Physiology of Equilibrium

Lecturer:Dr Herman Mulijadi MS.SpKP

 Learning Objective

1. Explain the component of organs and system that

participate in the maintenance of body balance
2. Explain the component of vestibular system
3. Draw the receptors in each component of the
vestibular system and explain how they work
4. Differentiate the angular and linear acceleration
5. Explain the component of the vestibular system that
sensitive to angular and linear acceleration
6. Explain the mechanism of sea sickness
7. Explain some experiment to test body balance
8. Define nystagmus and explain its mechanism

2
 Balance:

It is :
• the ability to maintain equilibrium
Or
• the ability to maintain your center of
mass/gravity over your base of support in
any given sensory environment .

09/08/2016
3
 Balance

• Balance is very complex involving multiple systems that

interact flawlessly and automatically to coordinate input
from our environment and the central nervous system
to produce a motor output and keep you upright/vertical.
Postural control is related to balance in the dynamic mode.

4
 Balance is a highly integrated network
the position of the orientation of the the perception of central nervous
head relative to the head in space and the static position &
the position during system - integrated
environment & orients on accelaration
the head to maintain movements. these information
posture and translated to
fine motor
movements
EMOTION,PERSONALITY,
BEHAVIOUR,ANXIETAS, PARIETAL ASSOCIATON
LIMBIC SYSTEM CORTEX
( POSTERIOR PARIETAL )
(HIPOCAMPUS-MEMORY) CORTICO
ASSOCIATIO
PARIETAL LOBE OF N AREAS
CEREBELLAR CORTEX
( CEREBELLUM ) BASAL MOTOR CEREBELLUM
THALAMO GANGLIA CORTEX
MOTOR
VISUAL CORTEX CORTICO
CENTER MID
CHIASMA PROJECTION DORSAL
BRAIN MEDIAL
OPTICUM CEREBELLAR BRAIN STEM
LEMNISCI
TRACT
SUPERIOR, MEDIAL,
N OPTICUS LATERAL, INFERIOR
GANGLION VESTIBULAR SPINAL SPINAL MOTOR
CORD NEURON

OF SKIN,JOINTS,
OF INNER
SUPPORTING
“INFORMASI OF EYES EAR
TISSUE
From
environment

ocular system - visual SENSORY RECEPTOR proprioceptive system

perception of spatial vestibular system -rotatory - information input
orientation is supplied by stimulation and linear from the feet, ankle,
the eyes acceleration Information hip, and neck Response Action
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 Balance System Elements

 Vestibulo-ocular System
– Coordinate head and eye movements to maintain stable gaze
and visual acuity while actively moving about
 Posture Control (vestibulo-spinal) System
– Maintain postural stability while actively moving about

Physiological Characteristics
 Vestibulo-ocular System
– Horizontal semicircular canal & visual inputs
– Responses dominated by short pathway reflexes
– Simple movement geometry & biomechanics
 Posture Control System
– Vertical canal, otolithic, visual & proprioceptive inputs
– Responses mediated by complex central pathways
– Responses influenced by task & environment
– Complex movement geometry & biomechanics
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 SPATIAL ORIENTATION / PERCEPTION
ORIENTATION OF HEAD ORIENTATION OF
ORIENTATION OF HEAD AND AND BODY RELATIVE TO AIRCRAFT IN SPACE
BODY IN SPACE OWN AIRCRAFT AND/OR (EARTH REF) AND/
( EARTH REF ) OTHER AIRCRAFT OR RELATIVE TO
OTHER AIRCRAFT

EMOTION,PERSONALITY,
BEHAVIOUR,ANXIETAS, PARIETAL ASSOCIATON CORTEX
LIMBIC SYSTEM (HIPOCAMPUS- ( POSTERIOR PARIETAL )
MEMORY)
REFLEX
VESTIBULAR MUSCLE
OCULAR REFLEX MOVEMENT
EYE HEAD
NECK
TRUNK PARIETAL LOBE OF
EXTRA
OCULAR
CEREBELLAR CORTEX
MUSCLE +
VISUAL CORTEX ( CEREBELLUM )

SPINAL CORD

BRAIN
THALAMO CEREBELLUM
LAT GENICULO NUCLEUS MID BRAIN + CORTICO
SUPERIOR COLLICULUS VISION MOTOR MOTOR
PROJECTION
THALAMIC CEREBELLUM
PRETECTUM ACCESORY PATH WAY CENTER MID
OPTIC NUCLEI BRAIN DORSAL
RADIATION
CHIASMA MEDIAL CEREBELLAR
OPTICUM VESTIBULAR NUCLEI LEMNISCI TRACT
SUPERIOR, MEDIAL,
LATERAL, INFERIOR
N VESTIBULARIS
SPINAL CORD
N OPTICUS GANGLION VESTIBULAR

