INTRODUCTION: When an aircraft banks pilots will reflexively tilt their heads in the opposite direction, known as the optokinetic cervical reflex (OKCR). This is elicited by the appearance of the horizon and is an attempt to keep the moving horizon stable on the pilots retina to help maintain spatial orientation. The appearance of the horizon and the visual environment changes at higher altitudes and there is little research studying the effects of this. Our hypothesis was that increasing altitude would alter the visual cues present and decrease the OKCR.METHODS: There were 16 subjects who flew two flights in a flight simulator while their head tilt, aircraft altitude, and angle of aircraft bank were recorded. The flights were at an altitude of under 1500 ft above ground and above 15,000 ft above ground.RESULTS: Aircraft bank caused head tilt in the opposite direction at both altitudes. A two-way ANOVA with Bonferroni post hoc tests showed that 86% of aircraft bank angles from 0 to 90 in either direction had a head tilt that was statistically significantly smaller at high altitude.DISCUSSION: This study shows that there appears to be a difference between the OKCR at low and high altitude. Pilots at higher altitude seem to exhibit a smaller head tilt for the same aircraft bank angle. More research is required to fully understand why there is a decrease in the OKCR at high altitude, as well as the actual consequences of the decreased reflex on pilot orientation.Stewart MA, Pingali S, Newman DG. Increasing altitude and the optokinetic cervical reflex.