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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 27  |  Issue : 1  |  Page : 47-50

Conducting Fukuda stepping test in a noisy clinic and the effects of sound


1 Department of Otorhinolaryngology, Hospital Sungai Buloh, Selangor, Malaysia
2 Department of Otorhinolaryngology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Date of Submission19-May-2020
Date of Decision29-Jun-2020
Date of Acceptance11-Aug-2020
Date of Web Publication26-Oct-2021

Correspondence Address:
Dr. Carren Sui Lin Teh
Department of Otorhinolaryngology, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_98_20

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  Abstract 


Context: The Fukuda stepping test (FST) is used to assess the labyrinthine function via the vestibulospinal reflex. The test is meant to be conducted in a quiet room, but in a busy clinic setting, it is often performed in the clinic itself, and individuals are exposed to environmental sounds. Aims: The aim of this study was to assess the effects of environmental sounds and the effects of fixed directional sound on the outcome of FST. Settings and Design: This is an observational study. Subjects and Methods: Thirty healthy participants performed the FST in the otorhinolaryngology clinic, in a sound-treated room, and then in a sound-treated room with the presence of a fixed directional sound where the angle of rotation, angle of displacement, and distance of displacement were compared. Statistical Analysis Used: Independent t-test and Chi-squared test were used for statistical analysis. Results: There was no statistical difference in the angle of rotation and angle of displacement in all three settings. Although the mean distance of displacement was above 50 cm in all three settings, there was a significant reduction between clinic versus sound-treated room (P = 0.016) and clinic versus room with sound-treated directional sound (P = 0.002). Fixed directional sound had no significant influence on the direction of rotation in all the participants. Conclusions: Performing FST in the standard clinic will not affect the results. Concurrently, we suggest omitting measurement of the distance of displacement in FST as it is not reproducible in our normal sample and is highly susceptible to auditory cues but to focus on the angle of rotation.

Keywords: Auditory cues, clinic setting, Fukuda stepping test, sound treated, Unterberger's test


How to cite this article:
Teh CS, Gima EA, Mamat HB, Lye MH, Din SB, Prepageran N. Conducting Fukuda stepping test in a noisy clinic and the effects of sound. Indian J Otol 2021;27:47-50

How to cite this URL:
Teh CS, Gima EA, Mamat HB, Lye MH, Din SB, Prepageran N. Conducting Fukuda stepping test in a noisy clinic and the effects of sound. Indian J Otol [serial online] 2021 [cited 2021 Dec 2];27:47-50. Available from: https://www.indianjotol.org/text.asp?2021/27/1/47/329102




  Introduction Top


Dizziness, vertigo, or imbalance is a common presenting complaint in our otorhinolaryngology (ORL) clinic. It affects both activities of daily living as well as quality of life. Correct diagnosis is crucial for specific treatment. To reach the correct diagnosis, it requires detailed history taking and series of examinations.[1],[2],[3],[4],[5],[6],[7]

One of the commonly used examinations is the Fukuda stepping test (FST) which was developed as a variation of Unterberger's Tretversuch.[1],[8],[9] Unterberger discovered that patients with inner ear lesions displayed a rotatory body movement when standing alternately on their legs. He had patients step in place to simulate one leg standing and had their arms held out horizontally to distract them from the task. The test was done in a dark and quiet room, and patients wore Frenzel glasses.[1],[3],[8]

Fukuda found Unterberger's Tretversuch to be useful but quantified the norm as displacement of no more than 0.5 m–1.0 m after 50 and 100 steps, respectively, and rotation no more than 30° for 50 and 45° for 100 steps.[1],[2],[8] The vestibulospinal outputs give ipsilateral tonic influence on antigravity muscles; therefore, a unilateral vestibular lesion would reduce tonic influence on the side of lesion. This inequal weight distribution on lower limbs will result in the patient turning toward the side of the vestibular lesion, while if nystagmus is present, it would beat toward the opposite side of the lesion.[2],[8]

Both Unterberger and Fukuda designed the test to be performed blindfolded, barefoot, and in a quiet room with even illumination. However, in a busy clinic setting, it is performed in the clinic itself and individuals are exposed to the environmental sounds. Studies suggest that ambient sounds may influence postural control by relying on auditory stimulus to maintain postural control.[3],[4],[5] Our study was aimed at assessing if the standard clinic is suitable to conduct FST as well as identifying the true effect of sound on the test.