SENSORY OF INNER OF SKIN,JOINTS,

OF EYES
RECEPTOR EAR SUPPORTING TISSUE
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 Organs and system that participate in the maintenance of body balance
Central
Adaptation
Sense body Execute
–Use sensory
position coordinated
inputs and body
relative to the body
movements
base of movements
appropriate to the
support task conditions

Somatosensory
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 Input from the muscles and joints
1) The somato-sensory system provides information about the relative
location of the body parts/
• Proprioception reflects the perception of the static position.
• Kinesthesia refers to the position during movements.
Information arises from peripheral sources (muscles, jt. capsule, soft
tissues):
Sensory receptors→ information to vestibular system & the medulla &
brainstem through the dorsal colummedial lemniscal pathway.

2) This information will assist in:

1) Coordinating eye, head &
neck movements to
stabilize the visual
system.
2) In maintaining posture,
muscle tone, & stiffness
in the muscles.
3) Coordinate movement
patterns

9 9
2) Input from the eyes / The visual system :
Through the retina, the optic nerve and thalamus → provide information
about the position of the head relative to the environment & orients the
head to maintain posture.

Sensory receptors in the retina are called

rods and cones.
 When light strikes the rods and cones,
they send impulses to the brain that
provide visual cues identifying how a
person is oriented relative to other objects.
For example, as a pedestrian walks along
a city street, the surrounding buildings
appear vertically aligned, and each
storefront passed first moves into and then
beyond the range of peripheral vision.

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 3) Input from The vestibular system:
Provides information on orientation of the head in space and on
accelaration.
Any movement, including weight shifts to adjust posture stimulate the
vestibular receptors → vestibular nerve → cerebellum → spinal cord for
postural control.
Sensory information about
motion, equilibrium, and spatial
orientation is provided by the
vestibular apparatus,
which in each ear includes the
utricle, saccule, and three
semicircular canals.
The utricle and saccule detect
gravity (vertical orientation)
and linear movement.
The semicircular canals, which
detect rotational movement, are
located at right angles to each
other and are filled with a fluid
called endolymph.
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Integration of sensory input
Balance information provided by the peripheral sensory organs—eyes, muscles
and joints, and the two sides of the vestibular system—is sent to the brain stem.
There, it is sorted out and integrated with learned information contributed by the
cerebellum (the coordination center of the brain) and the cerebral cortex (the
thinking and memory center).
The cerebellum provides information about automatic movements that have been
learned through repeated exposure to certain motions.
For example, by repeatedly practicing serving a ball, a tennis player learns to
optimize balance control during that movement.
Contributions from the cerebral cortex include previously learned information; for
example, because icy sidewalks are slippery, one is required to use a different pattern
of movement in order to safely navigate them

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 The Brain
1. Brainstem Vestibular Nuclei
Primary input comes from the vestibular portion of CN VIII (vestibular-cochlear)
There are 4 Vestibular Nuclei:

Function
Lateral/Deiter’s Help the body maintain a desired posture (ie.
Nucleus vestibulospinal reflexes)
Medial/Superior Coordinates eye, head, and neck movements

Inferior Integrate information from the cerebellum and other

sensory systems

 superior division: utricle, anterior part of saccule, and horiz & anterior canals
 inferior division: posterior part of saccule, and posterior canal
• to vestibular nuclei
• to cerebellum
Other inputs to vestibular nuclei:
•Cerebellum: primarily inhibitory
•Spinal cord
•Pontine reticular formation
•Contralateral vestibular nuclei 13
 From the Vestibular Nuclei:
• Vestibulo-Oculomotor Pathways:
– Direct: to oculomotor nuclei.
– Indirect: via reticular formation to oculomotor nuclei (III IV and VI)
• Vestibulo-Spinal Pathways:
– Lateral V-S-throughout spinal cord
– Medial V-S-cervical & thoracic
– Reticulospinal tract-via brainstem reticular formation
EMOTION,PERSONALITY, BEHAVIOUR,ANXIETAS,
PARIETAL ASSOCIATON CORTEX
LIMBIC SYSTEM (HIPOCAMPUS-MEMORY)
( POSTERIOR PARIETAL )

REFLEX MUSCLE
VESTIBULAR
MOVEMENT
OCULAR REFLEX

EYE HEAD
NECK
INTEGRATION AND INTERPRETATION OF SIGNAL BASED ON PAST EXPERIENCE
PARIETAL LOBE
AND OF CEREBELLAR
TRUNK
EXPECTANCY CORTEX +
EXTRA OCULAR ( CEREBELLUM )
MUSCLE
VISUAL CORTEX

