DOI 10.

1007/s11055-018-0621-5
Neuroscience and Behavioral Physiology, Vol. 48, No. 6, July, 2018

Vestibular Prosthetics: Concepts, Approaches, Results

I. V. Orlov, Yu. K. Stolbkov, and Yu. P. Gerasimenko

Translated from Rossiiskii Fiziologicheskii Zhurnal imeni I. M. Sechenova, Vol. 103, No. 3, pp. 250–267,
March, 2017. Original article submitted August 1, 2016. Revised version received December 5, 2016.

In contrast to hearing prosthetization, where the technology has been in development for more than 30
years, the challenge of vestibular prosthetization has been researched for no more than 15 years. However,
the involvement of the vestibular system in supporting the normal functioning of the visual, motor, and
other body systems defines its decisive contribution to spatial orientation in humans and animals. Damage
to the vestibular apparatus (labyrinth) leads to serious impairment to posture control, gaze stabilization, spa-
tial orientation, and psychological status, i.e., a person’s overall quality of life is sharply degraded. Animal
studies have developed techniques for the prosthetization of the semicircular canals, which perceive angular
acceleration and control eye movements in dynamic situations. New approaches based on replacement of
the lost natural afferent spike activity in the vestibular nerve by electrical stimulation via a multichannel
vestibular prosthesis have been successfully introduced into clinical practice.
Keywords: vestibular prosthesis, electrical stimulation, neurostimulation, semicircular canals.

General Characteristics of the Challenge. In con-
trast to hearing prosthetization, where the technology has
been in development for more than 30 years, the challenge
of vestibular prosthetization started to acquire clear outlines
only a little more than 15 years ago [26]. The first descrip-
tions of the systematic design and characteristics of semicir-
cular canal prostheses appeared in 2000 and 2002 [16, 17].
However, the involvement of the vestibular system in sup-
porting the normal functioning of the visual, motor, and oth-
er systems of the body define its decisive contribution to
spatial orientation in humans and animals. When vestibular
function is impaired or lost, the consequence is serious im-
pairments to postural control, gaze stabilization, spatial ori-
entation, and psychological status. All of these lead to sig-
nificant degradation of a person’s quality of life, such that
vestibular prosthetization cannot be regarded as a narrowly
specialized issue.
In the USA, the National Health Interview Survey
(2008) analyzed diseases of the labyrinth – the peripheral
component of the vestibular system (the intrinsic vestibular
apparatus). Questioning of 21782 people provided an assess-
Pavlov Institute of Physiology, Russian Academy of Sciences,
St. Petersburg, Russia; e-mail: ivorlov1@yandex.ru.
ment of the prevalence and social consequences of unilat-
eral and bilateral vestibular hypofunction (using the terms
accepted in the west) among the adult population of the
USA [10, 42]. Bilateral loss of vestibular sensation disables
people in whom the hair (receptor) cells of the vestibular
component of the labyrinth have been damaged by ototox-
ic agents, infections, Ménière’s disease, or other factors,
including surgical trauma during cochlear implantation.
People lacking the vestibuloocular and vestibulospinal re-
flexes of the labyrinth, which in normal conditions stabilize
eye and body position, suffer from visual blurring on head
movement, postural instability, chronic balance problems,
large increases in the risk of falls, and other consequences
of vestibular pathology [9, 37]. This can be supplemented
with shifting of images on movement of the head (oscillop-
sia) [26] and difficulties walking in the dark or on uneven
surfaces, as well as difficulty walking in a straight line [45].
This study presents corrected data from the national sur-
vey of the prevalence of bilateral vestibular hypofunction
in the USA: 28 adult patients per 100,000 of the population
(total 64046 Americans). Those taking the questionnaire
with diagnoses of bilateral vestibular hypofunction reported
changes to vehicle driving skills due to the symptoms, de-
creased social involvement, and difficulties in day-to-day

711
0097-0549/18/4806-0711 ©2018 Springer Science+Business Media, LLC
712
Fig. 1. The labyrinth of the rhesus macaque. 1) Superior semicircular canal;
2) lateral semicircular canal; 3) inferior semicircular canal. Openings for
introducing the electrodes of the vestibular prosthesis are shown (from [35]
with modifications).
life. Respondents with this diagnosis had a 31-fold increase
in the risk of falling as compared with the all-respondents
group, and 25% reported recent trauma associated with
falls. All these factors point to statistically significant degra-
dation of the questionnaire participants’ quality of life [45].
(Another calculation method gave a figure of 120/100,000
adults, or about 700,000 in the USA and European Commu-
nity or six million throughout the world [9].)
