Vestibular Agnosia is linked to abnormal functional brain networks

Activation of the peripheral vestibular apparatus simultaneously elicits a reflex vestibular nystagmus and the vestibular perception of self-motion (vestibular-motion perception) or vertigo. In a newly characterised condition called Vestibular Agnosia found in conditions with disrupted brain network connectivity, e.g. traumatic brain injury (TBI) or neurodegeneration (Parkinson’s Disease), the link between vestibular reflex and perception is uncoupled, such that, peripheral vestibular activation elicits a vestibular ocular reflex nystagmus but without vertigo. Using structural brain imaging in acute traumatic brain injury, we recently linked vestibular agnosia to postural imbalance via disrupted right temporal white-matter circuits (inferior longitudinal fasciculus), however no white-matter tracts were specifically linked to vestibular agnosia. Given the relative difficulty in localizing the neuroanatomical correlates of vestibular-motion perception, and compatible with current theories of human consciousness (viz. the Global Neuronal Workspace Theory), we postulate that vestibular-motion perception (vertigo) is mediated by the coordinated interplay between fronto-parietal circuits linked to whole-brain broadcasting of the vestibular signal of self-motion. We thus used resting state functional MRI (rsfMRI) to map functional brain networks and hence test our postulate of an anterior-posterior cortical network mediating vestibular agnosia. Whole-brain rsfMRI was acquired from 39 prospectively recruited acute TBI patients (and 37 matched controls) with preserved peripheral and reflex vestibular function, along with self-motion perceptual thresholds during passive yaw rotations in the dark, and posturography. Following quality control of the brain imaging, 25 TBI patients’ images were analyzed. We classified 11 TBI patients with vestibular agnosia and 14 without vestibular agnosia based on laboratory testing of self-motion perception. Using independent component analysis, we found altered functional connectivity within posterior (right superior longitudinal fasciculus) and anterior networks (left rostral prefrontal cortex) in vestibular agnosia. Regions of interest analyses showed both inter-hemispheric and intra-hemispheric (left anterior-posterior) network disruption in vestibular agnosia. Assessing the brain regions linked via right inferior longitudinal fasciculus, a tract linked to vestibular agnosia in unbalanced patients (but now controlled for postural imbalance), seed-based analyses showed altered connectivity between higher order visual cortices involved in motion perception and mid-temporal regions. In conclusion, vestibular agnosia in our patient group is mediated by multiple brain network dysfunction, involving primarily left frontal and bilateral posterior networks. Understanding the brain mechanisms of vestibular agnosia provide both an insight into the physiological mechanisms of vestibular perception as well as an opportunity to diagnose and monitor vestibular cognitive deficits in brain disease such as TBI and neurodegeneration linked to imbalance and spatial disorientation.

Correlation between Residual Dizziness and Modified Clinical Test of Sensory Integration and Balance in Patients with Benign Paroxysmal Positional Vertigo

Objectives: This study was performed to investigate the correlation between subjective residual dizziness and objective postural imbalance after successful canalith repositioning procedure (CRP) in benign paroxysmal positional vertigo (BPPV) by using questionnaires and modified Clinical Test of Sensory Integration and Balance (mCTSIB). Methods: A total of 31 patients with BPPV were included prospectively in the study. All included patients were successfully treated after initial CRP and their symptoms and nystagmus disappeared. Two weeks after CRP, all patients were asked to fill out the questionnaire including both Dizziness Handicap Inventory (DHI) and visual analog scale (VAS). We also conducted mCTSIB 2 weeks after CRP. We divided patients into two groups according to VAS: RD (residual dizziness) group, VAS＞0; non-RD group, VAS=0. We compared age, number of CRP, rates associated with three semicircular canals, DHI score and mCTSIB results between two groups. In addition, we analyzed the correlation between DHI score and mCTSIB results. Results: There were no significant differences in age, number of CRP, and rates associated with three semicircular canals between the two groups. RD group showed significantly higher DHI score and abnormal mCTSIB results than the non-RD group (<i>p</i>＜0.05). DHI score and the number of abnormal mCTSIB showed a statistically significant correlation. Conclusions: We demonstrated the correlation between DHI score and mCTSIB after successful CRP for BPPV. It also represents that subjective residual dizziness is correlated with objective postural imbalance even after successful CRP. Therefore, mCTSIB would be a useful test to evaluate both residual dizziness and postural imbalance after CRP in BPPV.