SPINAL CORD
THALAMO CEREBELLUM
LAT GENICULO NUCLEUS MID BRAIN VISION +
CORTICO
SUPERIOR COLLICULUS MOTOR PATH WAY
MOTOR CENTER PROJECTION
PRETECTUM ACCESORY OPTIC MID BRAIN CEREBELLUM
NUCLEI THALAMIC RADIATION
DORSAL CEREBELLAR
TRACT
CHIASMA MEDIAL LEMNISCI
OPTICUM
VESTIBULAR NUCLEI
SUPERIOR, MEDIAL,
LATERAL, INFERIOR
N VESTIBULARIS SPINAL CORD
N OPTICUS GANGLION VESTIBULAR

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 Cerebellum
 Maintenance of Equilibrium
- balance, posture, eye movement
 Monitors vestibular performance
Readjusts central vestibular processing of static & dynamic
postural activity
Coordination of half-automatic movement of
walking and posture maintenace
- posture, gait
 Adjustment of Muscle Tone
 Motor Leaning – Motor Skills
 Cognitive Function
Midline (vermal) regions regulate balance
and eye movements
Lateral regions control muscles of the
extremities.
The cerebellum plays a central role in
modulating ocular motor reflexes with the
goal of maximizing visual performance 15
 Relay Centers

►Thalamus
–Connection with vestibular cortex and reticular formation →
arousal and conscious awareness of body; discrimination between
self movement vs. that of the environment
►Vestibular Cortex
–Junction of parietal and insular lobe
–Target for afferents along with the cerebellum
►Both process vestibular information with somatosensory and
visual input

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Motor output
As sensory integration takes place, the brain stem transmits impulses to the
muscles that control movements of the eyes, head and neck, trunk, and legs, thus
allowing a person to both maintain balance and have clear vision while moving.

Motor output to the eyes

The vestibular system sends motor control signals via the nervous system to
the muscles of the eyes with an automatic function called the vestibulo-ocular
reflex- gaze stability.

Motor output to the muscles and joints

The motor impulses that are sent from the brain to the other muscles of
the body control their movement so that balance is maintained whether a
person is sitting, standing, or turning cartwheels – posture control /
vestibulo-spinalis reflex

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The coordinated balance system
The human balance system involves a complex set of sensorimotor-
control systems.
Its interlacing feedback mechanisms can be disrupted by damage to
one or more components through injury, disease, or the aging process.
Impaired balance can be accompanied by other symptoms such as
dizziness, vertigo, vision problems, nausea, fatigue, and concentration
difficulties.
The complexity of the human balance system creates challenges in
diagnosing and treating the underlying cause of imbalance.
Vestibular dysfunction as a cause of imbalance offers a particularly
intricate challenge because of the vestibular system’s interaction with
cognitive functioning,2 and the degree of influence it has on the control
of eye movements and posture

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 The Vestibular System

• Importance of Vestibular System

– Balance, equilibrium, posture,
head, body, eye movement
– It enables us to recognize our
static position, velocity, and
acceleration.
• Vestibular Labyrinth
– Otolith organs - gravity and tilt
– Semicircular canals - head
rotation
– Use hair cells, like auditory
system, to detect changes

The vestibular system is the basis of our three-

dimensional model of the world.
 It is the unifying system in our brain that coordinates
information received from other systems.
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 Main Components of the Vestibular System
Peripheral End Organs
Located in the inner ear, it is composed of five organs: the utricle
and saccule (otolith organs), and the three semi-circular canals.
The otolith organs sense the head’s linear acceleration and
Orientation of the head with respect to gravity or position relative to
gravity
The semicircular canals enable us to be aware of our three-
dimensional dynamic position.
 Vestibular Nerve
 Central Nervous System
Connections
 Motor Output
- Vestibular Ocular Reflex
(VOR)
- Vestibulospinal Reflex (VSR)
- Vestibulo-colic
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The function of the vestibular system can be
simplified by remembering some basic
terminology of classical mechanics.
All bodies moving in a three-dimensional
framework have six degrees of freedom: three of
these are translational and three are rotational.
The translational elements refer to linear
movements in the x, y, and z axes (the
horizontal and vertical planes).
Translational motion in these planes (linear
acceleration and static displacement of the
head) is the primary concern of the otolith
organs.
The three degrees of rotational freedom refer to
a body's rotation relative to the x, y, and z axes
and are commonly referred to as roll, pitch, and
yaw. The semicircular canals are primarily
responsible for sensing rotational accelerations
around these three axes. 21
 Vestibular outputs very rapidly influence eye, head, and
postural reflexes
• Vestibulo-ocular reflex
– The VOR generates compensatory eye movements in order to
stabilize gaze during head motion (i.e. Rotation of head to the
left results in rightward compensatory eye movement) Eye
velocity compensates for head velocity
• Vestibulospinal reflex
– Maintains vertical alignment of the trunk
– When the head tips in one direction, the body elongates to that
side and shortens on the other
– Postural changes in response to vestibular signals
• Vestibulo-colic reflex
- Activates the neck musculature to stabilize the head in space
Compensates for displacements of the head that occur during gait
– Head position maintained despite body movements