The primary objective of this study was to assess the effects of environmental sounds in a standard clinic setting on the angle of rotation, angle of displacement, and distance of displacement in FST. The secondary objective was to evaluate the effects of fixed directional sound on the outcome of FST.


  Subjects and Methods Top


Normal healthy individuals were screened for any history of ear infections, vestibular disorders, neuromuscular injuries, head injuries, or lower limb surgeries and were excluded if they had a history of the mentioned. They also did not undergo any formal hearing or vestibular testing. Informed verbal consent was then obtained from all participants.

The individuals were asked to march 50 steps with eyes closed and arms extended forward while counting out loud with each step taken. They were asked to maintain in their place of origin. This instruction was given for each setting which was ORL clinic (sound level monitored with Mobile app NIOSH SLM™), repeated in a sound-treated room and then in sound-treated room with the presence of a fixed directional sound. The fixed directional sound was produced using a Mobile Metronome smartphone app – Soundbrenner™ set at 120 beats/min placed at 45° randomly to the right or left of the participant played at 70 dB. In the sound-treated room, the walls are padded, floor carpeted, and sound-treated single door with dimmed lights. The participants were required to remove their shoes and march barefooted on the carpeted floor.

When the prescribed 50 steps were completed, the participant was asked to remain standing without moving, and the angle of rotation, angle of displacement, and distance of displacement were measured. [Figure 1] illustrates the method the measurements were taken.
Figure 1: The measurements calculated from the Fukuda stepping test. a = Angle of rotation, b = Angle of displacement, c = Distance of displacement

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Data were entered into an Excel™ spreadsheet, and readings for different rooms were compared using the independent t-test. Chi-squared test was used to compare the effects of directional sound on the rotational angle. P < 0.05 was taken to indicate statistical significance.


  Results Top


Thirty healthy participants (15 females and 15 males) aged between 21 and 40 (mean age: 29.2) were enrolled in this study.

Sound levels in each setting

The sound level reading in the clinic was between 65 and 75 dB, and the same clinic room was used for all the participants. The test was conducted during a regular clinic day. Like most clinic rooms, it was equipped with a clock, a phone, and a door which led out to the waiting areas. Each room was connected to the next through two side doors which allowed people and sound to pass through. The high sound levels were due to the occasional phone ringing and patients waiting outside, for example, children laughing, playing, or crying.

The sound level in the sound-treated room was 35–40 dB and 70 dB in a sound-treated room with fixed directional sound which was the metronome playing. The sound treatment of the room with the padding helped cut down most of the outside noise.

Angle of rotation and angle of displacement

The mean angle of rotation and angle of displacement in all three settings are in the normal range of below 30° and tabulated in [Table 1]. There was no statistical difference for the angle of rotation and angle of displacement between the three rooms [Table 2].
Table 1: Mean and standard deviation in each setting

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Table 2: Comparison of mean between the three settings (P)

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Distance of displacement

The mean distance of displacement was 90.9 cm in the clinic, 67.29 cm in the sound-treated room, and 60.29 cm in the sound-treated room with fixed directional sound [Table 1]. While the mean readings in all three environments were above the value deemed as normal by Fukuda of 50 cm, the reduction in the distance of displacement in clinic versus sound-treated room (P = 0.016) and clinic versus sound-treated room with fixed directional sound (P = 0.002) was significant [Table 2].

Effects of fixed directional sound

To study the effects of a fixed directional sound, 53.3% or 16 of the participants rotated toward the sound and the other 14 participants rotated away from the tone. There was no significant effect from the directional sound on the direction of rotation of the participants (P = 0.715).


  Discussion Top


FST is claimed to be more accurate than nystagmus and Romberg, but how it is performed may influence the outcome as it is suggested that some factors may affect the sway including tactile and auditory cues.[4],[5],[8],[10] The role of auditory cue on perceptual-motor processes is mainly researched in sports and psychology. Studies have shown the importance of auditory information for movement execution, control, timing, and learning.[11],[12] A classic example of the importance of auditory cues in sports is an experienced tennis player who will have decreased service precision when they are deprived of auditory feedback.[12]

A study involving rat pups showed a reflexive head turn toward a sound. However, binaural hearing was important for head orientation to sound as the rats would be turned toward the side of an unoccluded ear.[13]

Beyond that, literature review did not explain or demonstrate the effects of auditory cues on the direction of movement. In this pilot study, we wanted to go one step ahead to study the influence of the sound, whether it was just an auditory cue which helped a participant stay on the spot or if it pushed or pulled the participant. To observe for any directional influence, direction of rotation was observed in relation to the direction of sound. We had expected the metronome to help pull the participant toward the sound (as it did in the rat study) but were very surprised with the findings that almost equal number of participants were pulled as well as pushed away from the tone. This leads us to conclude that a fixed directional sound does not have a directional influence on the movement of a patient in FST.