Thus, the challenge of vestibular prosthetization can be
addressed from several points of view – the medical-biolog-
ical (including the psychological aspects), the technical and
technological, and also the social. One of the first reviews
on this theme [43] noted that the then existing (2002) tech-
nological and medical-biological methods allowed miniature
components to be made, which were essentially analogous
to those used in hearing implants but generating information
on the person’s intrinsic movements rather than the sounds
around that person. The authors emphasized that making
vestibular prostheses a reality requires studies in many areas,
including the development of matrix motion sensors trans-
forming perceived movements into physiologically meaning-
ful information and delivering this information to the central
nervous system (CNS), training patients to use prostheses,
and developing methods for assessing the effectiveness of de-
vices [43]. In reality, the list of developments needed, as be-
came clear, was longer than initially supposed (2000–2002).
The Concept of Vestibular Prosthetization. The ac-
tual concept of vestibular prosthetization in general terms
can be formulated quite briefly: it consists of replacing var-
ious aspects of the damaged peripheral vestibular function
with a prosthesis perceiving head movements and transmit-
ting the resulting information to the brain by stimulation of
the vestibular nerve [26].
At this point it should be noted that the current concept
of vestibular prosthetization is based on the results of exper-
Orlov, Stolbkov, and Gerasimenko
iments performed initially at the beginning and middle of
the 1960s, when animal studies addressed the functional
connections between the semicircular canals and the head,
eye, body, and limb movements occurring in response to
local electrical stimulation of the nerves of the semicircular
canals [4, 38]. At the same time, is cannot be said that these
data are the basis of vestibular prosthetization and the cur-
rent understanding of this term.
As noted by Lewis [26], animal studies have shown
that visual and perceptual defects associated with damage to
the vestibular periphery can be decreased using vestibular
implants, though data on correction of postural control are
currently “less than satisfactory.” Furthermore, experience
of work on animals and humans is restricted to restoration
of the function of the semicircular canals [21] (Fig. 1).
Attempts to restore the functions of the otolith component
have not as yet been made other than in [31], but will un-
doubtedly be needed in the future [21] (see [12] for a discus-
sion on this topic). Of all the vestibular reflexes, the vestib-
uloocular reflex is regarded as “one of the gold standards in
vestibular testing since it can be easily quantified (gain,
phase, and axis) and since it provides objective evidence of
the ability to restore gaze stabilization mechanisms in pa-
tients with bilateral loss of vestibular function” [31]. As a
result, this is the main parameter in animal and human stud-
ies (Fig. 4). The vestibuloocular reflex provides stability of
gaze on the object being observed, moving the eyes in the
direction opposite to that of head movements. When bilater-
al loss of vestibular function is present, the mechanisms of
compensatory image-stabilizing eye movements become
inadequate. The direct result of this is that the anomalous
decrease in dynamic visual acuity hinders the recognition of
faces and writing while walking [18].
The prosthesis consists of two parts – an outer and an
inner. The outer components include the movement sensor
fixed to the patient’s (or animal’s) head, the processor,
which transforms this information into a pattern of electri-
cal signals, and a power supply (battery). The inner part
consists of electrodes implanted close to branches of the
vestibular nerve or inserted into the ampulla of the semicir-
cular canals. Connections for information exchange can be
conductive [21], inductive [13], or radio frequency [35].
Implementation of the Concept. University Programs.
Specialisms of Research Groups. The concept of vestibular
prosthetization was implemented at the turn of the century
in several university laboratories in the USA and Europe.
Searching PubMed-NCBI for “Vestibular Prosthesis” yield-
ed about 1000 publications in the last 10 years. Analysis of
these publications gives a view of several of the leading re-
search groups and their leaders. These groups can be divid-
ed into two categories on the basis of the systems studied.
Two of the groups (Merfield, Della Santina) have worked
(mainly but not exclusively) in animals (guinea pigs, chin-
chillas, squirrel monkeys, rhesus macaques). Implantation
techniques were developed in animals, constructs were eval-
Vestibular Prosthetics: Concepts, Approaches, Results
uated, and the reliability and safety of prostheses and the
adequacy of the procedures were assessed in long-term ex-
periments. The ability to transfer the technology to clinical
practice was discussed. An illustration is provided by “The
Johns Hopkins Multichannel Vestibular Prosthesis Project”
under Della Santina at Johns Hopkins University (Baltimore,
USA) [5–14, 23, 24, 30, 34, 37, 45]. Its ongoing Vestibular
NeuroEngineering Lab project is to bring vestibular stim-
ulation via prostheses closer to clinical utilization by the
following scheme: 1) by creating a multichannel vestibular
prosthesis to restore the three-dimensional angular (induced
by angular acceleration) vestibuloocular reflex for all direc-
tions of head rotation (prosthetization of the semicircular
canal system); 2) by developing a model of the propagation
of electric currents in the labyrinth to determine optimum
electrode design; 3) by developing optimum stimulation par-
adigms; 4) by assessing the ability of the CNS to correct dis-
torted prosthesis-generated vestibular inputs; 5) by assessing
hearing after implantation; and 6) by extending the approach
to nonhuman primates, whose anatomy is similar to that of
humans [34].