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 The Vestibular System
• The Otolith Organs: Detect changes in head angle, linear
acceleration,gravity
 Macular hair cells responding to tilt
 Hair cells project into gelatinous type mixture that has calcium
carbonate crystals (otoconia) embedded within.
 Otoconia are gravity sensitive
• Utricle senses horizontal linear acceleration
• Saccule senses vertical linear acceleration

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 The Vestibular System

• The Semicircular Canal sense head

rotations - Angular accelerations
• Structure

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 Linear acceleration

Figure 14.2. The morphological polarization of vestibular hair cells and the polarization maps of the vestibular organs. (A) A
cross section of hair cells shows that the kinocilia of a group of hair cells are all located on the same side of the hair cell. The
arrow indicates the direction of deflection that depolarizes the hair cell. (B) View looking down on the hair bundles. (C) In the
ampulla located at the base of each semicircular canal, the hair bundles are oriented in the same direction. In the sacculus
and utricle, the striola divides the hair cells into populations with opposing hair bundle polarities. 25
The mechanisms underlying the depolarization and
hyperpolarization of vestibular hair cells depend,
respectively,
on the potassium-rich character of endo lymph and the
potassium-poor character of the perilymph that bathes
the basal and lateral portions of the hair cells.
Deflection of the stereocilia toward the kino cilium
causes potassium channels in the apical portions of the
stereocilia and kinocilium to open. K+ flows into the cell
from the endolymph, depolarizing the cell membrane
This depolarization in turn causes voltage-gated calcium
channels at the base of the hair cells to open, allowing
Ca++ to enter the cell.
The influx of Ca++ causes synaptic vesicles to release
their transmitter (aspartate or glutamate) into the
synaptic clefts, and the afferent fibers respond by under
going depolarization and increasing their rate of firing.

26
.
When the stimulus subsides, the stereocilia and
kinocilium return to their resting position, allowing most
calcium channels to close and voltage-gated potassium
channels at the base of the cell to open.
K+ efflux returns the hair cell membrane to its resting
potential (see Fig. 7).
Deflection of the stereocilia away from the kino cilium
causes potassium channels in the basolateral portions of
the hair cell to open, allowing K+ to flow out from the cell
into the interstitial space.
The resulting hyperpolarization of the cell membrane
decreases the rate at which the neurotransmitter is
released by the hair cells and consequently, decreases the
firing rate of afferent fibers.
Almost all vestibular primary afferent fibers have a
moderate spontaneous firing rate at rest (approximately 90
spikes per second). Therefore, it is likely that some hair cell
calcium channels are open at all times, causing a slow,
constant release of neurotransmitter.
The ototoxic effects of some aminoglycoside antibiotics
(e.g., streptomycin, gentamicin) may be due to direct
reduction of the transduction currents of hair cells.
27
Figure 14.5. Forces acting on the
head and the resulting displacement
of the otolithic membrane of the
utricular macula. For each of the
positions and accelerations due to
translational movements, some set of
hair cells will be maximally excited,
whereas another set will be
maximally inhibited. Note that head
tilts produce displacements similar to
certain accelerations.

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 Angular acceleration

Figure 14.7. The ampulla of the posterior semicircular canal

showing the crista, hair bundles, and cupula. The cupula is
distorted by the fluid in the membranous canal when the
head rotates. 29
 Response to Angular Acceleration
Beginning of Rotation Middle of Rotation Post-Rotational
Direction of Head Movement

Cupula

Relative Direction of Endolymph soon Head stops moving,

Endolymph catches up with but endolymph keeps
Inertia makes direction and velocity of on moving (again,
endolymph initially rotation. Cupula no because of inertia).
drag behind longer deflected. Cupula deflected in
when head starts to Hair cells no longer opposite direction.
rotate. Cupula stimulated.
deflected.

