{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T06:13:13Z","timestamp":1788415993384,"version":"build-2803163510"},"reference-count":36,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:p>\n                    The functional head impulse test (fHIT) measures what individuals can see during high-acceleration passive head impulses, quantifying the percentage of correctly identified briefly flashed optotypes rather than inferring gaze stabilization from kinematic eye velocity. This paper traces the technological evolution of fHIT from its conceptual origins in dynamic visual acuity testing to its standardized protocol (80-ms presentation at peak head acceleration binned across 1,000\u20137,000\u00b0\/s\n                    <jats:sup>2<\/jats:sup>\n                    ) and leverages clinical data to propose a new conceptual framework for functional vestibular assessment. Accumulated evidence reveals a stark dissociation between video head impulse test (vHIT) kinematic gain and fHIT functional performance, proving that the clinical bottleneck in real-world vestibular impairment is frequently the central capacity to integrate multisensory signals under visual and cognitive demands in real time. In peripheral vestibulopathies, fHIT demonstrates that functional vision depends entirely on the precise temporal clustering of covert saccades within the 80-ms optotype presentation window. In vestibular migraine, fHIT under optokinetic conflict could unmask central sensory re-weighting failures (sensory mismatch) completely missed by kinematic testing. In older people, fHIT performance\u2014unlike vHIT gain\u2014correlates with Tinetti Balance Scores, predicting fall risk with an odds ratio of 3.9, while dual-task studies confirm that concurrent cognitive load selectively degrades fHIT accuracy. Based on these converging dissociations, we propose a novel three-level functional framework that organizes gaze stabilization into peripheral reflex mechanics, saccadic substitution, and central sensory gating. This model establishes that the fHIT could directly probe the higher-level central integrative loop by simultaneously challenging gaze stabilization, visual discrimination, attentional allocation, and short-term memory encoding during unpredictable passive perturbations. This theoretical shift reframes abnormal functional performance alongside normal kinematic gain not as a paradox, but as an indicator of central processing or cognitive resource allocation\/attention deficits, providing a new blueprint for tailoring advanced vestibular rehabilitation.\n                  <\/jats:p>","DOI":"10.3389\/fneur.2026.1913947","type":"journal-article","created":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T05:21:15Z","timestamp":1788412875000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Beyond VOR gain: the functional head impulse test as a probe of multisensory integration and gaze stabilization"],"prefix":"10.3389","volume":"17","author":[{"given":"Stefano","family":"Ramat","sequence":"first","affiliation":[{"name":"Department of Computer, Industrial and Biomedical Engineering, University of Pavia","place":["Pavia, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruna Maria Vittoria","family":"Guerra","sequence":"additional","affiliation":[{"name":"Department of Computer, Industrial and Biomedical Engineering, University of Pavia","place":["Pavia, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Mandal\u00e0","sequence":"additional","affiliation":[{"name":"Department of Medicine, Surgery and Neuroscience, Neurology and Clinical Neurophysiology Section, University of Siena","place":["Siena, Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,3]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"56","DOI":"10.1159\/000490272","article-title":"Video Head Impulse Testing","volume":"82","author":"Welgampola","year":"2019","journal-title":"Adv Otorhinolaryngol"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1001\/archneur.1988.00520310043015","article-title":"A clinical sign of canal paresis","author":"Halmagyi","year":"1988","journal-title":"Arch Neurol"},{"key":"B3","doi-asserted-by":"publisher","first-page":"454","DOI":"10.1212\/01.wnl.0000299117.48935.2e","article-title":"Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades","volume":"70","author":"Weber","year":"2008","journal-title":"Neurology"},{"key":"B4","doi-asserted-by":"publisher","first-page":"602","DOI":"10.1212\/WNL.0000000000005206","article-title":"Recent advances in head impulse test findings in central vestibular disorders","volume":"90","author":"Choi","year":"2018","journal-title":"Neurology"},{"key":"B5","doi-asserted-by":"publisher","first-page":"528","DOI":"10.1002\/ana.410270512","article-title":"Instability of gaze during