To further demonstrate the lack of effect of auditory cues in aiding spatial orientation, one would expect the environmental noise of fixed directional sound to help the participant maintain on their spot. However, there was no difference in the angle of rotation and angle of displacement in all three settings, especially when comparing between the standard clinic which is filled with environmental localizing sounds such as from the clock, phone, and even sounds from beyond the clinic door made by other patients waiting outside. Okuzumi et al., using pure tone as a localizing source in a soundproofed room, also showed that it was not effective as directional orientation.[14] Munnings et al. also used metronome as a fixed direction sound, and they too showed no obvious difference in the angle of rotation between the anechoic room and clinic. Hence, our study has further strengthened the belief that auditory cues do not improve spatial awareness.[5]

An unexpected outcome from this study was the mean distance of the displacement among the normal healthy group, which was more than the normal recommended value of <50 cm. Even with the auditory cues in the third setting, the participants continued to stray beyond 50 cm. When compared to other studies, our findings were similar which showed wide variations within the participants.[2],[15],[16] Reason for this variation was not explained.

Although the readings were more than 50 cm, there was a significant reduction in the distance in the sound-treated room and with the metronome. There are two possible reasons for this reduction in the distance. There has been evidence to suggest that changes to movement based on auditory cues may extend to gait. Providing artificial sounds of footsteps may influence people's walking behavior. An example was a tendency for participants to walk more slowly when the footstep sound provided was that of “muddy ground” and for participants to walk faster when the footstep sound provided was that of “iced snow.”[17]

With this knowledge, walking in a carpeted room without shoes will reduce the naturalistic sounds as well as modify the tactile cue made by the impact of marching with footwear in the normal clinic resulting altered marching behavior. A suggestion to improve future studies to eliminate auditory cues as well as tactile cues from a padded floor is to conduct the FST in the clinic with earplugs. This would eliminate the need for a sound-treated room and reduce the variability in tactile cues.

The second reason for the reduction in the distance could be due to the learning effect. A study required the same group of healthy participants to perform FST for 3 days in a row. Day 1, 80% of the group exceeded the normal distance of displacement followed by 63% who exceeded on day 2 and 43% who exceeded on day 3. Bonani who led this study demonstrated two points. First, majority of the normal healthy participants exceeded the normal distance of displacement. The second point was the improvement in the performance of the participants was significant from day 1 to day 3. They attributed it to the learning effect.[2] Our participants too could have become more familiar with the task and may have been more attuned to the perception of movement. However, to reduce the learning effect, 50-step FST was chosen instead of 100 steps. Furthermore, it has been shown that the test–retest reliability is low in 100-step protocol.[2]

Looking at the FST as a clinical test, the performance of a clinical test is determined by its cut point value to maximize its sensitivity and specificity.[18] As there is so much variation among the normal population as well as the environment has so much influence in the results, our suggestion here is to omit the measurement of distance of displacement and focus on the angle of rotation. This will reduce the time taken to conduct the test as well as improve on the true positive yield. In the era where medical costs are escalating, FST is a low-cost, low-technical bedside test which is useful but should be performed in combination with other clinical tests such as Romberg's test, head shake, and head thrust and proceeded with tests such as videonystagmography, rotatory chair, and caloric test if available.[2],[5],[19]

An obvious limitation in our study would be the small number of participants involved in the study. The participants also did not undergo any formal vestibular testing but were screened for any history of ear infections, vestibular disorders, neuromuscular injuries, head injuries, or lower limb surgeries and were excluded if positive.

Previous studies have shown FST to be unreliable in chronically dizzy patients, more so in patients who have already compensated;[19],[20] thus, normal healthy participants were chosen to participate in this study to evaluate the effects of auditory cues. In future, we hope to engage a larger group including patients with acute vestibular deficits to strengthen our findings. A suggestion to modify the methodology would be to wear ear plugs to simulate an anechoic.


  Conclusions Top


FST is a test recommended to be performed in a quiet room with as little stimuli as possible to reduce auditory cues which may act as directional orientation. Our study has shown that performing the test in the standard clinic will not affect the angle of rotation or angle of displacement. Concurrently, we suggest omitting measuring the distance of displacement but to focus on the angle of rotation and angle of displacement in FST as the distance of displacement is not reproducible in our normal sample and is highly susceptible to auditory cues.

