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.
Dr. Emily Splichal quickly presents her thoughts on this case presentation.
So although this patient is presenting with a little bit more vestibular, cerebellar balance issues, this typically would not present into my office but if it would, my goal would be to rule out some sort of peripheral contributor as far as balance dysfunction, gait dysfunction, et cetera. My forte is particularly in peripheral neuropathies and the diagnosis and management of more peripheral neuropathy contributions to balance dysfunction. And the patients that do come in with more of a cerebellar, vestibular, post-stroke, cerebral palsy, Parkinson’s, any sort of CNS-based balance or movement dysfunction, I refer them out to specialists in that area. One thing that was mentioned I believe it was by Dr. Brandon, I’m not correct, is in the assessment technique that’s harnessed that they use because I wanna contribute something to this case here is that I refer to a specialist who uses a Computer Assisted Rehabilitation Environment. It’s called the CAREN System. C-A-R-E-N. And for people who are listening, can check out this assessment tool.
And similar to the other harnessed ones that exist is it is associated with diagnostic, but also rehabilitation potential or capabilities for those patients who do have a little bit more central nervous system type balance dysfunction. They can also be used obviously in post-surgical rehab to get the peripheral nerves firing as well. If I did have a patient who did have a balance dysfunction that was associated with more of a peripheral neuropathy, I would order all of the basic NCV, EMG diagnostic tests, although they’re not specific. So if a patient has decreased reflexes or altered fine points or vibratory protective sensation, I know that an EMG or NCV is going to be abnormal, so I don’t really weigh heavy on those diagnostic tests. With the peripheral neuropathies, what I do want people to think about is that we have both small nerve and large nerve neuropathies, where the small nerve neuropathies are classically the skin on the bottom of the foot.
And those are actually used in quiet stance. So when we do quiet stance, which is typically what a Romberg test is. Testing peripherally is the small nerve. Then that quiet stance is some of the first to go in a lot of our neuropathies. And small nerve diagnostic test is actually done through a biopsy. So you would have to biopsy the skin and then they count the small nerves that are in the skin. For any of my patients who do have neuropathy, I put them all on vitamin supplementation, that increases nerve growth factor. Some of those that I use include alpha lipoic acid, Acetyl-L-carnitine, L-methylfolate, Metanx as an FDA-approved medication for peripheral neuropathies. A lot of these are specialized around diabetic neuropathy, but can be used in other neuropathies as well. Typically, those peripheral neuropathy patients will present with similar balance and gait dysfunction, so I would wanna make sure that I rule that out.
And then, something that I would do in a patient that has a peripheral neuropathy balance dysfunction is to teach them how to recruit their proximal stabilizing neuromuscular system, particularly through the thoracolumbar fascia. And research has shown that the second area after the foot, as far as how the body senses shift in center of gravity and maintains gait and balance is through the proprioceptive reach thoracolumbar fascia. So almost all of the core musculature innervates or inserts into this thoracolumbar fascia, so teaching them proximal strategies is very beneficial to the patient or client that has a peripheral neuropathy balance gait dysfunction. Again, that’s me speaking about how a balance dysfunction would present to me. If it was truly a vestibular, cerebellar dysfunction, particularly in this case, I would refer them out. And the specialist that I do refer them to uses this CAREN System, which is great, because then I’m able to see the data as well and make sure that that patient is being followed up on.
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Dr. Emily Splichal DPM, MS, NASM, NSCA-CPT
Dr Emily Splichal, Podiatrist and Human Movement Specialist, is the Founder of the Evidence Based Fitness Academy and Creator of the Barefoot Training Specialist®, BarefootRx® and BARE® Workout Certifications for health and wellness professionals. With over 15 years in the fitness industry, Dr Splichal has dedicated her medical career towards studying postural alignment and human movement as it relates to foot function and barefoot training.