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.
Dave Fleming quickly presents his thoughts on this case presentation.
So this is a pretty cool standard case, certainly not for the individual involved in it, but as a practitioner. To get in to work with people who suffer in this kind of way, it’s such a rewarding process to be able to help them. So this presentation sounds very cerebellar in nature. If I wasn’t aware that it was a TBI problem, I would definitely wanna establish if that was the case before we started doing anything. And once again, I wouldn’t do anything with the individual if it was in the acute phase of a concussion.
Moving outside of that, it does appear to be quite cerebellar in nature, specifically very much for the midline or the vermis of the cerebellum. With balance disorders, it’s something I’ve enjoyed kind of working with to date. And one thing I would do is would assess blood pressure bilaterally. I’d have the person move from a seated to a standing position, if we’re looking to see if there’s orthostatic intolerance, which could lead me to possibly looking with the Purkinje cell layers of the cerebellum, which would indicate me to begin rehab really with gait stabilization work while I rotate and tilt the individual toward the side of the predominant lesion, trying to promote what’s called surround inhibition, which would essentially modulate the vestibular input. And my feedback for that would also be going back to the Romberg’s and seeing what the systemic response is to those kind of stimulations.
It’s something that I would do softly, softly and take our time over and have an agreement with the individual that we’re gonna try and work within certain tolerances, and I’m always gonna be sensitive to their feedback on how they’re feeling. The hyperacusis and anxiety suggest maybe there could be some issues with the midbrain, could be some over-firing of the midbrain, if especially there’s a heightened tactile response. That vestibular cerebellum, the vermis cerebellum is really not getting into play its modulatory role. It’s not getting to do what it’s supposed to do in this particular situation.
So I’d want to help the person. I would really wanna fire into that vermis and support it as much as possible so I can start help it modulate the contralateral midbrain to communicate with each cerebral hemisphere, predominantly the contralateral hemisphere, the hypothalamus, and the enteric nervous system ’cause there’s direct reciprocal connections from the cerebellum to the hypothalamus as well as the gut. Once the system is looking a little more stable, I would try to drive the vestibular system and the cortex with combined head angulations and visuomotor drills to fire into that vermis again. I would also include jaw motion and active cranial mobilizations to the same effect. The vestibular system can be impacted via the endocrine system and via the TMJ and the cranial sutures. I would certainly provide complex drills from the proximal joints ipsilaterally to the lesion, again to fire into the midline, and I’d certainly include scapular mobility works or circular scapular mobility work and just contact to the scapula.
The spine and the scapula and the clavicle are neural crest-derived tissues and also develop very closely with the vestibular system. Other joints to consider in this process would be the pelvis and very much associated to the [21:56] ____ spine. The goal of all of that would be to reafferent the specific cerebellar zones that requires the activation to get it to just be able to do its job. At the end of the day, this person is indicating with symptoms that their brain is just not helping them out. And so the beautiful thing about understanding the pathways, and to the limited degree that I do, is that when you fire these things you can just see these dramatic improvements in quality of life, and it can be a wonderful thing to be a part of.
Also, I noted just in the case history here, this is a great example of how a part of the brain classically spoken of with regards to movement, also modulates limbic pathways, also modulates emotional response and process of cognition, and the child’s depression and anxiety was also greatly improved once that brain was brought up to speed, once that frontal cortex and the cerebellum were communicating with each other again. So to summarize on that one, once we’ve really established the level of the lesion, the level of the problem, it’s just providing progressive and careful drills within fatigue levels that can help support the areas of the brain that have been damaged and they’re not doing their job, that that’s essentially through visuomotor. Head angulation in my world, I don’t have access to the cool machinery that gets used these days. But head angulation work, utilizing complex joint motion, lots of gait stabilization work, and even inhibiting certain extents of muscles to reduce feedback into parts of the cerebellum that you don’t want over-firing to allow the site that’s under-firing to come up to speed.
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David Fleming is creator and co founder of the Institute of Applied Movement Neurology or AMN Academy. With a BSc in Holistic Health Sciences and David is currently pursuing MSc and PhD in Integrative medicine with Quantum Physics, as well has completed numerous certifications ranging from Strength and Conditioning, Functional Biomechanics to Functional neurology. Teaching the Applied Movement Neurology system internationally he presents concepts of functional neurology, quantum physics, systems biology and much more to doctors, therapists, trainers and movement specialists alike.