Three other groups whose results will be discussed be-
low have developed prosthetization technologies and trans-
ferred them to clinical practice (Rubinstein) and the treatment
of patients with different types of vestibular pathology (main-
ly Ménière’s disease) (Guyot and Perez Fornos; van de Berg).
Implementation of the Concept. Technical and Tech-
nological Challenges. Animal experiments have uncovered
a whole series of technical and technological challenges en-
countered by nearly all the research groups involved in this
process. These challenges include, in particular, unwanted
mutual influences between cochlear and vestibular im-
plants. The closeness of the respective inputs in the inner
ear provides the opportunity for mutual damage to the elec-
trodes, vestibular function more often suffering, particularly
in relation to posture control [2, 25, 27, 30]. However, the
percentage risk level in most studies was assessed as low,
except in [25], where a figure of 31% was given. There is
only one report on the opposite situation (deterioration or
loss of hearing on implantation of vestibular prostheses) [9],
which indicated that electrodes could be implanted into the
ampulla of the semicircular canals in chinchillas without
significant loss of hearing, though the risk of the current
surgical technique is high. Implantation of vestibular pros-
theses in rhesus monkeys can lead to decreased hearing,
though by barely more than 10 dB, i.e., to a level not shown
to be significant [6, 41].
Another negative factor is the possibility of interelec-
trode crosstalk. Experimental and clinical practice has iden-
tified cases in which this type of interference occurs in the
facial, cochlear, and the ampullar nerve not being stimu-
lated at that point in time [28]. Decreases in current strength,
correction of electrode position, and electrode insulation all
help avoid this type of situation. Additional ways of de-
creasing interference levels are given in [41].
713
Vestibular prostheses have much in common with co-
chlear implants, as they stimulate the vestibular inputs with
electrical impulses. However, the microphone of a cochlear
implant acts only as an artificial sound sources, while ves-
tibular prostheses containing multiplanar motion sensors
and sending the corresponding control signals to the CNS
must be (and are) of a much more complex construction
[17]. Three-dimensional displacement and three-dimen-
sional rotation, as well as orientation relative to the gravita-
tional vector must be detected by combinations of sensors
(accelerometers, gyroscopes, magnetosensitive Hall ele-
ments), giving six degrees of freedom for the artificial laby-
rinth [41]. The authors felt that the main challenges of arti-
ficial labyrinths are drift, limiting the range of temporal and
spatial sensitivity, and the relatively high power consump-
tion, which hinder the use of prostheses over long periods of
time. In this regard we note that during the five years since
publication [41], part of the challenge was overcome by us-
ing ASIC (application-specific integration circuits) technol-
ogy. The high-voltage neurointerface chip for multichannel
vestibular prostheses released in 2016 (as part of the devel-
opment of the Johns Hopkins University project mentioned
above) provides for measurement of head movement pa-
rameters and modulation of the activity of the vestibular
nerve to restore the visual and posture-stabilizing reflexes.
The chip, which is able to stimulate branches of the vestib-
ular nerve by biphasic current impulses of up to 1.45 mA
with impulse duration 10 μsec/phase, has been tested with
success in rhesus monkeys [24]. Another specialized system
[39] encodes head movement signals converted to electrical
impulses by inertial sensors to stimulate vestibular nerve
fibers. This transforms the coordinate system for correction
of tilt (malalignment) between the natural and artificial iner-
tial sensors. It also imitates the frequency characteristics of
the response and the transformation of angular and linear
head movements seen (in normal conditions) in the nerves
of the semicircular canals and otolith organs. The design is
6.22 mm2 and has a power consumption of 1.24 mW. We
were unable to find any information on the practical appli-
cation of the device.
An additional means of decreasing power consumption
is proposed in [3]. This presents an alternative approach to
sensing angular speed (a gyroscope) based on the operating
principle of the natural semicircular canal, where rotation of
an insert mass of fluid (the endolymph) deforms the sensory
structure (the cupula). The gyroscope is made using the
commercial MEMS process. The sensitivity of this system
to angular speed is less than 1°/sec (comparable with that of
the vestibular system). Avoiding the use of a constantly
driven vibrating mass as used in contemporary gyroscopes,
the authors achieved ultralow power consumption – 300 μW
– which makes the device suitable for implantation.