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Figure 14.8. Functional organization of
the semicircular canals.
(A) The position of the cupula without
angular acceleration.
(B) Distortion of the cupula during
angular acceleration. When the
head is rotated in the plane of the
canal (arrow outside canal), the
inertia of the endolymph creates a
force (arrow inside the canal) that
displaces the cupula.
(C) Arrangement of the canals in pairs.
The two horizontal canals form a
pair; the right anterior canal (AC)
and the left posterior canal (PC)
form a pair; the left AC and the right
PC form a pair.
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 • The Vestibulo-Ocular Reflex (VOR)

Figure 14.10. Connections underlying the

vestibulo-ocular reflex. Projections of the
vestibular nucleus to the nuclei of cranial
nerves III (oculomotor) and VI (abducens).
The connections to the oculomotor nucleus
and to the contralateral abducens nucleus
are excitatory , whereas the connections to
ipsilateral abducens nucleus are inhibitory .
There are connections from the oculomotor
nucleus to the medial rectus of the left eye
and from the adbucens nucleus to the
lateral rectus of the right eye. This circuit
moves the eyes to the right, that is, in the
direction away from the left horizontal
canal, when the head rotates to the left.
Turning to the right, which causes
increased activity in the right horizontal
canal, has the opposite effect on eye
movements. The projections from the right
vestibular nucleus are omitted for clarity.

32
 Vestibulospinal Reflex (VSR)
Generates compensatory body movement to maintain head and
postural stability, thereby preventing falls
Figure 14.11. Descending
projections from the medial and
lateral vestibular nuclei to the spinal
cord.
The medial vestibular nuclei
project bilaterally in the medial
longitudinal fasciculus to reach the
medial part of the ventral horns and
mediate head reflexes in response
to activation of semicircular canals.
The lateral vestibular nucleus
sends axons via the lateral
vestibular tract to contact anterior
horn cells innervating the axial and
proximal limb muscles. Neurons in
the lateral vestibular nucleus receive
input from the cerebellum, allowing
the cerebellum to influence posture
and equilibrium. 33
 Lateral Vestibulospinal Tract
Lateral
Lateral Vestibulospinal Tract:
Vestibular • The inputs from the otolith organs project mainly
nucleus to the lateral vestibular nucleus, which in turn
sends axons in the lateral vestibulospinal tract to
the spinal cord.
• The input from this tract exerts a powerful
excitatory influence on the extensor (antigravity)
muscles. When hair cells in the otolith organs are
activated, signals reach the medial part of the
ventral horn. By activating the ipsilateral pool of
motor neurons innervating extensor muscles in the
trunk and limbs, this pathway mediates balance
and the maintenance of upright posture.
• Decerebrate rigidity, which is characterized by
rigid extension of the limbs, arises when the
brainstem is transected above the level of the
vestibular nucleus. The tonic activation of extensor
muscles in this instance suggests that the
vestibulospinal pathway is normally strongly
suppressed by descending projections from higher
levels of the brain, especially the cerebral cortex. 34
 Medial Vestibulospinal Tract
Lateral Medial Vestibulospinal Tract:
Vestibular
nucleus • Axons from the medial vestibular nucleus
descend in the medial longitudinal fasciculus
to reach the upper cervical levels of the
spinal cord.
• This pathway regulates head position by
reflex activity of neck muscles in response to
stimulation of the semicircular canals from
rotational accelerations of the head.
• For example, during a downward pitch of
the body (e.g., tripping), the superior canals
are activated and the head muscles
reflexively pull the head up. The dorsal
flexion of the head initiates other reflexes,
such as forelimb extension and hindlimb
flexion, to stabilize the body and protect
against a fall.
© 2001 by Sinauer Associates, Inc.
 Balance Control
Sensory Organization Motor Control
Determine Initiate Automatic/
Body Position Voluntary Movements

Compare, Select Select & Adjust

& Combine Senses Muscle Contractile Patterns

Visual Vestibular Somato- Ankle Thigh Trunk

System System Sensation Muscles Muscles Muscles

Environmental Generate
Interaction Body Movements

36
 Erect Standing Posture & the ‘Gravity Line’
(Sagittal Analysis)
•‘Gravity line falls:
–Forward of ankle
–Through or forward of the knee
–Through of behind the hip
(common hip axis)
–Behind or through thoracic spine
–Through acromium
–Through or forward of atlanto-
occipital jt.
Erect Standing Posture & the
‘Gravity Line’ (Frontal Analysis)
•Gravity line falls:
–Symmetrically between two feet
–Through the umbilicus
–Through the xiphoid process
–Through the chin & nose
–Between the eyes 37
 The ‘Gravity Line and Anti-gravity Muscles (Sagittal Plane)

• Gravity line falls: • Anti-gravity muscle:

