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184 BAlAnCE FunCtion AssEssmEnt And mAnAgEmEnt
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Technique
Patients are asked to stand with their arms at their sides
in the following four test conditions: (1) firm surface with
eyes open, (2) firm surface with eyes closed, (3) compliant surface (foam) with eyes open, and (4) compliant
surface (foam) with eyes closed. The foam should be
of sufficient density and thickness to support the individual’s bodyweight. Each position is timed for 30 s. If
patients are unable to maintain the position for 30 s, they
are provided two additional attempts, and the times for
the three trials are averaged. The position of the feet
(feet together versus feet apart) and footwear do not
influence the scores (Whitney & Wrisley, 2004; Wrisley
& Whitney, 2004). A total score is calculated by adding the times (or average times if more than one trial is
required) for the four test positions together.
Results
Normal Results
Normative data for the CTSIB has been published
in 69 healthy adults aged 20 to 70 years (El-Kashlan,
Shepard, Asher, Smith-Wheelock, & Telian, 1998).
Cohen et al. (1993) also presented data for a group of
neurologically asymptomatic adults for the CTSIB.
While a maximum score on the CTSIB is 180 (30 s for
each of six test conditions), only four of the test conditions are performed for the mCTSIB. Normal subjects
should be able to maintain the four test positions for
approximately 30 seconds, with a score close to 120.
Abnormal Results
An inability to maintain the four test positions for
approximately 30 seconds is considered to be abnormal.
Mechanism
The medial and lateral vestibulospinal and reticulospinal tracts are important components of the vestibular
contribution to postural control. The medial vestibulospinal tract originates in the medial vestibular nucleus
and contributes fibers to the medial longitudinal fasciculus. The lateral vestibulospinal tract originates in
the lateral vestibular nucleus and carries vestibular and
cerebellar information to the lower motor neurons. The
lateral vestibular nucleus receives afferent information
from the eighth nerve, as well as efferent information
from the vermis and fastigial nuclei in the cerebellum. Descending projections from the fastigial nuclei
to the vestibular nuclei and reticular formation influence axial and proximal motor control (Zhang, Wang,
& Zhu, 2016). The reticulospinal tract originates from
the reticular formation and influences muscle tone. It
also facilitates or inhibits volitional movement (pyramidal system) and myotatic reflexes. Myotatic reflexes
contribute to postural control by maintaining joint
stiffness. Volitional movement contributes to postural
control through the execution of learned, purposeful
movements. These purposeful movements can prevent
or counteract a loss of balance.
Test Performance
The mCTSIB is correlated with condition 2 (firm surface with eyes closed; r = 0.48), condition 4 (swayreferenced surface with eyes open; r = 0.30), and
condition 5 (sway-referenced surface with eyes closed;
r = 0.51) on the Sensory Organization Test (SOT) (Wrisley & Whitney, 2004). Weber and Cass (1993) found that
the mCTSIB condition 4 (standing on a compliant surface [foam] with eyes closed) had a sensitivity of 95%
and a specificity of 90% in comparison to the SOT in
patients with complaints of dizziness and imbalance.
Individuals with posterior canal BPPV demonstrated
greater sway velocity when standing on foam with eyes
open or eyes closed during the instrumented mCTSIB
(Zhou et al., 2015). No postural deficits were observed
in individuals with horizontal canal BPPV compared
with healthy controls (Zhou et al., 2015). In patients
with unilateral vestibulopathy, correlations between
the conditions on the CTSIB and the SOT composite
score ranged from −0.23 to −0.65 (Park et al., 2013).
Park et al. (2013) found the resulting sensitivity was
42% and the specificity was 68% for the mCTSIB to correctly identify individuals with unilateral vestibulopathy from healthy controls.
The VEDGE task force determined that the
mCTSIB was Reasonable to Recommend at this time
for patients with acute (zero to six weeks) and chronic
(greater than six weeks) vestibular disorders. The
mCTSIB was Reasonable to Recommend at this time
for patients with peripheral or central dysfunction and
in individuals with BPPV.
SUMMARY
The results of bedside tests of vestibular function such
as those described in this chapter are commonly considered to be well-established criteria for the appropri-
9. BEdsidE AssEssmEnt oF tHE vEstiBulAr systEm 185
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ate referral of patients for diagnostic testing. However,
a review of published literature regarding the tests in
question do have conflicting results. Rather, the tests
may be most appropriately used as a screening to alert
the examiner that additional testing is warranted or
to inform the examiner of specific functional impairments experienced by the patient. Although the tests
reviewed in this chapter tend to exhibit high specificity, their attendant low sensitivity renders them relatively unsuitable for diagnostic purposes in clinical
use. As such, these informal assessment tools should
not be considered to be substitutes for electrophysiologic testing, imaging studies, or other diagnostic
testing. If bedside tests are included in the screening
and referral process, new or improved versions and
combinations of the tests must be developed, investigated, and proven by clinician scientists. Without such
developments, it is likely that reliance on bedside tests
of vestibular function may lead to missed diagnoses or
inappropriate referrals for testing and follow-up care.