Stimulating Electrodes and Parameters of Stimu-
lation via Vestibular Prostheses. Fine (25–125 μm) plati-
num/iridium (90%/10%) alloy wires insulated with Teflon
714 Orlov, Stolbkov, and Gerasimenko

Fig. 2. A) The physiological effects of symmetrical biphasic electrical stimulation impulses (cathodic first phase, 1) are determined by
three parameters: current strength (4), impulse duration, and interphase gap (2). 3) The anodic phase; 5) the second impulse in the pair
(with the same characteristics as the first); 6) output (to semicircular canal); T – time interval between pairs of impulses; B) special
scheme encoding the stimulus in three-dimensional rotation of the head in chinchillas transforming the rate of head rotation in the
plane of a given semicircular canal to modulation of the rhythm of vestibular afferent discharges f = i/T in the corresponding electrodes
of the prosthesis. This occurs as a result of piecewise mapping of the linear rate of head movement onto the rate of impulses, which is
required for an effective approximation of the mean frequency of vestibular afferents (plot II). The input of the system (head speed) is
shown in plot I and the output impulse frequency of the prosthesis is shown in plot III. The intensity of the input stimulus corresponds
to 100% of the dynamic range in the chinchilla (from [7] with modifications).

[24] are generally used for stimulation of branches of the
vestibular nerve in experimental and clinical practice. The
minimal requirement applies not only to specific devices,
but also to the selection of stimulation parameters giving the
maximum effectiveness, i.e., the minimal requirement for
obtaining the maximum effect in the form of the vestibu-
loocular reflex and, secondly, excludes spread (leakage of
current into adjacent structures), which leads to divergence
of the planes of the semicircular canal being stimulated and
the vestibuloocular reflex [7, 42]. This current leakage can
distort the activation pattern of the vestibular nerve, induc-
ing mismatch between the perceived and actual axes of head
rotation. Della Santina et al. [5] suggested that with time,
central neural mechanisms can adapt and correct this tilt.
With the aim of verifying this hypothesis, vestibular deficit
was induced in five chinchillas by administration of genta-
micin into both labyrinths followed by unilateral implanta-
tion of a multichannel vestibular prosthesis on the head.
Comparison of three-dimensional angular vestibuloocular
reflexes during horizontal sinusoidal head rotation at a fre-
quency of 2 Hz and a peak rate of 50°/sec (in the dark) on
days 1, 3, and 7 of continuous use of the prosthesis showed
that vestibuloocular reflexes remained stable, retaining
about 70% of the normal strength (the ratio of eye speed to
head speed), while impairment of alignment significantly
decreased one week after stimulation started. Comparable
improvements were obtained on rotation of the head around
the axes of the other two semicircular canals. Impairments
to the linkage of eye movements improved progressively
over the same time frame. This indicates that the CNS
adapted to stimulation via the prosthesis and markedly im-
proved the balance of the axes of the three-dimensional an-
gular vestibuloocular reflexes in the first week after stimula-
tion started. Adaptive improvements could also occur in
members of other species, including humans [5].
The use of vestibular prostheses has limitations linked
with the need to use electrically balanced stimuli to avoid
developing irreversible electrochemical reactions and the
formation of their side products at junctions between elec-
trodes and body fluids [13]. Charge balance is achieved by
using short symmetrical impulses of biphasic alternating
current (AC) which excite close-lying nervous tissues but
has no effect on their effective inhibitory influences. When
nervous tissue is spontaneously active and the therapeutic
aim is to inhibit this activity, AC prostheses (for example,
deep brain stimulators or spinal cord stimulators) generally
act indirectly by exciting a pool of neurons, which then pro-
duce transsynaptic inhibition of the actual target. Many
publications on the theme of vestibular prosthetization re-
flect the search for more adequate labyrinth stimulation pa-
rameters for different purposes. Thus, excitation of the
nerve membrane has been shown to require short, high-am-
Vestibular Prosthetics: Concepts, Approaches, Results 715

Fig. 3. The concept of a safe direct current stimulator. The two panels represent the different states of the same device. Left – the current
flows from the lower electrode to the upper; right – the current changes direction but, as the valves change their state along with the direction
of the current, the ionic current (thick arrow) continues to flow through the liquid electrode from left to right through the tissue. Valve A1
is always in the same state as valve A2, while valve B1 is always in the same state as valve B2. All switches are synchronized with changes
in electrode polarity (from [13] with modifications).

plitude stimuli with a smaller quantity of charge than lon-
ger-lasting, low-amplitude stimuli [41]. A brief series of
high-frequency impulses is also a more powerful stimulus
than a long sequence of low-frequency impulses [38].
Two studies published in parallel, one of which was a
subject review of Pubmed, Medline, and Embase [41] and
the other was an experimental review article [7], noted that
maximal effects (strongest vestibuloocular reflex with low-
est stimulation current) were obtained with the initial phase
of the current being cathodic on the active (intralabyrin-
thine) electrode relative to the larger-area distant electrode.