Serious health threats of novel adulterants of the street heroin: a report from India during the COVID-19 pandemic

The COVID-19 pandemic and a consequent nationwide lockdown in India for several weeks had restricted the access to street heroin and treatment for substance abuse. Use of cutting agents to increase the volume or psychoactive effect has been widely practised under such circumstances. Our patient with opioid use disorder chased heroin with an unknown cutting agent to enhance psychoactive effect from the limited quantities of heroin. He suffered from an abrupt onset sedation, weakness, postural imbalance, slurred speech, cognitive dysfunctions and disinhibited behaviour. Symptoms rapidly reversed following abstinence and initiation of buprenorphine–naloxone. Gas chromatography-mass spectrometric analysis of the adulterant revealed high concentrations of benzodiazepines and barbiturates, alongside the usual cutting agents—caffeine and acetaminophen. Abrupt reduction in availability of ‘street drugs’ in conjunction with poor healthcare access can lead to the use of novel adulterants with potentially serious clinical and public health implications.

Use of transcranial direct current stimulation in poststroke postural imbalance

Independent gait following stroke is ultimate goal of rehabilitation. Non-invasive neuromodulation achieving it has never been reported. A 74-year-old woman suffered from subarachnoid haemorrhage, followed by hydrocephalus. Both were treated successfully. Even 1 year after the ictus, ambulation was difficult due to truncal instability with lateropulsion mainly to the left side. Transcranial direct current stimulation (tDCS) was applied to the parietal area (2mA for 20 min/day; anode on left side, cathode on right) for 16 days. The intervention improved her truncal instability and she achieved independent gait. tDCS of the parietal area could be a novel treatment option for gait disturbance due to postural instability following stroke.

A Comparative Study on Efficacy of Ballistic Stretching Versus Modified Hold Relax Technique in Increasing Hamstring Flexibility

In the literature, the terms “flexibility” and “muscle length” are often used synonymously when referring to the ability of muscles to be lengthened to their end range. The flexibility of the hamstring muscle is important in the prevention of injury, muscular and postural imbalance and maintenance of a full range of joint movement optimal musculoskeletal function and enhanced performance in day-to-day activities. To evaluate the comparative effectiveness of modified hold-relax technique and ballistic stretching for increasing hamstring flexibility in football players. To evaluate the comparative effectiveness of modified hold-relax technique and ballistic stretching for increasing hamstring flexibility in football players. This study includes (N=50) subjects with hamstring tightness within the age group of 18-28 years. They were randomly assigned into 2 groups (Group A and B). Group A had 25 (N=25) subjects who are treated with Modified hold- relax stretching, Group B had 25 (N=25) who are treated with ballistic stretching. The subjects were given intervention 3 sessions per week for 4 weeks. ANOVA one way classification was used to compare between and within the groups. Test within the subject of effect is highly significant for both the groups. Each group has p=0.000. Test between the subjects were used to compare between the groups, it showed highly significant p=0.000. But clinically modified hold- relax is superior to ballistic stretching. The findings suggest that modified hold- relax and ballistic stretching both was statistically significant in improving hamstring flexibility. But modified hold- relax technique showed better results compared to ballistic stretching.

POS1284 FASCIAL ULTRASOUND: THE CONTEXT FOR DRY NEEDLING TRIGGER POINTS IN TREATMENT OF MYOFASCIAL PAIN, POSTURAL IMBALANCE

