of
Equilibrium
Dr Herman Mulijadi MS.SpKP
Lesson Objecitves
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 .
03/03/15
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.
orientation of
the head in
space and on
accelaration
EMOTION,PERSONALITY,
BEHAVIOUR,ANXIETAS,
LIMBIC SYSTEM
(HIPOCAMPUS-MEMORY)
the perception of
the static position
& the position
during
movements.
central nervous
system - integrated
these information
and translated to
fine motor
movements
PARIETAL ASSOCIATON
CORTEX
( POSTERIOR PARIETAL )
PARIETAL LOBE OF
CEREBELLAR CORTEX
( CEREBELLUM )
VISUAL CORTEX
CHIASMA
OPTICUM
N OPTICUS
INFORMASI
THALAMO
MOTOR
CORTICO
CENTER MID
PROJECTION
BRAIN
MEDIAL
LEMNISCI
SUPERIOR, MEDIAL,
LATERAL, INFERIOR
GANGLION VESTIBULAR
OF EYES
OF INNER
EAR
CORTICO
ASSOCIATIO
N AREAS
BASAL
GANGLIA
DORSAL
CEREBELLAR
TRACT
SPINAL
CORD
MOTOR
CORTEX
CEREBELLUM
BRAIN STEM
SPINAL MOTOR
NEURON
OF SKIN,JOINTS,
SUPPORTING
TISSUE
From
environment
SENSORY RECEPTOR
vestibular system
-rotatory stimulation and
linear acceleration
Information
proprioceptive
system information input
from the feet, ankle,
hip, and neck
Response Action
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
Sense body
position
relative to the
base of
support
Somatosensory
Adaptation
Use sensory
inputs and body
movements
appropriate to the
task conditions
Execute
coordinated
body
movements
The Brain
1. Brainstem Vestibular Nuclei
Primary input comes from the vestibular portion of CN VIII (vestibular-cochlear)
There are 4 Vestibular Nuclei:
Lateral/Deiters
Nucleus
Function
Help the body maintain a desired posture (ie.
vestibulospinal reflexes)
Medial/Superior
Inferior
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
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
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 Learning 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
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
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.
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
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.
.
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.
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.
Response to Angular
Acceleration
Beginning of Rotation
Direction of Head Movement
Middle of Rotation
Post-Rotational
Cupula
Relative Direction of
Endolymph
Inertia makes
endolymph initially
drag behind
when head starts to
rotate. Cupula
deflected.
Endolymph soon
catches up with
direction and velocity of
rotation. Cupula no
longer deflected.
Hair cells no longer
stimulated.
Balance Control
Sensory Organization
Initiate Automatic/
Voluntary Movements
Determine
Body Position
Compare, Select
& Combine Senses
Visual
System
Vestibular
System
Environmental
Interaction
Motor Control
SomatoSensation
Ankle
Muscles
Thigh
Muscles
Generate
Body Movements
Trunk
Muscles
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
Anti-gravity muscle:
Gastroc-soleus
Quadriceps
Hip extensors
Paraspinals
Neck extensors
Limits of Stability
Vestibular System
Linear Acceleration
Vestibule
Angular Acceleration
Otolithic Membrane
Cupula
Semicircular Canals
Anterior, Posterior, Lateral
Kinocilium
Utricle
Saccule
Sensory Epithelium: Macula
Hair Cells
Superior
Inferior Vestibular
Medial Nuclei
Lateral
Lateral
Vestibulospinal
Tract
MLF
Vestibulospinal Reflexes
The stepping test evaluates te vestibulo spinal response of
lower extrimities to labyrinthine stimuli
UNTERBERGERS 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
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 )
Nystagmus
Primary diagnostic indicator in
identifying vestibular lesions
Physiologic nystagmus
vestibular, visual, extreme lateral gaze
Pathologic nystagmus
spontaneous, positional, gaze evoked
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
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
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
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 chnges 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
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
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
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
MOTION SICKNESS
MOTION SICKNESS IS A CONDITION CHARACTERIZED
PRIMARILY BY NAUSEA,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
CEREBRAL
CORTEX
HIPOTALAMUS
RETINA
VESTIBULER
CEREBELLUM
PITUITRY
MOTION
STIMULI
VESTIBULER
APPARATUS
SOMATO
SENSORIS
RECEPTOR
VESTIBULER
NUCLEI
CTZ
AUTONOMIC
CENTRE
VOMITING
CENTRE
NAUSEA,
DIZZINESS,
SOMNOLENCE,
HEADACHE,
DEPRESSION,
PERFORMANCE
DCREAMENT
INCREASED
SECRETION
ADH,ACTH,GH,
PRL
SWEATING,
PALLOR,
DECREASED
GASTRIC
MOTILITY,
CARDIOVASCUL
ER &
RESPIRATORY
CHANGES
VOMITING
1.
2.
Konflik Sensoris
Ketidakcocokan sensorik dari berbagai reseptor sensorik
perifer yaitu antara mata/visus, propioseptif
Benson membagi Beberapa tipe
RECEPTOR
BRAIN MECHANISME
MOTOR CONTROL
SYSTEM
EYES
OTOLITH &
OTHER
GRAVI
PASSIVE
MOVEMENT RECEPTOR
UPDATES INTERNAL
MODEL (ADAPTATION)
COMPERATOR
MISMATCH
SIGNAL
MOTION
STIMULI
SEMI
CIRCULAR
CANAL
VOLITIONAL
AND REFLEX
MOVMENT
INTERNAL MODEL
NEURAL STORE OF
EXPECTED SIGNAL
LEAKY
INTEGRATOR
THRESHOLD
ACTIVE MOVEMENT
RESPONS
( OUTPUT )
NEURAL
CENTRES
MEDIATING
SIGN &
SYMPTOMS
OF MOTION
SICKNESS
MOTION
SICKNESS
SYNDROM
67
CATEGORY OF CONFLICT
VISUAL (A) VESTIBULER(B)
TYPE I
SIMULTANT DIFF
TYPE 1 : BOTH SYSTEM
CONCURRETLY SIGNAL
CONTRADICTING OR
UNCORRELATED
INFORMATION
TYPE II* a
A+ &BTYPE 2 (i): VISUAL CUES
WITHOUT THE EXPECTED
AND NORMALLY
CORRELATED VESTIBULAR
SIGNAL
TYPE II b
A- &B+
* BENSON 1984
CANAL(A) OTOLITH(B)
CINERAMA SICKNESS ,
SIMULATOR SICKNESS,
HAUNTED SWING, CIRCULAR
VECTION
POSISTIONAL ALCOHOL
NYSTAGMUS, CALORIC
STIMULATION OF SEMICIRCULARIS,
VESTIBULAR DISSORDER/e.g
PRESSURE VERTIGO, CUPULO
LITHIASIS, BPPV
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
69
Any Question?