This latter is placed either in the musculature of the neck or
the crus commune (the common part of the superior and
inferior semicircular canals). The balance between the ca-
thodic and anodic phases prevents irreversible corrosion of
the electrodes and the formation of metal oxides at elec-
trode:tissue junctions. The effects of frequency-modulated
symmetrical biphasic impulses of direct (within a phase)
current are determined by four main parameters: impulse
frequency, current amplitude, impulse duration, and the du-
ration of the period with no current between the two phases
of opposite polarity [7, 41] (Fig. 2). Both groups of authors
noted that the optimum strategy for encoding stimuli re-
mains unidentified. The effects of frequency-modulated
symmetrical biphasic impulses of direct (within a phase)
current were analyzed by varying these stimulation parame-
ters for the semicircular canals in chinchillas [7, 34].
Increases in stimulation frequency over the range 0–400 im-
pulses/sec to encode the angular rate of the head increased
the amplitude of the vestibuloocular reflex without losing
the relative constancy of the three-dimensional (3D) axis of
rotation of the eye [26, 34]. Increases in current strength (of
the balanced biphasic impulses) increased the rate of vestib-
uloocular reflexes, though there was an increase in the di-
vergence (impaired alignment) of the expected and actual
axes of rotation of these reflexes [10]. Stimulation via the
prosthesis was found to be able to induce vestibuloocular
reflexes to head rotation rates of ~50°/sec without loss of
alignment. However, more intense stimuli increase the tilt
between the axes of the evoked eye movement and head
rotation, which needs to be encoded. If the prosthesis has to
provide accurate encoding of three-dimensional head rota-
tion throughout the natural range of movements, whose
speed can exceed 300°/sec, there has to be a compromise
between the dynamic range and the misalignment of the
evoked vestibuloocular reflexes. Increases in impulse am-
plitude (0–325 μA) also led to an increase in the amplitude
of the response, though there was a false shift in the axis of
eye movements (presumptively due to propagation of the
current to adjacent structures). Decreases in impulse dura-
tion (from 340 to 28 μsec) decreased the magnitude of the
discharge required to obtain a specified response amplitude
and induced a smaller shift in the axis of rotation of the eye
than impulses of greater duration. Changes in the interphase
gap over the range 25–175 μsec were indifferent (they had
no effect on the result). Thus, the basis for optimization of
stimulus encoding for use in prostheses must consist of
short, frequency-modulated biphasic impulses restoring the
sensation of head rotation [7].
In health, the vestibular system encodes head move-
ments by altering the discharge frequency in vestibular af-
ferents relative to the baseline (spontaneous) frequency in
716
proportion to the rate of head rotation. A multichannel pros-
thesis [8] “imitates” this encoding scheme, modulating the
frequency and amplitude of current impulses to above or
below the baseline level. Stimulation of one labyrinth via
the prosthesis imitating normal baseline discharges of the
vestibular afferents induces the vestibuloocular reflex with
a wider range of eye speeds in response to stimuli simulat-
ing frequencies above the baseline level (arousal) as com-
pared with stimuli simulating frequencies below this level
(inhibition). Modulation of the frequency above the normal
baseline level extended the range of inhibitory rates of eye
movement, but narrowed the range of excitatory rates.
Simultaneous modulation of frequency and current strength
(co-modulation), exceeding all tested baseline levels, sig-
nificantly extended the range of excitatory eye rates as com-
pared with separate modulation of frequency or current
strength. These data may be useful in selecting the optimum
baseline stimulation levels for extending the range of inhib-
itory eye movements with simultaneous retention of a wide
range of excitatory movements by co-modulation [8].
In contrast to alternating current (AC), direct current
(DC), delivered via a metal electrode, can excite, inhibit,
or modulate neuron sensitivity. However, this stimulation
is unsafe because of the interaction between electrodes and
tissues described above. Report [13] presented a prototype
of a safe stimulator prosthesis controlling the delivery of
a DC ion current into the selected tissue via a conductive
gel salt bridge and a flexible micropipette electrode. This is
achieved by switching the bridge valves in phase with the
square-wave impulses of the alternating current delivered
to the metal electrodes. Although the gel freely conducts
the ionic current from the stimulator, it blocks to and fro
movement of tissue fluid in the tubular salt bridge, provid-
ing a physical barrier preventing biological contamination.
This approach allowed a DC ionic current to be produced
along the tissue without impairing the limitations associated
with obtaining a balanced discharge on the salt electrodes.
A safe direct current stimulator (SDCS) (Fig. 3) provided
both excitation and inhibition of the activity of the nerve
branches of the semicircular canals to improve the range of
eye movements during stimulation of the inner ear in chin-
chillas. The safety of the stimulator was supported by its ef-
fectiveness without adverse consequences after continuous
direct current (80 μA) stimulation of the labyrinth in chin-
chillas for 15000 sec (more than 4 h, or three orders of mag-
nitude longer than specified by western medical standards).
In contrast, passage of this current though traditional Pt/Ir
(platinum/iridium) microelectrodes of similar size induced
signs of biological tissue damage after ~40 sec [13]. Studies
in Della Santina’s laboratory demonstrated the effective-
ness of the safe direct current in addition to the convention-
al paradigm of vestibular stimulation though a prosthesis,
previously based solely on impulse frequency modulation.
