Relationship Between Vestibular Reactions and Vegetative Reflexes, Studied in Man by Means of a
Revolving Chair of New Design” by P. Frenckner, and L. Preber, 1956, Acta Oto-Laryngologica, 46(3), 207–220.
Reprinted with permission.
14
A
B
FIGURE 1–13. The Fluur rotational chair. A. Chair positioned for
nasion-occipital eccentric rotation. B. Chair positioned for interaural
axis eccentric rotation. From “A Novel Rotary Chair” by E. Fluur, 1960,
Acta Oto-Laryngologica, 52:1–6, 210–214. Reprinted with permission.
15
FIGURE 1–14. The Johnson and Taylor rotational chair. From “The
Importance of the Otoliths in Disorientation” by W. H. Johnson, 1964,
Aerospace Medicine, 35, 874–877. Reprinted with permission.
FIGURE 1–15. Heidelberg chair. From “Der Heidelberger Planeten-
Drehstuhl, eine neuartige Mehrzweck-Drehstuhlanlage für Vestibularisreflexprüfungen” by W. Ey, and H. Feldman, 1964, Archiv Ohren-,
Nasen- u. Kehlkopfheilk. 184, 73–80. Reprinted with permission.
16
1. Historical Perspective of Human Rotation and Centrifugation 17
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This was largely due to the fact that stimulus
delivery was manually generated, or electrically
driven through inefficient motors and turntables.
It was not until the late 1960s and early 1970s,
when the advent of computer-controlled precision
torque motors were able to deliver more consistent and reliable stimuli, thus improving the various outcome measures.
The slow advancement of rotational research
and its use in clinical assessments in the early
twentieth century may have also been due to one
of the most (if not the most) significant discovery
in clinical vestibular physiology. In 1906, Róbert
Bárány published, “Untersuchungen ueber den
vom Vestibularapparat des Ohres reflektorisch
ausgel
Begleiterscheinungen” (“Investigations of Rhythmic Nystagmus and Its Accompanying Manifestations Arising From The Vestibular Apparatus of the
Ear”) (Nylen, 1965). In this work, he described the
caloric response for which he was later awarded the
Nobel Prize in Physiology and Medicine in 1914.
In fact, no other Nobel Prize has been awarded
in the field of vestibular medicine (noting that
George von Békésy also received the Nobel Prize
in Physiology and Medicine in 1961, although
this was for his work in the field of hearing science
on the cochlear traveling wave). The caloric test
became an otolaryngological breakthrough for the
discovery of labyrinthine disease and identifying normal vestibular function. Given the caloric
test’s success and the concomitant unreliability of
rotational data at the time, the rotational test was
likely overshadowed by the simplicity and widespread acceptance of caloric irrigations.
östen rhythmischen Nystagmus und seine
ROTATION IN THE MID-TO-
LATE TWENTIETH CENTURY
During the mid-twentieth century, the caloric test
flourished due to its increased diagnostic sensitivity for vestibular disease, while rotational chair
testing received only a moderate degree of attention, secondary to its inherently unreliable nature.
However, with the advent of “personal” computing in the later quarter of the twentieth century,
and the increased knowledge regarding vestibular
physiology (such as the discovery of the neural
integrator and the velocity storage mechanism
by Raphan, Matsuo, and Cohen in 1979), research
and development in the field of rotational testing
was once again about to flourish and emerge as a
highly specialized vestibular test, both in clinical
and research settings.
The introduction of smaller (personal) computers in the late 1960s and early 1970s significantly changed the clinical canvas of nearly every
physiologic test, and rotational testing was no
exception. With the personal computer came significant advancements in the ability to deliver
exacting stimuli through new torque motors with a
higher degree of precision and low vibration noise,
thus eliminating the immeasurable variability and
clinical uncertainty associated with manually produced brake-rotations common with the Bárány
chair. Moreover, the discovery of the corneoretinal
potential by Emil du Bois-Reymond (1818–1896)
in 1948 opened the door for the objective measurement of nystagmus (Brey, McPherson, & Lynch,
2008a). Recording of the corneoretinal potential
through electrooculography (EOG) allowed for
the quantification of nystagmus, rather than the
subjective timing of the post-rotary nystagmus
decay response, which introduced much needed
sensitivity to rotational analyses.
The number of accounts of rotational investigations beginning in the late 1960s into the 1970s
was exponential in growth. From the development
and application of new linear sleds, to the development of more advanced yaw angular rotational
chairs (and rooms), numerous published reports
detailing the various vestibular ocular response
parameters and new stimulus paradigms, occurred
at a rapid pace. Niven, Carroll Hixson, and Correia (1965) devised the “Coriolis Acceleration
Platform,” which was able to produce 16 feet/sec
linear accelerations with a peak linear acceleration
of 3-gravitational forces (McNally & Stuart, 1967).
This study is often cited as the first investigation to show nystagmus with linear acceleration.
However, the use of linear sleds was extraordinarily expensive due to the shear size of the
laboratory needed to build and use such equipment. To address the massive size requirements
needed for such linear sled experiments, Johnson
and Taylor (1961) devised an electrically driven
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