Sport As A Factor in Improving Visual Spatial Cognitive Deficits in Patients With Hearing Loss And Chronic Vestibular Deficit Part 1

Abstract: 

Hearing loss and chronic vestibular pathologies require brain adaptive mechanisms supported by cross-modal cortical plasticity. They are often accompanied by cognitive deficits. 

The relationship between hearing loss and memory has received much attention. Hearing loss may have a certain negative impact on memory, but this does not mean that hearing loss will completely disable memory. On the contrary, we can take some measures to alleviate the impact of hearing loss on memory.

First, it is very important to treat hearing loss in time. If you feel that your hearing is declining, you should immediately seek professional medical advice. This may include methods such as using hearing aids or undergoing surgery to effectively deal with hearing problems. Doing so can effectively alleviate the impact of hearing loss on memory.

Second, you can consider taking some hearing rehabilitation courses to cultivate and improve your listening skills. This method can help you better understand and process sound information, thereby helping your memory work more efficiently. In addition, participating in activities and social activities can also help you reduce the stress and anxiety caused by hearing loss, which is very beneficial for enhancing memory.

Finally, maintaining a positive attitude is key. Don't regard hearing problems as a burden or a burden but as an opportunity for balance and improvement. Learning some new skills or hobbies and gradually exploring your potential and abilities are all conducive to improving your memory. Remember, hearing loss may bring you some challenges, but you can achieve a better quality of life by actively facing and solving these problems. It can be seen that we need to improve memory, and Cistanche can significantly improve memory because Cistanche is a traditional Chinese medicine with many unique effects, one of which is to improve memory. The effect of Cistanche comes from the various active ingredients it contains, including tannic acid, polysaccharides, flavonoid glycosides, etc. These ingredients can promote brain health in many ways.

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Spatial memory is a cognitive process responsible for recording information about the spatial environment and spatial orientation. Visual-spatial working memory (VSWM) is a kind of short-term working memory that allows spatial information to be temporarily stored and manipulated. It can be conditioned by hearing loss and also well-compensated chronic vestibular deficit. 

Vestibular rehabilitation and hearing aid devices or training can improve the VSWM. We studied 119 subjects suffering from perinatal or congenital hearing loss, compared with 532 healthy subjects and 404 patients with well-compensated chronic vestibular deficit (CVF). 

VSWM was evaluated by the eCorsi test. The subjects suffering from chronic hearing loss and/or unilateral or bilateral vestibular deficit showed a VSWM less efficient than healthy people, but much better than those with CVF, suggesting a better multimodal adaptive strategy, probably favored by a cross-modal plasticity which also provides habitual use of lip reading. 

The sport activity cancels the difference with healthy subjects. It is therefore evident that patients with this type of deficit since childhood should be supported and advised on a sports activity or repeated vestibular stimulation.

Keywords: hearing loss; vestibular deficit; visual-spatial working memory; cognition; Corsi's test.

1. Introduction

Spatial memory is a cognitive process responsible for recording information about the spatial environment and spatial orientation. It enables a person to remember different locations as well as spatial relations between objects and it allows one to remember where an object is about another object. Spatial working memory (SWM) is a kind of short-term working memory (WM) that allows spatial information to be temporarily stored and manipulated. 

It has a limited capacity and is quite vulnerable to interference. It is well known that the dorsolateral prefrontal cortex takes part in SWM thanks to a network, extending across several cortical areas, including the posterior parietal cortex, frontal eye field, supplementary motor area, premotor cortex, anterior cingulate cortex, occipital cortex, hippocampal formation. 

In addition to being closely intertwined with attentional and oculomotor programming, in particular, related to saccadic movements, it has also been shown that SWM involves higher-order cognitive processes, such as executive functioning, at the earliest stages of information processing. 

Thus, depending on strategies elaborated and task demands, the same spatial information may be represented in SWM by different patterns of activation in the brain. This view is consistent with a model of memory arising from the interaction between higher-order cognitive top-down processes governed by the prefrontal cortex and stimulus-specific brain regions. 