locomotion in patients with deficient vestibular function","volume":"27","author":"Grossman","year":"1990","journal-title":"AnnNeurol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"979","DOI":"10.3389\/fneur.2018.00979","article-title":"Functional Head Impulse Testing Might Be Useful for Assessing Vestibular Compensation After Unilateral Vestibular Loss","volume":"9","author":"Sj\u00f6gren","year":"2018","journal-title":"Front Neurol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"39","DOI":"10.3389\/fneur.2012.00039","article-title":"A Device for the Functional Evaluation of the VOR in Clinical Settings","volume":"3","author":"Ramat","year":"2012","journal-title":"Front Neurol"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.3109\/00016488709107283","article-title":"The dynamic illegible E-test. A technique for assessing the vestibulo-ocular reflex","author":"Longridge","year":"1987","journal-title":"Acta Otolaryngol"},{"key":"B9","first-page":"790","article-title":"Computerized dynamic visual acuity test in the assessment of vestibular deficits","volume":"19","author":"Herdman","year":"1998","journal-title":"Am J Otol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"1044","DOI":"10.1001\/archotol.128.9.1044","article-title":"Comparison of Head Thrust Test With Head Autorotation Test Reveals That the Vestibulo-ocular Reflex Is Enhanced During Voluntary Head Movements","volume":"128","author":"Della Santina","year":"2002","journal-title":"Arch Otolaryngol Head Neck Surg"},{"key":"B11","doi-asserted-by":"publisher","first-page":"329","DOI":"10.1007\/s10162-006-0047-6","article-title":"Dynamic Visual Acuity during Passive Head Thrusts in Canal Planes","volume":"7","author":"Schubert","year":"2006","journal-title":"J Assoc Res Otolaryngol"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1097\/01.mao.0000244351.42201.a7","article-title":"Gaze stabilization test: a new clinical test of unilateral vestibular dysfunction","author":"Goebel","year":"2007","journal-title":"Otol Neurotol"},{"key":"B13","doi-asserted-by":"publisher","first-page":"686","DOI":"10.1001\/archoto.2010.99","article-title":"A new dynamic visual acuity test to assess peripheral vestibular function","volume":"136","author":"Vital","year":"2010","journal-title":"Archives of Otolaryngology\u2013Head and Neck Surgery"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1109\/IEMBS.2010.5627138","article-title":"A software program for the head impulse testing device (HITD)","author":"Boehler","year":"2010","journal-title":"Conf Proc IEEE Eng Med Biol Soc"},{"key":"B15","doi-asserted-by":"publisher","first-page":"165","DOI":"10.3389\/fneur.2013.00165","article-title":"A New Tool for Investigating the Functional Testing of the VOR","volume":"4","author":"Colagiorgio","year":"2013","journal-title":"Front Neurol"},{"key":"B16","doi-asserted-by":"publisher","first-page":"e110322","DOI":"10.1371\/journal.pone.0110322","article-title":"The effect of vestibulo-ocular reflex deficits and covert saccades on dynamic vision in opioid-induced vestibular dysfunction","volume":"9","author":"Ramaioli","year":"2014","journal-title":"PLoS One"},{"key":"B17","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1007\/s00415-018-8910-z","article-title":"The functional head impulse test: preliminary data","volume":"265","author":"Corallo","year":"2018","journal-title":"J Neurol"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1300651","DOI":"10.3389\/fneur.2023.1300651","article-title":"Evaluation of vestibulo-ocular reflex with functional head impulse test in healthy individuals: normative values","volume":"14","author":"Cengiz","year":"2023","journal-title":"Front Neurol"},{"key":"B19","doi-asserted-by":"publisher","first-page":"436095","DOI":"10.3389\/fneur.2019.00365","article-title":"The Functional Head Impulse Test to Assess Oscillopsia in Bilateral Vestibulopathy","volume":"10","author":"van Dooren","year":"2019","journal-title":"Front Neurol"},{"key":"B20","doi-asserted-by":"publisher","first-page":"241","DOI":"10.1016\/bs.pbr.2019.04.028","article-title":"The functional head impulse test: Comparing gain and percentage of correct answers","volume":"248","author":"Versino","year":"2019","journal-title":"Prog Brain Res"},{"key":"B21","doi-asserted-by":"publisher","first-page":"3787","DOI":"10.21203\/rs.3.rs-449538\/v1","article-title":"The Role of the Functional Head Impulse Test with and without Optokinetic Stimuli in Vestibular Migraine and Acute Unilateral Vestibulopathy: Discovering a Dynamic Visual Dependence","volume":"10","author":"Casani","year":"2021","journal-title":"J Clin Med"},{"key":"B22","doi-asserted-by":"publisher","first-page":"606","DOI":"10.1093\/brain\/awy355","article-title":"Abnormal visuo-vestibular interactions