Lisette Jackson

ENG
Fall 2014

The effect of mental alerting on peripheral vestibular nystagmus during spontaneous, gaze (308
left, 308 right) and body positional (left & right lateral lying) testing using
electronystagmography (ENG)

Article Review

The vestibulo-ocular reflex (VOR) is a reflex that maintains clear vision during head
movement. Vestibular nystagmic output can be suppressed by medicine, drowsiness, and mental
distraction. Electronystagmography (ENG) and videonystagmography (VNG) are tests that
record peripheral type nystagmus. To maximize the nystagmus output, the suppression of the
VOR reflex should be minimized. Mental alerting reduces the suppression of nystagmus by
cortical influence over the vestibular centers in the brainstem. Prior research indicates the
success of mental alerting in Calorics testing; however, little research has measured the effects
during ENG/VNG testing. This study investigates the effects of alerting on peripheral vestibular
nystagmus during ENG spontaneous gaze and positional testing.
The study selected 30 patients who displayed significant gaze or positional nystagmus
(slow phase velocity 6 deg/s) in at least one test condition. Of the 30 patients, 10 were male
and 20 were female. All patients were between the ages 30-79 years. The patients who consented
underwent an 8 month period of ENG assessment.
The patients underwent ENG assessment with both alerting and non-alerting protocols
using the Meta-4 two-channel ENG recording system. Gaze nystagmus was assessed in the
central direction (spontaneous nystagmus) with gaze 30 to the left and right. Positional
nystagmus was assessed in the left and right lateral lying position. For mental alerting tasks,
counting arithmetic was performed vocally, with the difficulty adjusted for the ability of each
patient. For the no-alerting tasks, patients remained silent without performing counting tasks.
The examiners split the patients into two groups, group A and group B, with 15 members each.
Group A performed the ENG tests without visual fixation (eyes closed). Patients were tested with
mental alerting (MA) for 15 seconds, followed by 15 seconds without MA, followed by 15
seconds of MA. Patients in group B performed also performed each ENG test without visual

fixation. Patients were tested without MA for 15 seconds, followed by 15 seconds of recording
with MA, followed by 15 seconds of no MA. Five seconds were given for instruction and the
slow phase velocity (SPV) of the nystagmus was measured for the final 10 seconds of each ENG
trace.
For group A, the SPV response for the 10 seconds period prior to and following the no
mental alerting period was averaged. It was compared to the SPV response during the no-alerting
period. For group B, the SPV response recorded the 10 second period prior to and following
mental alerting. It was compared to the SPV response during the middle alerting period. This
allowed for possible adaptation of nystagmus. If the difference in nystagmus was 3 deg/s it was
scored as No difference. Nystagmus differences >3 deg/s were scored as either Greater with
alerting or Greater with no alerting. Results were examined through ANOVA analysis.
Patients who mentally alerted were found to have a significantly larger nystagmus (higher
value SPV) than with no alerting. Of the 30 patients, 12 had spontaneous/gaze nystagmus, while
20 had positional nystagmus (two having both). Of the patients with spontaneous or gaze
nystagmus, there was no real difference between alerting and no alerting for eight of the 12
patients. However, for four of those patients, alerting enhanced the nystagmus. No patient had
greater nystagmus with no alerting than with alerting. For the 20 patients with positional
nystagmus, alerting had no effect on 12 patients, but enhanced the nystagmus in seven patients.
Four of these patients showed no nystagmus at all without alerting and three of the 20 patients
had nystagmus less than 6 deg/s. One patient with positional nystagmus showed greater
nystagmus with no alerting than with alerting, which may be due to anxiety. There was no
significant difference between spontaneous/gaze nystagmus and positional nystagmus or between
group A and B. Mental alerting was found to have a larger effect on males. Mental alerting

during both spontaneous/gaze and positional testing resulted in significantly greater magnitude
of nystagmus slow phase velocity being recorded compared to no alerting.
The findings of this study show the importance of mental alerting in real-life clinical
situations. Many clinics report nystagmus < 6 deg/s as insignificant. This study showed how
many patients may have nystagmus that is overlooked by clinicians who do not mentally task
patients. This study found seven of 20 had positional nystagmus < 6 deg/s without alerting, and
four of these had no nystagmus at all without alerting. When these 11 patients were alerted,
prominent nystagmus was found. This study showed how some patients could be misdiagnosed
due to the lack of mental alerting.
It is important to validate clinical work with research to provide the best possible care for
patients. Research measures almost every aspect of diagnostic tests to see which methods are
proven to be most successful. This study, along with many others, aids clinicians in providing the
best possible diagnosis and plan of treatment for patients. Without research, clinicians would not
have the knowledge of which diagnostic methods were more successful, and clinical data could
be misinterpreted.
I prefer to use mental alerting tasks that involve food, since New Orleans is a city that
identifies with good restaurants. I like to ask patients to name ice cream and pizza toppings, as
well as favorite restaurants. For patients with a high skill set, I prefer to use arithmetic counting,
such as counting in 2s or down from 100.
Theadvantagesofusingmentalalertinginclude:theenhancementofnystagmusduring
ENG/VNGtesting,easieridentificationofnystagmus(greaterdifferencebetweenresults),and
properinterpretation.Somedisadvantagesinclude:morestepsforthecliniciantoperformduring
alengthytest,difficultyforhearing/speakingpatients,anddifficultyforpatientswithdementia.