Simultaneous stimulation with a direct current and impulse
trains, when the direct current is used to decrease or elimi-
Orlov, Stolbkov, and Gerasimenko
nate natural spontaneous activity, may provide more effec-
tive control of the frequency of vestibular afferent discharg-
es, improving both the inhibitory and excitatory dynamic
ranges of vestibuloocular responses. Improvements in these
responses during simultaneous stimulation are consistent
with suppression of the spontaneous activity of the vestibu-
lar nerve by the direct current. For inhibitory impulse stim-
uli, suppression of activity by the direct current probably
facilitates encoding by pulse bursts, decreasing spontaneous
activity in vestibular afferents and allowing impulse bursts
to simulate the encoding of inhibitory head movements.
Isolated use of the direct current can have both excitatory
and inhibitory influences on vestibuloocular reflexes. As ex-
pected, the dynamic range for the inhibitory direct current
was ~1/3 of the range for the excitatory current. The likely
explanation is that the spontaneous frequency of vestibular
afferents is usually ~60 impulses/sec. Stimulation with a ca-
thodic direct current can elevate this to a level of ~350 im-
pulses/sec, while the inhibitory anodic current can decrease
the frequency only to 0 impulses/sec [13, 14]. Testing of the
stimulator in its current form, although generally satisfac-
tory, identified a number of technical problems (stepwise
regulation of the direct current, lack of software to change
its polarity or amplitude, large size, etc.). Further studies
in Della Santina’s laboratory developed a new-generation
stimulator (Safe Direct Current Stimulator 2, SDCS2) [14].
The entire system is miniaturized and the stimulator input
has a current-sensitive element to ensure the constancy of
the output current. The device is autonomous, has a mod-
ular design, and provides for safe use of a direct current in
experiments with different versions of neuronal control.
These developments [13, 14] have a common and
promising “side exit,” specially noted by the authors. Neu-
roprostheses able to both excite and inhibit nervous tissue
can significantly increase the efficacy of the treatment of
many neurological deficits. For example, prostheses for aid-
ing urination must simultaneously excite the sacral nerves
to activate the muscles of the urinary bladder and inhibit the
lumbar nerves to relax the urethral sphincter. Disorders in-
ducing uncontrolled neuron discharges (tinnitus, chronic
pain, epilepsy, etc.) can be treated with prostheses providing
neuron inhibition [13, 14].
It should be noted that data on stimulation parameters
for neural structures, including the characteristics of the
electrodes and control devices, can be used in restorative
medicine, particularly when treatment is linked with long-
term or chronic procedures.
With the aim of getting a better understanding of the
biophysics of the stimulation of branches of the vestibular
nerve and developing electrodes with optimum selectivity, an
anatomically accurate model of the origination of the current
in the implanted labyrinth was created [24]. The geometry of
the model was generated using high-resolution three-dimen-
sional reconstructions of computerized micromagnetic reso-
nance tomographic and computerized microtomographic
Vestibular Prosthetics: Concepts, Approaches, Results
scans of the labyrinth in chinchillas (Chinchilla lanigera).
The virtual electrodes were positioned using anatomical
markers and the configuration of the potential field during
current impulse origination was calculated using the finite el-
ements method. The model can predict the structure of the
potential field, the current strength passing though the laby-
rinth from the prosthesis, and the position of the axis of rota-
tion of the eyes. Approaches to the anatomy of a nonhuman
primate and humans are currently being developed [24, 34].
Clinical Aspects of Vestibular Prosthetization. We
note that in the USA and European countries, the number
of patients with bilateral vestibular impairments is around
is very approximately 500,000–700,000 [9, 45]. Swiss and
Dutch clinicians involved in this field [21] believe that
these numbers are underplayed, for the following reasons.
Difficulties in evaluating start with diagnosis, when patients
try to describe the symptoms arising from changes in the
state of a system whose functions they do not understand.
These functions are numerous. In addition to the widely
known control of posture and vision (in dynamic situa-
tions), the vestibular system also has roles in regulating the
cardiovascular system, bone metabolism, sleep, respiration,
and spatial orientation, and is linked with the limbic sys-
tem [21]. And while there are concrete words for describing
deterioration in hearing or vision – deafness or blindness
– there are no (or almost no) such words for describing ves-
tibular disorders. Patients are therefore only able to give
unclear descriptions of their problems and often fail to be
understood by doctors. These difficulties are well illustrated
by questioning of 19 patients with bilateral vestibular deficit
in whom the interval between the first symptoms and estab-
lishment of the diagnosis averaged 2.5 years [21, 29]. All
patients underwent ophthalmological review, as they had
complained of visual indistinctness while walking. These
also underwent neurological examination, because of com-
plaints of impaired balance. Finally, most of them attended
a psychiatrist as they felt they were suffering from depres-
sion. And so on. Attempts have been made to substitute for
vestibular function by vibrotactile feedback, whereby devi-
ation of the patient from the vertical led to delivery of pro-
portional vibrostimulation of increasing intensity [44] or, in
other cases, acoustic signals [21], though these were less
effective than hoped.