Visual attention has a cross-modal influence on activity in this network. The visual-spatial exploration component provides information for the visual-spatial working memory (VSWM). Spatial working memory problems are frequently reported following brain damage within both left and right hemispheres but with the severity often being greater in individuals with right hemisphere lesions. 

The increase in performance with advancing age supports the notion that SWM capacity increases with maturation throughout childhood with an ameliorative effect of education. It declines across the life span even in the absence of disease-related cerebral pathology. Sex differences are often reported in spatial abilities. Until a few years ago, it was widely accepted that men outperformed women on almost all spatial tasks. 

However, some studies show conflicting results, which can be ascribed to the complexity of the variables involved in the visuo-spatial domain, and can be better explained by differences in spatial competencies. Indeed, these differences could reflect the use of different strategies, rather than different competencies, used by the two sexes. 

Hearing loss and chronic vestibular pathologies require adaptive cerebral mechanisms capable of modifying the usual networks, they can interfere between themselves and thus, they are often accompanied by cognitive deficits which become clearer with aging [1–3]. 

In both pathological conditions, the adaptation is supported by a cross-modal cortical plasticity. Cross-modal plasticity refers to the phenomenon when deprivation in one sensory modality (e.g., the auditory modality as in deafness or vestibular deficit) results in the recruitment of cortical resources of the deprived modality by intact sensory modalities (e.g., visual or somatosensory systems) [4–6]. 

In particular, the adaptation to vestibular deficit is considered an important example of this kind of neuronal plasticity. Thanks to wide central connections, the vestibular system is not merely involved in reflexes, but it is also connected to cognitive processes. 

A growing body of literature suggests that it has a substantial impact on cognitive function. These cognitive interactions include memory, attention, mental imagery, body awareness, and social cognition. Emerging research suggests that the vestibular system can be considered a potential window for exploring brain function beyond that of maintenance of balance, and into areas of cognitive, affective, and psychiatric symptomology [7]. 

Cognitive deficits occur frequently among patients with vestibular abnormalities of any type [8]. Behavioral studies in rodents and humans have demonstrated that damage to the vestibular system specifically leads to cognitive deficits in spatial learning and memory, navigation, mental rotation, and mental representation of three-dimensional space, which are not necessarily related to any particular episode of vertigo or dizziness, and therefore these deficits may occur even in patients who are otherwise well-compensated [8–13], especially so for the elderly [14]. 

Neither the side of the lesion nor the duration of the disease influences cognitive performance. SWM deficits are usually not associated with general memory deficits or whole-brain atrophy.

Children with VL show similar cognitive difficulties to adults, in tasks involving dynamic cognitive processes (higher attentional load) than in tasks requiring static cognitive processes such as visual attention tasks [15]. 

In addition, the relationship between peripheral hearing loss and cognition is well documented in previous comprehensive reviews [16,17]. Particularly in mice, even only moderate hearing loss is characterized by progressively poorer performances in spatial working and recognition memories, with more p-tau and lipofuscin in the hippocampus [18,19]. 

It has been speculated that hearing loss was associated with an increased rate of dementia diagnosed before age 60 [20], and that vestibular loss can facilitate mild cognitive impairment and Alzheimer's disease [21]. 

Hearing loss in children leads to various deficiencies, such as impaired language, poorly developed reading and writing skills, difficulties in mnemonic learning, deficit in mathematical reasoning, and an inability to comprehend space and time.

Hearing loss which arises in infancy can be considered a substantial signal of weakness (a non-specific state of vulnerability, a reduced physiological reserve, and a reduced resistance to stress) especially with aging; this leads to a deterioration in memory, perception, attention, and linguistics. 

This condition, especially in children, represents a social isolation risk and a reduced capability to participate in social activities such as sports. Regarding this, it is worth mentioning that in Geneva in 1992, UNESCO (UNESCO, Service des Loisirs, Geneva, Switzerland, 1992) redacted the paper for the children's rights in sport, and in 11 points it underlines that sport is a fundamental right for children and a commitment to exercise helps them to release tension and grow up healthy and fit. 

