Purpose of review: This review aims to summarize the current literature describing vestibular-autonomic interactions and to describe their putative role in various disorders’ clinical presentations, including orthostatic dizziness and motion sensitivity. Recent findings: The vestibular-autonomic reflexes have long been described as they relate to cardiovascular and respiratory function. Although orthostatic dizziness may be in part related to impaired vestibulo-sympathetic reflex (orthostatic hypotension), there are various conditions that may present similarly. A recent clinical classification aims to improve identification of individuals with hemodynamic orthostatic dizziness so that appropriate recommendations and management can be efficiently addressed. Researchers continue to improve understanding of the underlying vestibular-autonomic reflexes with recent studies noting the insular cortex as a cortical site for vestibular sensation and autonomic integration and modulation. Work has further expanded our understanding of the clinical presentation of abnormal vestibular-autonomic interactions that may occur in various conditions, such as aging, peripheral vestibular hypofunction, traumatic brain injury, and motion sensitivity. Summary: The vestibular-autonomic reflexes affect various sympathetic and parasympathetic functions. Understanding these relationships will provide improved identification of underlying etiology and drive improved patient management.

Background:The cervical vestibular evoked myogenic potential (cVEMP) is a reflexive change in sternocleidomastoid (SCM) muscle contraction activity thought to be mediated by a saccular vestibulo-collic reflex. CVEMP amplitude varies with the state of the afferent (vestibular) limb of the vestibulo-collic reflex pathway, as well as with the level of SCM muscle contraction. It follows that in order for cVEMP amplitude to reflect the status of the afferent portion of the reflex pathway, muscle contraction level must be controlled. Historically, this has been accomplished by volitionally controlling muscle contraction level either with the aid of a biofeedback method, or by an a posteriori method that normalizes cVEMP amplitude by the level of muscle contraction. A posteriori normalization methods make the implicit assumption that mathematical normalization precisely removes the influence of the efferent limb of the vestibulo-collic pathway. With the cVEMP, however, we are violating basic assumptions of signal averaging: specifically, the background noise and the response are not independent. The influence of this signal-averaging violation on our ability to normalize cVEMP amplitude using a posteriori methods is not well understood.Purpose:The aims of this investigation were to describe the effect of muscle contraction, as measured by a prestimulus electromyogenic estimate, on cVEMP amplitude and interaural amplitude asymmetry ratio, and to evaluate the benefit of using a commonly advocated a posteriori normalization method on cVEMP amplitude and asymmetry ratio variability.Research Design:Prospective, repeated-measures design using a convenience sample.Study Sample:Ten healthy adult participants between 25 and 61 yr of age.Intervention:cVEMP responses to 500 Hz tone bursts (120 dB pSPL) for three conditions describing maximum, moderate, and minimal muscle contraction.Data Collection and Analysis:Mean (standard deviation) cVEMP amplitude and asymmetry ratios were calculated for each muscle-contraction condition. Repeated measures analysis of variance and t-tests compared the variability in cVEMP amplitude between sides and conditions. Linear regression analyses compared asymmetry ratios. Polynomial regression analyses described the corrected and uncorrected cVEMP amplitude growth functions.Results:While cVEMP amplitude increased with increased muscle contraction, the relationship was not linear or even proportionate. In the majority of cases, once muscle contraction reached a certain “threshold” level, cVEMP amplitude increased rapidly and then saturated. Normalizing cVEMP amplitudes did not remove the relationship between cVEMP amplitude and muscle contraction level. As muscle contraction increased, the normalized amplitude increased, and then decreased, corresponding with the observed amplitude saturation. Abnormal asymmetry ratios (based on values reported in the literature) were noted for four instances of uncorrected amplitude asymmetry at less than maximum muscle contraction levels. Amplitude normalization did not substantially change the number of observed asymmetry ratios.Conclusions:Because cVEMP amplitude did not typically grow proportionally with muscle contraction level, amplitude normalization did not lead to stable cVEMP amplitudes or asymmetry ratios across varying muscle contraction levels. Until we better understand the relationships between muscle contraction level, surface electromyography (EMG) estimates of muscle contraction level, and cVEMP amplitude, the application of normalization methods to correct cVEMP amplitude appears unjustified.

