Improvements in Cognition, Anxiety, Malaise, Balance stability Scores, and Postural Orthostatic Tachycardic Syndrome in a 21-year-old Female Patient Following Neurological Rehabilitation and Clinical Nutrition Strategies.
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Carrick Institute, United States
Presentation:
A 21-year-old female patient presented with social anxiety, decreased mental clarity with associate brain fog, generalized malaise and postural orthostatic tachycardia syndrome (POTS) not associated with orthostatic intolerance. The history included episodes of pre-syncope and syncope which progressed into episodes of tachycardia with changes in position too quickly. History included a diagnosis of depression with episodes of anxiety (not associated with a diagnosable cyclothymic disorder). A preliminary POTS diagnosis was established via physical examination findings via >30 beats per minute with positional changes including sit-to-stand. Quantifiable and specific testing ordered via tilt table study at 2, 5, and 10-minute intervals and a Quantitative sudomotor axon reflex test (QSART). Both tests produced positive findings indicating a POTS diagnosis.
Findings:
During neurocognitive testing on the C3 Logix program, upon intake, Trails A time was measured at 35.1 seconds while Trails B time was measured at 45.9 seconds. Her initial symptom severity score was 76% based on the associated subjective questionnaire where 0% is no symptoms. A Comprehensive Assessment of Postural Systems (CAPS®) (Pagnacco 2014) was performed assessing the patient's balance and stability, on both a solid and foamed surface, with his eyes opened, eyes closed, and with multiple head positions. Her average balance and stability score on intake was calculated as 75.12%. Tilt table studies observed blood pressure and heart rate (bpm) via ECG are as follows in serial testing: 101/74 to 136/81 (64-100 bpm), 103/76 to 131/83 (71-114 bpm), and 98/73 to 137/81 (81-129 bpm) at 30 degrees within 5 minutes. An additional 30 degrees inclination was added after 10 minutes to 60 degrees total with findings as follows: 116/81 to 137/78 (75-113 bpm), 107/75 to 140/82 (81- 132 bpm), 109/78 to 140/82 (86-134 bpm) over a 30-45 minute duration. Serial testing occurred consecutively over 3 days. The testing duration had a mean of 62 minutes. QSART testing included “sympathetic cholinergic failure due to loss of cholinergic terminals from failure due to abnormal regulation of sympathetic nerve traffic to intact cholinergic terminals” per report. Gastrointestinal pain and severe fatigue after eating a meal that does not resolve for one hour post-prandial were observed and clarified on a 75-80% basis via questionnaire.
Methods:
A 12-day multi-modal neurological rehabilitation program was administered in 12 one-hour treatment sessions (Carrick, 2017). Each session consisted of neurological and vestibular rehabilitation exercises directed towards the cerebellum and vestibulosympathetic integration, somatosensory evoked potentials, tilt table treatment associated with passive integration to gravity and alleviation of active error signaling, orthoptic training, and off-vertical axis rotation (Gdowski 1999) using a multi-axis rotational chair. Based on clinical symptoms indicating alterations in energy production, she was placed on an intermittent fasting diet for a 2 week period with continual fasting for 16 hours in a 24 hour period. She was also placed on multiple nutrient formulas to alleviate nutritional deficiencies. Her 25(OH) vitamin D level measured by immuno-extraction immunoassay was 24 pg/ ml (normal 9–54 pg/ml) while her 1,25(OH)2 vitamin D3 level was 21 pg/ml (normal 30–67 pg/ml). Accordingly, she was referred to her medical doctor and started calcitriol 0.25 mcg orally daily.
Outcomes:
Upon discharge, Trails A time decreased to 29.6 seconds (-15.7%), and Trails B time decreased to 37.3 seconds (-18.7%). Symptom severity score decreased to 16 (-78.9%) where 0 is no symptoms. The average balance and stability score improved resulting in a score of 89.17% (+18.7%). HR both seated and upright was 72-74-67 bpm with blood pressure normalization with a mean of 114/69 at variable inclinations on the tilt table. After 3 months, her 1,25(OH)2 vitamin D3 level on synthetic calcitriol was 43 pg/ml. Gastrointestinal discomfort and fatigue after eating a meal improved 50% over 30 days and 85% after 3 months per a subjective questionnaire.
Conclusions:
The author suggests further investigation into the use of multi-modal neurological and vestibular rehabilitation strategies, tilt table integration of gravity and supplemental clinical nutrition strategies for the treatment of POTS with associated anxiety, and cognitive impairment. The author also suggests further investigation into multi-modal, intensive approaches to improve stability scores, autonomic stress test results, symptom severity scores and multimodal integration associated with proper neurological function.
Acknowledgements
The authors would like to thank and acknowledge Professor Frederick Carrick and his pioneering work in the field of clinical neuroscience. The authors would also like to thank the Carrick Institute for providing the education utilized to create the multi-modal treatments implemented in this case study.
References
1. Carrick FR, Clark JF, Pagnacco G, Antonucci MM, Hankir A, Zaman R, and Oggero E (2017) Head–Eye Vestibular Motion Therapy Affects the Mental and Physical Health of Severe Chronic Postconcussion Patients. Front. Neurol. 8:414. doi: 10.3389/fneur.2017.00414
2. Gdowski GT, McCrea RA. Integration of vestibular and head movement signals in the vestibular nuclei during whole-body rotation. J Neurophysiol (1999) 82:436–49
3. Pagnacco G, Carrick FR, Wright CH, Oggero E. In-situ verification of accuracy, precision and resolution of force and balance platforms. Biomed Sciences instrumentation (2014) 50:171-8
4. Simon M, Maerlender A, Metzger K, Decoster L, Hollingworth A, McLeod TV. Reliability and Concurrent Validity of Select C3 Logix Test Components. Developmental Neuropsychology (2017) Oct; 0: 1-14. Doi: 10.1080/87565641.2017.1383994.
Keywords:
Postural orthostatic tachycardia syndrome (POTS),
Anxiety,
brain fog,
Fatigue,
malaise,
Gastrointestinal pain,
Vitamin D,
QSART (quantitative sudomotor axon reflex testing),
Tilt table study,
Autonomic abnormalities
Conference:
International Symposium on Clinical Neuroscience, Orlando, United States, 24 May - 26 May, 2019.
Presentation Type:
Poster Presentation
Topic:
Clinical Neuroscience
Citation:
Eason
TD
(2019). Improvements in Cognition, Anxiety, Malaise, Balance stability Scores, and Postural Orthostatic Tachycardic Syndrome in a 21-year-old Female Patient Following Neurological Rehabilitation and Clinical Nutrition Strategies..
Front. Neurol.
Conference Abstract:
International Symposium on Clinical Neuroscience.
doi: 10.3389/conf.fneur.2019.62.00005
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Received:
18 Apr 2019;
Published Online:
27 Sep 2019.
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Correspondence:
Dr. Trevor D Eason, Carrick Institute, Cape Canaveral, United States, drtrevoreason@outlook.com