In particular, the paper underlines that parents must encourage physical exercise due to the notorious psychophysics advantages that cannot be regained at a later age, so parents must not deny children those possibilities. Severe hearing and vestibular deficits are often associated with patients with newborn and infant hearing loss. The balance training proved effective in improving SWM in healthy people [22–24]. 

Vestibular rehabilitation [25] and auditory and cognitive training [26,27] proved effective in improving the SWM, and also in patients suffering from chronic vestibular deficit and hearing loss. Hearing devices (cochlear implants and bone-anchored hearing implants) can improve WM in children with sensorineural hearing loss [5,28]. 

In particular, children with cochlear implants demonstrated better performance in VSWM and short-term memory skills than in auditory working memory and auditory short-term memory skills. 

Significant positive relationships were found between visual working memory and reading outcomes [29]. There is a lack of studies on the possibility that sports can interfere with any cognitive problems connected with simultaneous hearing and vestibular deficits. We therefore considered the possibility of using VSWM to evaluate the ability of sports activity to improve cognitive functions.

2. Methods

Collaborating with the scientific board of Ente Nazionale Sordi (ENS), specifically with the Milan and Reggio Emilia branches, and with the Federazione Sport Sordi Italia (FSSI) we examined 104 deaf individuals, divided into two groups; those over and those under 65 years old. 

The sample (ENS group) was composed of 77 men (74%) and 27 women (26%). The average age was 49 years old (SD 18). Participation was exclusively voluntary. Bilateral hearing loss was always present, severe in 26 individuals (25%) and profound in 78 (75%). Hearing loss was present at birth in 61 cases (58.6%), within the first year in 34 (32.8%), and within 13 years in the remaining 9 (8.6%). 

Hearing loss was hereditary in 41 cases (39.4%). The cause was unknown in 32 (30.8%), post-infective in 31 (29.8%). No individual had a cochlear implant. All the subjects examined communicate using correct sign language and lipreading. 

Only 32 subjects (30.8%) had had vertigo during their lifetime. Of the participants, 73 (70.2%) regularly practiced various sports (FSSI group), 31 (29.8%) never practiced physical activity or practiced irregularly (ENS group). 

An additional group examined was the Italian national deaf female volleyball team (TEAM volleyball group) which won the silver medal at the 2018 Paralympics and the 2019 European Championship. The group is composed of 15 athletes with an average age of 22.7 years old (SD 3.99). In this group the cause of deafness is hereditary in 7 cases (46.7%), unknown in 5 (33.3%), and viral in 3 (20%).

Hearing loss originated at birth in 12 cases (80%), within the first few months in 2 (13.3%), and within 3 years in one case (6.7%). Three athletes had a cochlear implant. Only one athlete had had vertigo. 

Thanks to the translation of sign language, every individual was adequately and preemptively instructed on the tests they would be subject to, for both the methods and the scope of the test. The occurrence of a vestibular deficit was evaluated through the Video Head Impulse Test (v-IHT) [30–32]. 

The patient is sitting and is looking forward, she is asked to keep her eyes fixed on a target positioned on a wall about a meter away. The examiner who is behind the head of the patient, keeping it still, rotates it abruptly and unpredictably towards the left or the right with an amplitude of a maximum of 10–20 degrees for 20 times per side. 

The head and eye movements are recorded by goggles worn by the patient which are equipped with cameras. If the examined labyrinth, and therefore her vestibular-ocular reflex (VOR), is normal, the subject is capable of compensating for the accelerating head movement stimulated by the examiner and of keeping her gaze on the target. 

If the VOR gain is pathological, the eyes lose track of the target during the head's rotational movement as they rotate exactly in the same direction and with the same speed. The pathological subject, different from the normal subject (Figure 1), at the end of the abrupt rotation, will make a corrective rapid ocular movement (known as saccadic) to re-establish the sight on the target. 

In this manner, the vestibular function of both the labyrinths can be precisely evaluated in less than 10 min. A specific software evaluates the presence of saccadic movements and the VOR gain for each labyrinth. The calibration is rapid and simple, with two lasers built into the goggles.

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