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Eye Movement Recording and
Ocular Motility Testing
Neil T. Shepard, Michael C. Schubert, and Scott D. Z. Eggers
INTRODUCTION
Provided is a discussion of the technical aspects of
eye movement recording techniques, the routine clinical evaluation of the ocular motor systems involved
with gaze stability, saccade production, smooth pursuit tracking, and the optokinetic system. In addition
are the interpretations for each of these tests and how
they can be used in routine clinical investigations of
the dizzy patient, principally for the purpose of site-oflesion determination.
To better understand the interpretation of these
tests and how they can be used to localize lesions to
the central nervous system (CNS), the reader is referred
to Chapter 3 and other sources (Leigh & Zee, 2006) for a
review of the neurologic pathways involved in each of
the ocular motor tasks listed above. In a review of that
nature, you find overlaps in the neural pathways especially between gaze stability to an eccentric target and
saccade production, gaze stability to a primary target
and smooth pursuit, smooth pursuit and optokinetic
activity. Therefore, although the tests for ocular motor
functioning can be used to indicate CNS involvement
and, in some cases, suggest differential lesions within
the CNS, specific site-of-lesion determination clearly
is not always possible. In many cases, both brainstem
and cerebellar structures may be implicated, and further differentiation with physiologic testing alone is
not possible with routine clinical techniques. There are,
however, other combinations of results that are highly
suggestive of specific regions of the brainstem or cerebellum involved in abnormal ocular motor control.
Using specific patient examples of abnormal eye movements, the following discussion attempts to delineate
the global CNS indicators from those with more specific site-of-lesion implications. But first we need to discuss briefly the task of recording eye movement.
EYE MOVEMENT RECORDING TECHNIQUES
The measurement of the vestibulo-ocular reflex (VOR)
and ocular motility requires the use of sophisticated
methods to transform the movements of the eyes into
signals that can be digitized, processed, and analyzed.
There are at least three methods for accomplishing
this. The methods include electro-oculography (EOG)
(electronystagmography [ENG]), infrared videonystagmography (VNG) (i.e., video-oculography [VOG])
techniques and scleral search coil techniques. In this
chapter we will constrain the discussion of eye movement recording techniques to those used in contemporary vestibular system assessment clinics. Those
techniques include ENG and VNG.
Electro-Oculography/
Electronystagmography
Origin of the Corneoretinal
Potential and Electrode Use
The electrical transducer of the visual system is the retina, which also serves as the source of the corneoretinal
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potential (CRP). The CRP is a bioelectrical signal that
is measured during EOG, which is the recording technique used in ENG. The eyeball has a dipolar orientation like a “battery,” with the cornea being positively
polarized and the retina negatively polarized. This
standing potential is propagated through the eye
by volume conduction, where it is capable of being
recorded with conventional surface electrodes.
As the cornea is positively charged and the retina is negatively charged, two electrodes placed at
the outer canthus of each eye and routed into a differential amplifier should “see” neither a positive nor a
negative charge with the eyes in primary position (Figure 10–1A). If the eyes move conjugately to the right,
the electrode at the right outer canthus should record
a positive charge (i.e., as the positive pole of the right
eye is pointed toward it) and the electrode at the left
outer canthus should record a less positive charge (i.e.,
as less of that cornea is pointing toward that electrode)
(Figure 10–1B). A leftward conjugate eye movement of
similar magnitude results in the left electrode recording positive charge and the right electrode with a less
positive charge (Figure 10–1C). The convention in EOG
recordings is for upward trace deflections to represent
rightward and upward eye deviations, and for downward trace deflections to represent leftward or downward eye deviations.
Assuming the examiner observes a full, conjugate
range of movement of the eyes during informal testing, most clinicians record EOG using a “bitemporal”
electrode array (Figure 10–2). It must be stated that for
bitemporal recordings, electrical activity for the two
eyes is “averaged.” This means that disconjugate movements of the eyes will be missed and underscores the
importance for the clinician to examine informally the
movements of the eyes to detect gross or subtle ocular
motility disorders such as disconjugate eye movements
before electrodes are placed on the face or goggles are
placed over the eyes. An alternative to the bitemporal
electrode placement is the monocular technique (Figure 10–3). The monocular recording technique permits
the recording of eye position for each eye separately.