Background:Muscles and fascia are the major source of pain in rheumatic diseases. Dry needling under ultrasound guidance (DN-US) is a crucial therapeutic approach to treat muscle pain [1,2], the definition `myo-fascial` calls for searching trigger points (TrPs) in fascia to improve the treatment effectiveness.Objectives:Aim was to evaluate the relevance of fascial ultrasound for DN-US in myo-fascial pain.Methods:We included 36 patients (21 females, 20-69 years old) with myofascial pain different localisations (low back, limbs, shoulder, neck pain), postural imbalance; did DN-US protocol according to R. Bubnov [1]: trigger points were identified according, fine (28G) steel needle DN-US was applied. Additionally considered fascial structures for detecting areas of abnormalities (hypervascularity, heterogeinity, hypomotility, adhesions) aka `trigger points` and potental nerve compression/irritation and did precise DN-US where appropriate.Results:In all patients movement restored and pain decreaed after muscles DN; in 30 patients additionally we detected and did successful DN-US the major fascial points as follows: thoracolumbar fascia, sacroiliac joint, pelvis ligaments, rotator cuff; potential nerve compressions (e.g., arcade of Frochse, soleus arcade); nerve sheath surrounding nerves (sciatic nerve, brachial plexus) and vessels (thoracic outlet syndrome), smaller fascia, joint capsule thickening. We detected higher rates of motility, improvement postural balance and pain decrease, fewer sessions needed in patients after extensive protocol.Conclusion:Fascia dry needling is accessible and effective method for myo-fascial pain treatment, may provide additional mechanical benefit and help to maintain treatment effect. Affected fascia can be considered as relevant trigger points, specific ultrasound symptoms should be validated.References:[1]Bubnov R Trigger Points Dry Needling Under Ultrasound Guidance for Low Back Pain Therapy. Comparative Study. Annals of the Rheumatic Diseases2015;74:624. http://dx.doi.org/10.1136/annrheumdis-2015-eular.2323[2]Bubnov R, Kalika L, Babenko L. Dynamic ultrasound for multilevel evaluation of motion and posture in lower extremity and spine. Annals of the Rheumatic Diseases 2018;77:1699. http://dx.doi.org/10.1136/annrheumdis-2018-eular.3949Disclosure of Interests:None declared

Plantar Pressure Variations Induced by Experimental Malocclusion—A Pilot Case Series Study

Background: All body systems involved in ensuring a healthy posture (musculoskeletal system, oculomotor, oto-vestibular and occluso-cranial-mandibular) are essential in maintaining postural balance. Research Question: Does experimental malocclusion in subjects in static position determine variations in plantar pressure? Methods: Overall, 31 subjects were included in the study. The plantar pressure was evaluated in five different points: lateral and medial heel, midfoot, 1st and 5th metatarsal area. Using a specially designed splint, an artificial malocclusion was induced on the right hemimandibular arch. The pressure was measured at 0 (T0), 15 (T1) and 30 min (T2) after splint application. Results: The right external plantar sensors recorded statistically significant differences in pressure values after 15 min of splint wear (5th metatarsal area, p = 0.05; midfoot, p = 0.04). Important pressure values were also recorded by the left internal plantar sensors (1st metatarsal, p = 0.01; medial heel, p = 0.006), after 30 min of splint wear. Conclusions: Asymmetrical experimental malocclusion produces early changes in plantar pressure, a proof of compensatory mechanisms induced by secondary postural imbalance.

Relationship between anxiety and static and dynamic balance disorder in subjects with cerebrovascular accident (stroke) diagnosis

Background: Sensory systems are responsible for maintaining balance, being vision, vestibular and somatosensory, and all these systems suffer changes in patients with stroke sequelae and studies bet that anxiety is likely to influence the inability of the subject to use these systems, enhancing the postural imbalance in stroke patients. Objective: To analyze the interference of anxiety on the static and dynamic balance of patients diagnosed with stroke. Methods: Fifteen patients with stroke, aged 40 to 80 years, were assessed using the Hospital Anxiety and Depression Scale, Timed Up and Go test for dynamic balance and the Berg Scale for static balance. Data were tabulated in Excel and analyzed using SPSS - Statistical Package for Social Science (version 20.0). Results: Significant values were found for the correlation between anxiety and balance, in which the results analyzed showed that the balance of patients with stroke can be negatively exacerbated due to the anxiety that affects them. Conclusion: It can be concluded from these results that anxiety can alter the balance of these patients and thus, it is shown the importance of a multidisciplinary treatment from the first moment to leverage the treatment.

Pain characteristics and features of impairment motor pattern in young people suff ering from vertebrogenic lumbosacral pain syndromes

Based on a survey of 99 young people suffering from vertebrogenic lumbosacral pain syndromes in 100 % of patients a impairment of the motor pattern is shown, which is manifested by postural imbalance not only in the muscles of the pelvic girdle, but also in the muscles of the neck, chest and shoulder girdle, as well as a shift in the center of gravity, caused either by asymmetry of the legs with deformation of the body in the frontal plane, or in the sagittal plane, depending on the location of the pain with symmetry of the lower extremities. Key words: vertebrogenic lumbosacral pain syndromes, motor pattern