The Effect of Muscle Contraction Level on the Cervical Vestibular Evoked Myogenic Potential (cVEMP): Usefulness of Amplitude Normalization

Abstract

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. 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. Prospective, repeated-measures design using a convenience sample. Ten healthy adult participants between 25 and 61 yr of age. cVEMP responses to 500 Hz tone bursts (120 dB pSPL) for three conditions describing maximum, moderate, and minimal muscle contraction. 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. 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. 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.