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.
Stephen King presents his thoughts on this case presentation.
So this probably isn’t something that’s in my area of specialty or something that I’d probably see walking to my clinic and such. But given that it’s an area that I’m probably not as confident with as some others, I’d be making sure as part of the assessment that I check their vital signs, probably did a full cranial nerve examination and neurological examination. And if I had any concerns from that, referring them off to the GP sort of physician and even for some potential imaging before I look to deal with that. Once anything sinister is ruled out, I’d probably be looking at incorporating a multi-disciplinary approach in with this as well. So I’ll be incorporating a psychologist in there and getting a vestibular specialist on board as well. It’s a fair bit to be going through for anyone, I guess, let alone an 11-year-old in this case. So, yes, some help from some of those areas may be beneficial in this case too.
So I’d love to have access to the NeuroCom. Jeff does. I unfortunately not. But I’d probably look at using the stuff that I’ve got available so the pressure plates and the force plates to try and measure the center of pressure and the ability for the patient to be able to control their own body position and using that in conjunction with different types of reaches using our Movement Assessment Tool at the same time to try and get some objective numbers about the area of the sphere of function of the patient basically and how far they can control their own mass and momentum, their own body weight. I’d probably have a look at gait assessment as well if possible and do some visual assessment as well, as well as just a general musculoskeletal assessment in my scope of practice. Then I’d probably look rehabilitation-wise to try and challenge his system and take it a bit above and beyond what they’re able to tolerate. Working within success though. So I think in these cases, as David said, you don’t wanna push them too fast or too far too soon and monitoring their symptoms as you go.
So studies will ask what is successful and letting the success feeds success will hopefully give you a good outcome with this case, making sure that you challenge the progress of the vision and the vestibular system as everyone else has said. I could talk about how I’d go about doing this but I think with some of the other stuff the other guys have said it’s probably not gonna do it justice I think. But I’d also try and consider in this case looking at the principles of neuroplasticity and stuff that may all be important. So given that we’re dealing with an 11-year-old in this case, making sure that the task and the exercises and stuff that you’re doing with this patient is specific to them and they can understand and comprehend it and making sure it’s meaningful to them as well. Making sure that they’re doing it at the right intensity both while they’re in the clinic but at home as well. And plenty of repetitions to try and drive those neuroplastic changes that we want. Again, that Goldilocks theory, not too much, not too little, just that right amount. Trying to find the balance with that.
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Stephen King B.SC, M.H.SC, MPT
Steve has a unique skill set being qualified as a Physiotherapist, Osteopath, personal trainer and strength and conditioning coach. He is currently a director of the Functional Movement Group and co-creator of The M.A.T (Movement Assessment Tool). He has a keen interest in functional performance testing and using objective data, technology and analytics in his practice. Steve is also a current SMA-Victoria board member and performing research with both the University of Queensland and Victoria University in Australia.