– Forward of ankle – Gastroc-soleus
– Through or forward – Quadriceps
of the knee
– Through of behind – Hip extensors
the hip (common hip
axis)
– Paraspinals
– Behind or through
thoracic spine
– Through acromium
– Through or forward – Neck extensors
of atlanto-occipital

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Limits of Stability

39
40
 Vestibular System

Linear Acceleration Angular Acceleration

Vestibule Otolithic Membrane Cupula Semicircular Canals

Anterior, Posterior, Lateral
Kinocilium

Utricle Saccule Hair Cells

Sensory Epithelium: Macula Specialized Epithelium: Crista ampularis
Vestibular Ganglion (Scarpa’s Ganglion)
Superio
Vestibular Nerve
r Inferior Vestibular
Macula in Horizontal Medial Nuclei
Macula in Vertical Plane Lateral
Plane Maximally Maximally stimulated
stimulated when head when head bent forward-
bent side to side backward.
Cerebellum
Fastigial Nuc Lateral MLF
Flocculonodular lobe Vestibulospinal
Vermis Tract
41
 Vestibular Function Tests

►Posturography Static & dynamic

►Caloric test
►Rotary Chair test

42
 Vestibulospinal Reflexes test
Cerebellar function:
The midline cerebellar structure, the vermis are concerned with posture, gait,
and truncal equilibrium
•ROMBERG’S TEST is screening test for standing balance
Patient stands with feet together, arms by the side with eyes open then closed
•Peripheral vestibular lesions- the body’s centre of gravity is displaced to the side
of the labyrinthine lesion
•Central disturbances- pattern of unsteadiness of gait and direction of fall are
irregular.

43
Test hemispheric function
Past pointing is a vestibulo spinal test of upper extrimities

44
 Test hemispheric function
POSITIONAL TESTS ( cerebellar lesions)
Finger-nose pointing- overshooting indicates cerebellar lesion

45
Test hemispheric function

46
 POSITIONAL TESTS ( cerebellar lesions)
Dysdidokinesia- central cerebellar lesion

47
 Vestibulospinal Reflexes
The stepping test evaluates te vestibulo spinal response of lower extrimities to
labyrinthine stimuli
•UNTERBERGER’S Stepping Test
•Stepping on the spot with the eyes closed and arms outstretched for 30 sec
•Peripheral disorders- rotation of body axis to the side of the labyrinthine lesion
•Central disorders the deviation is irregular
•Only deviations of > than 30o is significant

48
 Nystagmus

• Involuntary rhythmical oscillation of eyes away

from the direction of gaze, followed by return of
eyes to their original position.
• The direction of the fast component determines
the direction of the nystagmus ( towards the
dominant vestibular centre, inhibitory impulses are
suppressed i.e the side of the lesion )

49
 Nystagmus
►Primary diagnostic indicator in identifying
vestibular lesions
►Physiologic nystagmus
– vestibular, visual, extreme lateral gaze
►Pathologic nystagmus
– spontaneous, positional, gaze evoked
►Labeled by the direction of the fast
component
►Central vs. peripheral cause differentiated by
duration

50
Type Nystagmus
1. Pendular nystagmus : an equal speed of eyes in boh
direction, extra vestibular origin e.g congenital ocular
nystagmus
2. Jerk nystagmus: biphasic quality with fast and slow
component, usualy response to vestibular stimulation
such as caloric testing

Direction Nystagmus
Right, left, up and down or rotary clockwise or counter clockwise

Form Nystagmus
Horizontal, vertical, rotary, diagonal or mix

51
Nystagmus Intensity
Anderson,s classification:
1. First degree- appear with the patient gazing in the
direction of fast component
2. Second degree- appears with gaze in the neutral position
3. Third degree- appears in all direction of the gaze

Unilateral or mono ocular versus binocular.

Mono ocular typer is rare

Spontaneous or induced Nystagmus

1. The spontaneous type appears with no external presented to
the patient
2. The induced type may appear secondary to pathologic
process or due to a stimulus applied for diagnostic purpose
e.g. positional or thermal induced nystagmus

52
 Spontaneous Nystagmus

• First Degree – nystagmus present only when the eyes deviate to the
side of the lesion
• Second Degree – nystagmus present when patient looks straight
ahead
• Third Degree – nystagmus present in both directions

Classification of spontaneous nystagmus

1. Normal : vertical with eyes closed, horizontal with eyes coles
voluntary, less than 6 degress to 10 degress/second
2. Vestibular: has fast and slow component, decreased with fixation,
conjugate, horizontal
3. Ocular : sinusoidal suppressed by convergence and enhanced by
fixation, Congenital, occupational
4. Central : by exclusion e.g paroxymal alternating nystagmus; a jerky
type present in neutral position but shift direction spontaneously
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54
55
 Positional Nystagmus

Nystagmus in which was caused by a particular head position.