in vestibular migraine: a cross sectional study","volume":"142","author":"Bednarczuk","year":"2019","journal-title":"Brain"},{"key":"B23","doi-asserted-by":"publisher","first-page":"2842","DOI":"10.1007\/s00415-020-09905-1","article-title":"The integration of multisensory motion stimuli is impaired in vestibular migraine patients","volume":"267","author":"Versino","year":"2020","journal-title":"J Neurol"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1007\/s00405-021-06811-8","article-title":"The clinical significance of fHIT in migraine patient without vertigo symptom","author":"Konukseven","year":"2022","journal-title":"Eur Arch Otorhinolaryngol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"812678","DOI":"10.3389\/fneur.2021.812678","article-title":"Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit","volume":"12","author":"Mallampalli","year":"2021","journal-title":"Front Neurol"},{"key":"B26","doi-asserted-by":"publisher","first-page":"123","DOI":"10.3233\/VES-210040","article-title":"The relationship between functional head impulse test and age in healthy individuals","volume":"32","author":"Emekci","year":"2022","journal-title":"J Vestib Res"},{"key":"B27","doi-asserted-by":"publisher","first-page":"964017","DOI":"10.3389\/fneur.2022.964017","article-title":"Risk of falls, vestibular multimodal processing, and multisensory integration decline in the elderly\u2013Predictive role of the functional head impulse test","volume":"13","author":"Politi","year":"2022","journal-title":"Front Neurol"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1159\/000544719","article-title":"Investigation of the Effect of Cognitive Additional Tasks on Functional Head Impulse Test in Healthy Individuals","author":"Sezer","year":"2025","journal-title":"Audiol Neurootol"},{"key":"B29","doi-asserted-by":"publisher","first-page":"887","DOI":"10.3390\/brainsci10110887","article-title":"Vestibular Functioning in Children with Neurodevelopmental Disorders Using the Functional Head Impulse Test","volume":"10","author":"Caldani","year":"2020","journal-title":"Brain Sci"},{"key":"B30","doi-asserted-by":"publisher","first-page":"881","DOI":"10.1111\/coa.14087","article-title":"Role of the functional head impulse test in evaluating vestibulo-ocular reflex abnormalities in individuals with Parkinson's disease","volume":"48","author":"Karababa","year":"2023","journal-title":"Clinical Otolaryngology"},{"key":"B31","doi-asserted-by":"publisher","first-page":"261","DOI":"10.3233\/VES-201626","article-title":"Vestibular semicircular canal function as detected by video Head Impulse Test (vHIT) is essentially unchanged in people with Parkinson's disease compared to healthy controls","volume":"32","author":"Hawkins","year":"2022","journal-title":"J Vestib Res"},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.1159\/000503677","article-title":"Restoring the high-frequency dynamic visual acuity with a vestibular implant prototype in humans","author":"Starkov","year":"2020","journal-title":"Audiol Neurootol"},{"key":"B33","doi-asserted-by":"publisher","first-page":"10","DOI":"10.3389\/fneur.2019.00387","article-title":"Functional Head Impulse Test in Professional Athletes: Sport-Specific Normative Values and Implication for Sport-Related Concussion","author":"Romano","year":"2019","journal-title":"Front Neurol"},{"key":"B34","doi-asserted-by":"publisher","first-page":"2324","DOI":"10.1152\/jn.00864.2016","article-title":"New insights into vestibular-saccade interaction based on covert corrective saccades in patients with unilateral vestibular deficits","volume":"117","author":"Colagiorgio","year":"2017","journal-title":"J Neurophysiol"},{"key":"B35","doi-asserted-by":"publisher","first-page":"445","DOI":"10.1152\/jn.00382.2022","article-title":"Corrective saccades in acute vestibular neuritis: studying the role of prediction with automated passively induced head impulses","volume":"129","author":"Kerkeni","year":"2023","journal-title":"J Neurophysiol"},{"key":"B36","doi-asserted-by":"publisher","first-page":"e0227406","DOI":"10.1371\/journal.pone.0227406","article-title":"Head impulse compensatory saccades: Visual dependence is most evident in bilateral vestibular loss","volume":"15","author":"Pogson","year":"2020","journal-title":"PLoS One"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1913947\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T05:21:16Z","timestamp":1788412876000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1913947\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,3]]},"references-count":36,"alternative-id":["10.3389\/fneur.2026.1913947"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2026.1913947","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,3]]},"article-number":"1913947"}}