Rubinstein et al. noted [15] that there is an acute need
for new approaches to the treatment of vestibular dysfunc-
tion. Apart from plugging the semicircular canals for dehis-
cence of the superior canal and the popularization of in-
tratympanic injections for Ménière’s disease, the treatment
for vestibular pathology has remained essentially unchanged
for nearly four decades. These destructive procedures are
usually the best variant for patients with episodic manifesta-
tion of diseases (Ménière’s disease) not responding to less
invasive treatments [15].
Clinicians ultimately come up against the need to create
artificial vestibular devices for humans [21, 28, 29]. The first
717
experiments in this direction on people were performed in
Geneva, Switzerland. The results were presented at a meeting
of the Bárány Society (Paris, 2004) and published in [21, 42].
International collaborative studies have since made exten-
sive progress in creating artificial vestibular devices for hu-
mans [20–22, 31, 33, 38, 40, 42]. The authors of a prototype
vestibular prosthesis were pleasantly surprised to discover
that patients adapted to prostheses quickly (no more than 30
min), in contrast to the situation in animal experiments,
where this took a number of hours [12]. (The difference may
be associated with differences in preparative manipulations
in animals and humans.) In addition, symptoms in patients
could be decreased significantly and even eliminated by
smoothly increasing stimulation intensity instead of cutting
it in sharply. Adaptation time on sudden cessation of stimu-
lation was even shorter than for activation, at no more than
3 min. This means that the patient could switch the prosthe-
sis on and off several times a day for washing, sleeping, etc.,
without experiencing discomfort. Thus, there was evidently
no need to develop systems for continuous power supply or
for a waterproof device, which simplifies introduction of the
prosthesis into clinical practice [21]. Thus, a necessary con-
dition for restoring bidirectional eye movements by stimula-
tion via a unilateral prosthesis was provision of an artificial
spontaneous (baseline) efferent discharge frequency. This
activity could then be increased to generate eye movements
in one direction and decreased to generate movements in the
opposite direction in accordance with head movements.
Stimulation consisted of a series of balanced biphasic im-
pulses (400 μsec/phase, the initial phase being cathodic) at a
frequency of 200 impulses/sec. Current amplitude was in-
creased gradually with steps of 10–50 μA. Changes in the
rate of the slow phase of nystagmus (>2°/sec) or the occur-
rence of any “vestibular” sensation, as reported by the pa-
tient, was evaluated as the vestibular threshold. The current
amplitude at which unpleasant sensations occurred (pain on
stimulation of the facial nerve) were selected as the upper
comfort level. These two limits defined the dynamic range of
stimulation. Overall, the authors of [21] recorded nystagmus
in 12 patients (24 of 27 implanted electrodes). Use of an
electrode implanted in the lateral semicircular canal restored
the vestibuloocular reflex with a gain coefficient close to
normal; the baseline activity level was modulated in accor-
dance with signals from an inertial head movement sensor
[21, 31]. The authors believed this was the first demonstra-
tion of the restoration of vestibular function in humans (at
least partial restoration) [21]. However, they still ended their
article with great caution: “Results up to date strongly sup-
port the feasibility of a vestibular implant to rehabilitate pa-
tients with bilateral vestibular deficit. However, it is still pre-
mature to say how long it will take to obtain a vestibular
implant for clinical use.” Illustrations of the influence of the
vestibular prosthesis on the quality of the vestibuloocular re-
flex in patients with decreases of bilateral vestibular deficit
are given in Figs. 4 and 5.
718 Orlov, Stolbkov, and Gerasimenko

Fig. 4. Vestibuloocular reflexes in two patients with implanted prostheses in response to sinusoidal rotation (peak speed 30°/sec,
complete darkness) at frequencies of 0.1–2 Hz. Continuous lines show averaged oscillations (±standard deviation – dotted lines) in
the horizontal angular speed of the head (1) and eye (2). Stimulation parameters via prosthesis: series of balanced biphasic impulses
(200 μsec/phase) delivered at a frequency of 400 impulses/sec (from [31] with modifications).

Over a period of seven years (2007–2013), the same
Dutch-Swiss group followed 11 patients with bilateral loss
of vestibular function. All patients underwent implantation
of a prototype prosthesis stimulating the ampullar branches
of the vestibular nerve. Eye movements and sensations
evoked by stimulation were recorded and documented. All
patients achieved slow, controlled eye movements, increas-
ing successful activation of the vestibuloocular pathways.
However, both the dynamic range and the amplitude of
evoked eye movements were different in different patients.