Classification;
1. Type I is direction-changing nystagmus, the direction of fast component
change as the subject change the head position.
2. Type II is direction fixed nystagmus. There is no change the direction of
the fast component as the subject changes head position
3. Type III is irregular. The response may alternate between types I and II
or may change direction even though the subject doesnot change the head

56
 Paroxymal positional Nystagmus / BPPV

Nystagmus in which was caused by change in position such as looking up

to a ceiling or turning over the bed, The vertigo typically is brought on by
sudden change in head position, but subsides as the subject maintain the
provocative position. The vertigo is usually transient and frequently
associated with nusea and vomiting.

57
 Paroxymal positional Nystagmus / BPPV
• Hallpike Manouvre
• Patient sits on bed, head turned 45 degrees to left or right.
• Patient is rapidly laid back with head over edge of bed 30 degrees below
the horizontal. Eyes open look for nystagmus.
• After 30 sec return patient to upright position
• Repeat with head to other side

58
Neck torsion ( cervical) nystagmus and vertigo

Nystagmus is a form of positional nystagmus. The stimulus is a neck

torsion induced by turning the head on the body with nech twisting to
produce and alteration in the head – body relationship.
Patients with the cervical or neck torsion nystagmus displays myriad of
symptomp

59
 Vestibulo-ocular reflex

• ROTATIONAL TESTS
• Nystagmus Induced by accelerating and
decelerating rotating chair, tests both labyrinths
simultaneously
• CALORIC TESTS
• COWS- cold water opposite side, warm water
same side, direction of nystagmus
• Extent of caloric response indicates function of
labyrinth

60
 Vestibulo-ocular Reflex

• Electronystagmograghy
• Positive potential between the cornea and retina
recorded as eyes move from straight ahead gaze
• Test includes different head positions, eyes open,
closed and caloric tests

61
62
 MOTION SICKNESS
Motion sickness is a condition characterized primarily by
cardinal symptom is nausea, and cardinal signs are vomiting,
parlor, and cold sweating, that occur when a man is exposed to
real or apparent motion stimuli with which he is un familiar and
hence un adapted

63
 NEURAL STRUCTUR OF MOTION SICKNESS
SIGN & SYMPTOM
CENTRAL NERVOUS SYSTEM
NAUSEA,
CEREBRAL DIZZINESS,
CORTEX SOMNOLENCE,
HEADACHE,
DEPRESSION,
PERFORMANCE
HIPOTALAMUS DCREAMENT

RETINA
VESTIBULER INCREASED
CEREBELLUM SECRETION
ADH,ACTH,GH,
PITUITRY
PRL

SWEATING,
PALLOR,
MOTION VESTIBULER DECREASED
VESTIBULER
STIMULI NUCLEI GASTRIC
APPARATUS
MOTILITY,
CARDIOVASCU
AUTONOMIC LER &
CTZ CENTRE RESPIRATORY
SOMATO
CHANGES
SENSORIS
RECEPTOR
VOMITING
CENTRE VOMITING

NEURAL STRUCTUR OF MOTION SICKNESS, BENSON 1977 64

 NAUSEA : GREEK = NAUXIA = SEA - SICKNESS

Nevertheless, motion sickness is, in certain respect is

misnomer because symptom is not always caused by motion
stimulation and is not a disease
Another term: Motion Maladaptation Syndrome

Aetiology of motion sickness

1. Sensory conflict hypothesis; Input error;

2. Neural mismatch hypothesis ; Central error

65
 Sensory conflict

 Conlict between signal from the eyes, the vestibular and

others receptor stimulated motion / prprioceptive
Neural mismatch
Neural mismatch / central error
• The Information from eyes, vestibular and others
receptor are not match with the expected the
information to receive  past experiece  motion
sickness
• Memory theory describe the motion sickness adaptation

66
 NEURAL MISMATCH HYPOTHESIS
RESPONS
STIMULUS RECEPTOR BRAIN MECHANISME ( OUTPUT )
( INPUT )

MOTOR CONTROL VOLITIONAL

SYSTEM AND REFLEX
MOVMENT
INTERNAL MODEL
ACTIVE MOVEMENT NEURAL STORE OF
EXPECTED SIGNAL
EYES

UPDATES INTERNAL
SEMI COMPERATOR MODEL (ADAPTATION)
CIRCULAR
MOTION CANAL
STIMULI
NEURAL MOTION
CENTRES SICKNESS
OTOLITH & MEDIATING
OTHER SYNDROM
SIGN &
PASSIVE GRAVI SYMPTOMS
MOVEMENT RECEPTOR LEAKY OF MOTION
INTEGRATOR SICKNESS