Background Vestibular migraine (VM) is one of the common causes of episodic dizziness, but it is underdiagnosed and poorly understood. Previous research suggests that otolith reflex pathway performance is often impaired in this patient group, leading to altered perception of roll plane stimuli. Clinically, this perception can be measured with subjective visual vertical (SVV) testing. Purpose The aim of this study is to compare static SVV performance (absolute mean SVV tilt, variance) in a cohort of patients diagnosed with VM to results obtained from clinically derived normative data. Study Design Retrospective case review. Study Sample Ninety-four consecutive patients between 18 and 65 years of age diagnosed with VM were included in this comparison to clinically derived normative data. Data Collection and Analysis Retrospective chart review was completed. Demographic data, symptom report, and vestibular laboratory results were documented. SVV performance was documented in terms of absolute mean SVV tilt and response variance. Results Abnormal mean SVV tilt was described in 54% (n = 51) of patients with VM. Including abnormal response variance increased those identified with abnormal presentation to 67% (n = 63). Laboratory findings were insignificant for semicircular canal function, but of those with abnormal ocular vestibular myogenic potential results (n = 30), 77% (n = 23) demonstrated both abnormal SVV and utriculo-ocular reflex performance. There were no associations noted for SVV performance and demographic or other self-report variables. Conclusion Absolute mean SVV tilt and response variance are often abnormal in patients diagnosed with VM. These findings support theories suggesting atypical intralabyrinthine integration within the vestibular nuclei and cerebellar nodular pathways.

Vestibular evoked myogenic potentials are currently the most clinically accessible method to evaluate the otolith reflex pathways. These responses provide unique information regarding the status of the utriculo-ocular and sacculo-collic reflex pathways, information that has previously been unavailable. Vestibular evoked myogenic potentials are recorded from tonically contracted target muscles known to be innervated by these respective otolith organs. Diagnosticians can use vestibular evoked myogenic potentials to better evaluate the overall integrity of the inner ear and neural pathways; however, there are specific considerations for each otolith reflex protocol. In addition, specific patient populations may require protocol variations to better evaluate atypical function of the inner ear organs, vestibular nerve transmission, or subsequent reflex pathways. This is a review of the clinical application and interpretation of cervical and ocular vestibular evoked myogenic potentials.

Tools used for the identification, evaluation, and monitoring of concussion have not been sufficiently studied in youth or real-world settings. Normative and reliability data on sideline concussion assessment measures in the youth athlete population is needed. Pre-season normative data for 515 athletes (93.5% male) aged 5 to 16 on the Standardized Assessment of Concussion (SAC/SAC-Child), modified Balance Errors Scoring System (mBESS), Timed Tandem Gait (TTG), and the King–Devick Test (KDT) are provided. A total of 212 non-injured athletes repeated the measures post-season to assess test–retest reliability. Mean performance on the SAC-C, mBESS, TTG, and KDT tended to improve with age. KDT was the only measure that demonstrated good to excellent stability across age ranges (ICC = 0.758 to 0.941). Concentration was the only SAC/SAC-C subtest to demonstrate moderate test–retest stability (ICC = 0.503 to 0.706). TTG demonstrated moderate to good (ICC = 0.666 to 0.811) reliability. mBESS demonstrated poor to moderate reliability (ICC = −0.309 to 0.651). Commonly used measures of concussion vary regarding test–retest reliability in youth. The data support the use of at least annual sport concussion baseline assessments in the pediatric population to account for the evolution in performance as the child ages. Understanding the variation in the stability and the evolution of baseline performance will enable improved identification of possible injury.