The electrode pairs are routed to a differential
amplifier that literally subtracts the electrical signal
recorded by the inverting electrode input from the electrical signal recorded by the non-inverting electrode
input (see Figures 10–2A through 10–2E). In doing
this, electrical activity that is unrelated to the CRP (i.e.,
unwanted electrical interference) that is common to
both the inverting and non-inverting electrodes (e.g.,
stray 60-Hz electrical signals, EKG interference) will be
subtracted out (and eliminated), a technique referred to
as common mode rejection (CMR). This should result
in a reduction in the noisiness of the EOG recordings.
A B C
figure 10–1. The corneoretinal potential (CRP). The cornea is positively charged and the retinal is negatively
charged. A. When the eye is in midline position a pair of electrodes placed on either side of the eye will see neither
a positive nor a negative voltage. B. When the eye turns to the right, a positive electrical potential is generated.
C.When the eye turns to the left, a negative electrical potential is generated.
A
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B
C
figure 10–2. Bitemporal electrode montage and the connections to a two-channel differential amplifier (i.e., two channels permit the recording of horizontal and vertical eye
deviations). A. The horizontal and vertical amplifier outputs to a printer when the eyes are
at primary (central) gaze (i.e., there is no pen deflection). B. The horizontal and vertical
amplifier outputs to a printer for a rightward eye deviation. Notice that a rightward eye
movement results in an upward pen deflection in the horizontal channel (a leftward eye
deviation would result in a downward pen deflection). C . The horizontal and vertical amplifier outputs to a printer for an upward eye deviation. Notice that an upward eye deviation
results in an upward pen deflection in the vertical channel (a downward eye movement
would result in a downward pen deflection). continues
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D
E
Figure 10–2. continued D. The horizontal and vertical amplifier outputs to a printer for an
oblique eye deviation (i.e., an up/right eye movement).
represented by deflections in both the horizontal and vertical channels. E .
and vertical amplifier outputs to a printer for a torsional eye movement.
eye is rotating about its anterior/posterior axis there is neither a deviation in the horizontal
nor in the vertical channels. This figure was adapted from An Introduction to ENG, by C . W.
Stockwell, 2004. Schaumburg, IL: GN Otometrics.
The electrical signals resulting from conjugate
horizontal eye deviations are approximately 20 µV
per 1 degree of eye deviation in normal subjects with
normal retinal function. These eye signals must be
amplified by a factor of approximately 10,000 for the
eye signals to be within an amplitude range that can
be digitized and processed by most computerized data
acquisition and processing systems. It should be noted
as shown in Figure 10–2E, torsional movements of the
eye without distinct horizontal or vertical movements
result in tracings without any deviation, since there is
no movement of the dipole laterally or vertically. Figures 10–1 through 10–3 are shown with a strip chart
recorder and pins for illustration. Currently, most systems on the market illustrate the traces on to a computer monitor screen.
Notice that the eye movement is
The horizontal
Notice that as the
Infrared Video Recording Techniques
Although scleral search coils are still considered the
gold standard for eye movement recordings, infrared
video tracking systems have rapidly become the stateof-the-art technique for recording eye movements.
A method for creating a vision-denied condition is the
final component of the hardware. Video tracking systems make use of pupil localization technology and the
reflective properties of the corneal surface to calculate
pupil position and angle of gaze. Implementation of the
system varies between manufacturers, but most make
use of a goggle-type headpiece to illuminate the eyes
that contains infrared diodes, dichroic glass “mirrors”
that reflect the image of the eyes into a single camera
or a pair of cameras that record the image of the eye.
10. EYE MOVEMENT RECORDING AND OCULAR MOTILITY TESTING 193
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Figure 10–3. Electrode locations and four-channel amplifier connections for a monocular montage.
A headband holds the assembly over the eyes (Figures
10–4 and 10–5). This setup fixes the camera in place
relative to the head, ensuring that changes in observed
pupil position are caused solely by eye movements
rather than a combination of head and eye movements.
The use of the dichroic glass allows the patient to
follow the visual targets during ocular motility testing)
but will reflect the eye image(s) into the left and right
eye cameras. Last, there are controls on the goggles that
permit the image of the eye to be raised, lowered, converged, diverged, or focused.
TECHNIQUE AND INTERPRETATIONS
OF OCULAR MOTILITY TESTING
In the evaluation of the dizzy patient, the eyes provide
the most direct access to the evaluation of the peripheral vestibular system. However, the pathways from
the labyrinthine structures involve significant neurologic substrate in the brainstem and cerebellum with
controlling influence from higher centers in the midbrain and cerebral cortex. Therefore, correct interpretation of eye movements relative to the periphery rely on
normal function of the central pathways. Also, symptoms of dizziness can result from lesions in the central
Figure 10–4. Model wearing a monocular, video eye
movement recording system. The lens reflects the left eye
image into a head-mounted video camera.
neural pathways or at the central nuclei. Secondary to
these issues, it becomes important to use the eyes as
our window into the CNS-controlling structures for eye
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