67
68 68
 TYPE & CATAGORIES OF SENSORY CONFLICT*

TYPE OF CONFLICT CATEGORY OF CONFLICT

VISUAL (A) – VESTIBULER(B) CANAL(A) – OTOLITH(B)

TYPE I SIMULTANT WATCHING WAVE FROM SHIP, USE CORIOLIS , MAKING HEAD MOVEMENT
IN ABNORMAL ACCELERATION
DIFF BINOCULAR IN MOVING VEHICLE,
ENVIRONMENT WHICH MAY BE
MAKING HEAD MOVEMENT WHEN VISION
TYPE 1 : BOTH SYSTEM CONSTANT (e.g HYPER OR HYPO
CONCURRETLY SIGNAL IS DISTORTED BY OPTICAL DEVICE,
PSEUDO CORIOLIS STIMULATION GRAVITY OR FLUCTUATING ( LINIER
CONTRADICTING OR OSCILATIONSPACE SICKNESS,
UNCORRELATED
VESTIBULAR DISSORDER,MENIER’S
INFORMATION

TYPE II* a
A+ &B-
TYPE 2 (i): VISUAL CUES
WITHOUT THE EXPECTED AND
NORMALLY CORRELATED
VESTIBULAR SIGNAL
CINERAMA SICKNESS , SIMULATOR
SICKNESS, HAUNTED SWING,
CIRCULAR VECTION
POSISTIONAL ALCOHOL NYSTAGMUS,
CALORIC STIMULATION OF
SEMICIRCULARIS, VESTIBULAR
DISSORDER/e.g PRESSURE VERTIGO,
CUPULO LITHIASIS, BPPV

LOW FREQUENCY (<0.5 Hz) TRANSLATION

TYPE II b
A- &B+
TYPE 2 (ii) : THE VESTIBULAR CUES
NOT ACCOMPANIED BY THE
EXPECTED VISUAL CUES
LOOKING IN SIDE A MOVING VEHICLE OCCILATION, ROTATING LINEAR
WITHOUT EXTERNAL VISUAL REFRENCE ACCELERATOR VECTOR (e.g BARBEQUE-
(e.g BELOW DECK IN BOAT) READING IN SPIT ROTATION, ROTATION ABOUT AN OFF
MOVING VEHICLE VERTICAL AXIS

* BENSON 1984 * TYPE 2 : ONE SYSTEM SIGNAL INFORMATION IN THE ABSENCE

OF THE EXPECTED SIGNAL FROM OTHER SYSTEM
69
Efek anti emetik : kombinasi efek
peripheral (gastrokinetik) dan antagonis
terhadap reseptor Dopamin D2 Antagonis
di CTZ (chemoreceptor Trigger Zone)
: Domperidone dan Metoklopramide
Antihistamin me (-) severity motion
sickness dengan c menghambat
sinyal pada neural mismatch dan
bekerja langsung , efektif untuk
diberikan sebelum atau sesudah
muntah.

Ondansetron
•Blokade sentral di CTZ pada area post
rema dan nucleus traktus solitaries
sebagai kompetitif selektif reseptor 5-
HT3
•Memblok reseptor 5-HT3 di perifer
pada ujung nervus saraf vagal di sel
enterokromafin di traktus
gastrointestinal

Scopolamin mencegah
terjadinya motion sickness
dengan mengurangi sinyal
neural mismatch dan
memfasilitasi proses adaptasi

70 70
Thanks for your attention

Any Question?

71
 Reference
Lauralee Sherwood: Human Physiology;. Department of Physiology and
Pharmacology School of Medicine West Virginia University. rooks/Cole
10 Davis Drive Belm
Arthur C. Guyton, M.D., John E. Hall, Ph.D:Text Book of Medical Physiology;.
Department of Physiology and Biophysics University of Mississippi Medical
Center Jackson, Mississippi, 11th ed. Philadelphia, Saunders.
Vander et al's : Human Physiology: The Mechanisms of Body Function,
9th ed , the McGraw-Hill Publishing
Gerard J. Tortora.,Bryan Derrickson: Principles of Anatomy and
Physiology. 12th ed, John Wiley & Sons, Inc.
Jerome. Kossoy.MD. F.A.C.S.: The Oto-Neurologic Examination, Acta
Otolaryngologica. Suppl 343. UPPSALA,1977
A.J. Benson: Motion sickness. in Aviation medicine, Butterworths, 2nd Ed

Other sources,

72