The axes of eye rotation corresponded to the nerve branches
stimulated in 17 of the 24 electrodes tested. Furthermore, in
at least one case, evoked eye movements were similar to
movements during natural activity on walking. Thus, stim-
ulation was a safe and effective means of activating the ves-
tibular system even in a very heterogenous population of
patients with diseases of very different etiologies and dura-
tions. The authors concluded [19] that adequate processing
of this information may convert the vestibular prototype
implant into an effective artificial organ of balance.
At the same time, “real” replacement of vestibular fun-
ction by a prosthesis requires a head movement speed sen-
sor with the appropriate circuits, though Ménière’s disease
may not require any such sensor. This concept has until re-
cently been developed by Rubinstein’s group [15, 21, 28,
29, 32, 35]. It differs fundamentally from the concepts of
Merfeld’s group, Della Santina’s group, or the group led by
Guyot and Perez Fornos. One comment [31] noted that the
initial approach of Rubinstein’s group consisted of develop-
ing a vestibular stimulator not intended for encoding head
movements [15]. The purpose of the device was to treat
Ménière’s disease by controlling repeated episodes of verti-
go while keeping patients’ vestibular functions close to nor-
mal. Rubinstein’s group also conducted parallel studies on
animals (rhesus moneys), confirming that eye movements
could be induced electrically (and, thus, that the vestibular
apparatus could be activated) on the basis of the suggestion
that this would allow post-implantation preservation of
hearing and pre-existing vestibular functions [35]. Attacks
of Ménière’s disease occur as a result of, among others, sud-
den loss spontaneous afferent activity in the affected ear due
to depolarization block resulting from displacement of the
endolymph and perilymph because of rupture of the mem-
branous labyrinth [36]. Eye movements recorded during
attacks of Ménière’s disease generally coincide in time with
loss of spontaneous activity [1, 35]. A prosthesis can in prin-
Vestibular Prosthetics: Concepts, Approaches, Results
Fig. 5. Mean (± error of the mean, ordinate) phase-locked gain of the ves-
tibuloocular reflex in three patients with implanted prostheses with the
prosthesis switched off (1) and on (2). The depth of modulation was 50%
of the dynamic range for each patient. The abscissa shows the frequency of
mechanical oscillations of the stand with the patients (Hz) in the dark. The
parameters of electrical stimulation delivered via the prosthesis were as in
Fig. 4 (from [31] with modifications).
ciple terminate these symptoms by replacing the lost spon-
taneous discharges with unmodulated electrically induced
afferent activity. This “vestibular cardiostimulator” does not
require a speed sensor as such. The only need is for the de-
vice to be switched on when symptoms appear or to leave it
on during periods of frequent attacks [27]. This procedure
can be useful for patients for the treatment of vestibular dis-
orders using a relatively simple device not requiring the use
of modulated signals controlled by head movements [35].
Rubinstein’s group has recently switched to developing de-
vices encoding movements [32], with the ability to induce
tilting of the body by electrical stimulation of the labyrinth
under computer control.
In summary, the complex challenges of vestibular
prosthetization are being addressed by multidisciplinary hi-
tech studies in American and European laboratories, along
with clinical trials, whose participants are optimistic regard-
ing the practical feasibility of creating optimum vestibular
prostheses.
Conclusions. Vestibular prosthetization is a young and
dynamically advancing hi-tech branch of modern restorative
medicine whose arsenal includes experience of current meth-
ods for diagnosis, microsurgery, IT technologies, including
computer modeling, and other complex procedures. This has
shrunk the gap in the treatment of two types of pathology –
auditory and vestibular – which arise in the middle ear.
There is currently extensive interest in experimental
techniques addressing the labyrinth in animals, specifically
719
the semicircular canals, which perceive angular accelera-
tion and control eye movements in dynamic situations (ves-
tibuloocular reflexes). Restoration of postural regulation,
which is controlled by, among others, vestibular receptors,
remains the subject of deeper studies because of a number
of unresolved technical and technological challenges.
However, even “only this” significantly eases the lives of
people with bilateral vestibular deficit, bringing them out of
the state of helplessness.
In comparison with results obtained in animals, the di-
rect clinical achievements are more modest because of the
obvious difficulties in diagnosis, the high risks of surgical
intervention, and, evidently, the small number of specialist
clinics and the costs of surgery. It should be borne in mind
that both groups of authors – researchers and clinicians –
converge on the view that the optimum strategy for encod-
ing stimuli created by vestibular prostheses remains to be
identified.
Finally, the qualitative and quantitative composition of
research and medical groups (which usually have more than
10 members) should be emphasized – they include not only
biomedical staff, but also IT specialists and engineers, as
well as high-quality laboratory animal care staff. In addition,
they are well equipped and take part in wide international
and national collaboration. These factors taken together in-
duce a belief in success among the participants.
This study was supported by the Russian Foundation
for Basic Research (Grant No. 16-29-08173ofi-m).
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