Acknowledgment

We would like to thank Ms. Amy Teing for the statistical guidance provided.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Grommes C, Conway D. The stepping test: A step back in history. J Hist Neurosci 2011;20:29-33.  Back to cited text no. 1
    
2.
Bonanni M, Newton R. Test-retest reliability of the Fukuda Stepping Test. Physiother Res Int 1998;3:58-68.  Back to cited text no. 2
    
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Zhong X, Yost WA. Relationship between postural stability and spatial hearing. J Am Acad Audiol 2013;24:782-8.  Back to cited text no. 3
    
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Kanegaonkar RG, Amin K, Clarke M. The contribution of hearing to normal balance. J Laryngol Otol 2012;126:984-8.  Back to cited text no. 4
    
5.
Munnings A, Chisnall B, Oji S, Whittaker M, Kanegaonkar R. Environmental factors that affect the Fukuda stepping test in normal participants. J Laryngol Otol 2015;129:450-3.  Back to cited text no. 5
    
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Martins ES, Bastos VH, de Oliveira Sanchez M, Nunes MK, Orsini M, Ribeiro P. Effects of vestibular rehabilitation in the elderly: A systematic review. Aging Clin Exp Res 2016;28:599-606.  Back to cited text no. 6
    
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Obermann M, Bock E, Sabev N, Lehmann N, Weber R, Gerwig M, et al. Long-term outcome of vertigo and dizziness associated disorders following treatment in specialized tertiary care: The Dizziness and Vertigo Registry (DiVeR) Study. J Neurol 2015;262:2083-91.  Back to cited text no. 7
    
8.
Fukuda T. The stepping test: Two phases of the labyrinthine reflex. Acta Otolaryngol 1959;50:95-108.  Back to cited text no. 8
    
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Unterberger S. New objective registrable vestibular rotation reaction, obtained by standing on the spot. The kick attempt. Arch Ohren Nasen Kehlkopfheilkd 1938;145:273-82.  Back to cited text no. 9
    
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Zhang YB, Wang WQ. Reliability of the Fukuda stepping test to determine the side of vestibular dysfunction. J Int Med Res 2011;39:1432-7.  Back to cited text no. 10
    
11.
Schaffert N, Braun-Janzen T, Mattes K, Thaut MH. A review on the relationship between sound and movement in sports and rehabilitation. Front Psychol 2019;10:244.  Back to cited text no. 11
    
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Stanton TR, Spence C. The influence of auditory cues on bodily and movement perception. Front Psychol 2019;10:3001.  Back to cited text no. 12
    
13.
Kelly JB, Judge PW, Fraser IH. Development of the auditory orientation response in the albino rat (Rattus norvegicus). J Comp Psychol 1987;101:60-6.  Back to cited text no. 13
    
14.
Okuzumi H, Tanaka A, Haishi K, Sasaki T. Effect of tone on directional orientation during stepping in place with eyes closed. Percept Mot Skills 1995;80:719-22.  Back to cited text no. 14
    
15.
Jordan P. Fukuda's stepping test. A preliminary report on reliability. Arch Otolaryngol 1963;77:243-5.  Back to cited text no. 15
    
16.
Zilstorff-Pedersen K, Peitersen E. Vestibulospinal reflexes. Spontaneous alterations in the position of normal persons doing the stepping test. Arch Otolaryngol 1963;77:237-42.  Back to cited text no. 16
    
17.
Bresin R, deWitt A, Papetti S, Civolani M, Fontana F. Expressive sonification of footstep sounds. In: Proceedings of ISon 2010, 3rd Interactive Sonification Workshop. Stockholm; 2010. p. 51-4.  Back to cited text no. 17
    
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Honaker JA, Shepard NT. Performance of Fukuda Stepping Test as a function of the severity of caloric weakness in chronic dizzy patients. J Am Acad Audiol 2012;23:616-22.  Back to cited text no. 18
    
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Honaker JA, Boismier TE, Shepard NP, Shepard NT. Fukuda stepping test: Sensitivity and specificity. J Am Acad Audiol 2009;20:311-4.  Back to cited text no. 19
    
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Reiss M, Reiss G. Further aspects of the asymmetry of the stepping test. Percept Mot Skills 1997;85:1344-6.  Back to cited text no. 20
    


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    Tables

  [Table 1], [Table 2]



 

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