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Chiropractic Journal of Australia : CJA March 2012
29 Chiropractic Journal of Australia Volume 42 Number 1 March 2012 In addition to ruling out cardiac pathology and seizures, determine if the child is taking any medications, especially any cardiac or blood pressure medications.6 Headache and syncope suggests a central nervous system cause such as arteriovenous malformation, Arnold-chiari malformation or arachnoid cysts.43,44 This presentation warrants referral for CT imaging. Pathological causes of syncope are not common, and the diagnosis is established in most cases by thorough history and examination.6,45 Referral for EEG should be made if brain disorders are possible. Tilt testing is an option, but has varied reports of reliability.46-48 Comprehensive testing can also include glucose, hematocrit and ECG.49 Some authors recommend ECG in all cases who seek attention,4,6 whilst others recommend testing based on the presentation of the patient.45 In this patient described a decision not to refer and to proceed with management was based on (i) previous thorough medical examination; and (ii) absence of history fndings suggesting the need for referral. The author is aware that more thorough examination (as outlined above) could have been conducted, but elected to perform only the most relevant procedures due to the distress of the patient. If referral is not indicated and there are no contraindications, then a trial of chiropractic care is indicated. Short lever, low amplitude, non-rotary manual adjustments, using specifc listings to ensure the most precise correction, is advocated. Other useful management tips relate to aborting the acute syncopic episode. Some research indicates that it is possible to abort an episode by either (i) lying supine, and elevating legs, (ii) whilst sitting, cross the legs, and tense the abdomen and thighs and (iii) squatting (the most effective).1 Other considerations Chiropractic management leading to resolution of neurogenic (vaso-vagal) may be more common than reported. The author was able to fnd only one other case discussing improvement in syncope with chiropractic (an adult patient). Further reports of improvement of cases of syncope may lead to more extensive studies being conducted. Studies are required to determine the percentage of paediatric patients responding to chiropractic care of neurogenic syncope. Opportunities exist for co-operation between the medical profession (medical testing, thus ruling out pathological causes of syncope), and the chiropractic profession (management using specific chiropractic adjustments), thus providing higher levels of study design. CONCLUSION This case report describes signifcant reduction in the clinical episodes of neurogenic (vaso-vagal) syncope in a paediatric patient after chiropractic care. The response may have occurred as a result of interaction between the neuro- spinal elements and the autonomic nervous system. Further studies are required to determine the exact mechanisms of the response. Clinical management strategies are discussed to assist the chiropractor in clinical decision making in the paediatric patient with syncope. ACKNOWLEDGEMENTS I wish to thank Dr Peter Rome for providing assistance with the literature search. In addition, I wish to thank Dr Braden Keil, Dr Paul Chamberlain, Dr Louise Nelson, and Dr Alyson Murray, for providing invaluable critique during the proof reading process. REFERENCES 1. Wieling W, Ganzeboom KS, Saul JP. Refex syncope in children and adolescents. Heart 2004;90:1094-100. 2. Grubb BP, Kanjwal Y, Kosinski D. The postural tachycardia syn- drome: A concise guide to diagnosis and management. J Cardiovasc Electrophysiol 2006;17:108-12. 3. Martin K, Bates G, Whitehouse WP., Transient loss of consciousness and syncope in children and young people: what you need to know. Arch Dis Child Educ Pract Ed 2010;95:66-72. 4. Driscoll DJ, Jacobsen SJ, Porter CJ, Wollan PC. Syncope in children and adolescents. J Am Col Cardiol 1997;29:1039-45. 5. Bo I, Carano N, Agnetti A, Tchana B, Allegri V, Sommi M, et al. Syncope in children and adolescents: a two-year experience at the Department of Paediatrics in Parma. Acta Biomed 2009;80:36-41. 6. Lewis DA, Dhala A. Syncope on the pediatric patient: The cardiolo- gist’s perspective. Pediatric Clinics of North America 1999;46:(2)205- 19. 7. Savage DD, Corwin L, McGee DL, Kannel WB, Wolf PA.. Epide- miologic features of isolated syncope: the Framingham Study. Stroke 1985;16:626-29. 8. Shimizu T, Shimada H, Shirakura K. Scapulohumeral reflex (Shimazu): It’s clinical significance and testing maneuver. Spine;1993:18(15):2182-90. 9. Plaugher G, editor. Textbook of clinical chiropractic. Baltimore (MD): Williams and Wilkins;1993. 10. Herbst RW. Gonstead chiropractic science and art. Mount Horeb (WI): Sci-Chi Publications;1980. 11. Davies NJ. Chiropractic Pediatrics. London: Harcourt;2000. 12. Anrig C, Plaugher G, eds. Pediatric Chiropractic.Baltimore (MD): Williams and Wilkins;1986. 13. Hannah, J., Changes in systolic and diastolic blood pressure for a hypotensive patient receiving upper cervical specifc: A case report. Chiropr J Aust 2009;39:118-21. 14. Ebrall P. W. Ellis W. Transient syncope in chiropractic practice: A case series. Chiropr J Aust 2000;40:82-91. 15. Barrett A. The presentation and management of the syncopal acute low back pain patient in chiropractic practice. Br J Chirop 2000;4(4):61- 4. 16. Bergmann T, Cleveland A, Conley R. Syncope provoked by head movement. JNMS 1998;6:130-7. 17. Díaz JF, Tercedor L, Moreno E, García R, Álvarez M, Sánchez J, et al. Vasovagal syncope in pediatric aptients: A medium-term follow-up analysis. Rev Esp Cardiol 2002;55:487-92. 18. Sumner GL, Rose MS, Koshman ML, Ritchie D, Sheldon RS. Recent history of vasovagal syncope in a young, referral-based population is a stronger predictor of recurrent syncope than lifetime syncope burden. J Cardiovasc Electrophysiol 2010;21:1375-80. 19. Sheldon R, Rose S, Flanagan P, Koshman ML, Killam S. Risk factors for syncope recurrence after a positive tilt-table test in patients with syncope. Circulation 1996;93:973-81. PAEDIATRIC SYNCOPE MANAGEMENT STEWART
CJA June 2012