Case Presentation: 11 year-old male presents with a history of vasovagal syncope and symptoms of dizziness, nausea, headaches, depression, anxiety, photophobia, and hyperacusis
We are describing 11-year-old male who presents to a functional neurology clinic with a history of vasovagal syncope and symptoms of dizziness, nausea, headaches, depression, anxiety, photophobia, and hyperacusis.
During this examination, the patient demonstrated positive Romberg’s, inability to stand unassisted with pulsivity in all directions with a predominance of leftward retropulsivity. The patient demonstrated decreased left patellar reflex, hyperacusis on the right, saccadic intrusions in leftward and upward as well as saccadic eye movements away from any light stimulus. All aberrant eye movements were confirmed by videonystagmography. The patient participated in a two-week vestibular rehabilitation program that included multi-axis labyrinth and otolithic stimulation paired with specific eye movements and exercises.
Jeff Frame quickly presents his thoughts on this case presentation.
Obviously, in this situation, I have limited background in dealing with these types of individuals. I do work with neurological patients, but in terms of one with vasovagal syncope and at the age that we’re dealing with, just some of the questions and things that I would look at with the individual start off with, obviously just general history, birth, any issues happening with that. Simple things like blood pressure. Do they tend to have low blood pressure? Are there any heart arrhythmias? Really trying to rule out any more serious issues prior to going in and doing some testing and assessment. Simple things like dehydration, low blood sugar, what’s their oxygen saturations? Those types of things in those individuals is what I’d be looking at first before I really started looking into neurological things, which again is a little beyond my scope of knowledge.
But I do understand that when people have syncope, balance, dizziness issues, we have to start to determine the root of the cause. Is it a vestibular thing? Is it a sensory? Is it a visual issue? And really, before we begin to even do some of the assessments, just work on balance and stability issues to help decrease the susceptibility of falling. When I first read this, I didn’t really catch on to the fact that this individual has the inability to stand unassisted, so that’s gonna change my original prognosis here or plan of action.
I was originally thinking about we do have access to a NeuroCom Balance SMART Master System, which is a device that allows us to test and look at many different parameters. Maybe I should talk a little bit more about what it is. It’s basically a device that has a dynamic force plate with rotational capabilities to quantify vertical forces when someone’s standing on it through their feet, to measure their center of mass position, and to measure postural control. It has a dynamic visual surrounding to measure patient’s use of visual info and to maintain balance. So we’re able to start to tap into those different sensory systems to be able to get an understanding of where their root cause of their problem or the trigger for the syncope.
You can also use it to provide assessment and retraining capabilities with visual biofeedback in either a stable or unstable support, and in a static or dynamic environment. Obviously, in this individual, we would have it in a very static environment due to the inability to stand unassisted. There is a harness system that would put them in there, and then slowly assess what their capabilities are. In the beginning, they can be just very simple just standing and look at how much they’re swaying around. There’s also visuals on the screen that allows them to be able to see what they’re doing as they’re on there for that biofeedback. Again, with this individual, based on the eye issues that we’re talking about, I don’t know how well that would work, but again just with the scope of what I have access to, these are things that I would do and have to see what the patient’s able to perform.
But there’s certain tests like an SOT, so Sensory Organization Test. That’s gonna be something that we’re gonna use to look at the three sensory system: The somatosensory, the visual, and the vestibular. And the somatosensory is our ability to look at objects in our external environment through touch and position in proprioception. So again, this individual’s in a surrounding, they have visual, their touch, they can feel the floor moving around. Where are they at in position in their general world surroundings there?
There’s also things like Limits-of-Stability Test, which is gonna allow the individual to displace their center of gravity in the four cardinal planes as well as four diagonal planes. So it’s like a game in a sense that the individual’s trying to move their little avatar onto the screen into different positions and see how well are they able to do that and what compensatory mechanisms are they doing to perform that? Again, giving us more information into understanding where the root of the syncope is coming from. And again, most often, it’s more that vestibular. There’s also tests to look at reaction time. The movement of their center of gravity, the velocity of that movement, directional control. Motor control tests. Again, ability of the automatic motor system to quickly recover following an unexpected external disturbance. So we try to put them in an environment that’s gonna cause them to all of a sudden move backwards and move forward and see how they react to those movements.
And again, those are assessments, but you can also use those tools for retraining. And again, in a safe environment and a harness that’s gonna prevent them from falling and also give them more of a sense of security while they do that, so they’re less likely to compensate. Again, based on just my limited background, those are things that I have access to, and things that I would begin to look at the individual and then pass that information on to folks with more knowledge in those areas and experts in those areas.
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Jeff Frame, MS, ACLS, EMT, USACF, CSCS, SICI, FMS
With an extensive research background, Jeff has obtained credentials from USA Cycling as an Expert Coach and SICI’s Advanced Bike Fit Specialist, Triathlon Fitting, and Custom Bike Fitting certifications. Jeff served as faculty for some of the largest Universities in America, and was instrumental in the development of 2 new biomechanics research labs. Jeff created BioVelo, LLC (a company focused on cycling) consisting of consulting, product development, professional advanced bike fitting, coaching/training, custom orthotics and speaking. During this time he was also recruited by IU Health to develop and implement a clinical gait lab and service line where he still serves as the Coordinator of Motion Analysis.