Successful Treatment of Vasovagal Syncope Due to Blood-Injury Phobia by Physical Maneuvering

No magic cure!


Topic Area
Medicine
Article Type
Primary Research

Logic / Design


Point of Paper
Very clear
Main Conclusions
Not supported by evidence presented

Reproducibility


Key Procedures
Did not attempt to reproduce

Clarity


Overall Clarity
Very good

Impact


Impact
Doesn't add anything meaningful

Transparency


Funding Sources
Unable to comment
Subject / Patient Consent:
Properly given
Conflicts of Interest
Not aware of any

Details


This paper describes the use of various body positions in order to overcome vasovagal syncope. So, before I begin this review I need to give a bit of background as to why I have been reading this – esp. as I am a molecular microbiologist, not an MD, and medical case studies are usually outside of my wheelhouse! This is a personal subject for me, as I have suffered with vasovagal syncope my entire life. As a young child I was extensively tested for epilepsy – which fortunately came back negative, but I would still continue to faint in many situations (school, church, doctor’s offices, cinemas) – which was very distressing to both myself and people around me. With age I have become an expert at spotting the early symptoms and act by taking myself away from the situation. I also avoid potential trigger situations. This has had an impact on my life – obviously it’s not a huge issue, compared with other conditions people suffer with, but it has meant that I didn’t pursue a medical career, I have to sit on the end of rows in lecture theatres/cinemas/airplanes (for an easy escape if I sense the symptoms), I’ve scared people to near death when I do pass out in front of them, I’ve avoided medical treatment/crowds/horror movies/theme parks (basically anything that sets off the flight or fight response)… and this is all very typical behavior from others who also suffer from this condition.

On top of the vasovagal syncope, I also have panic attacks about the thought of having a vasovagal episode (oh the joys!), and because phobias and the triggers are so irrational both are very hard to treat. Lying down is a must – as that way I don’t have to deal with needing stitches if I do faint (it’s happened before and then the concept of having stitches sets off the reflex once again). One of the only treatment options is desensitization therapy – basically being exposed to the triggers in a safe setting – which has helped me to an extent but not completely. Tensing of the leg and arm muscles is another method which has been suggested to me, and IME this does help, but I am not sure if it’s just in raising my blood pressure (which is the medical explanation) or also as a distraction from over thinking about what is happening and concentrating, instead, on contracting and releasing my muscles. Another is taking drugs such as Xanax prior to doctors’ procedures and numbing affected areas prior to blood draws etc with a numbing cream designed for babies containing lidocaine – which actually works very well (in conjugation with the lying down, desensitization and Xanax) so I don’t start going into involuntary shock from the feel of the needle piercing my skin, and I can now have blood taken without a full-on panic attack and fainting episode!

However, this requires considerable advance planning, and doesn’t help if I find myself in a situation where I am exposed to a trigger unexpectedly. I have had times at the doctors when they say ‘oh we’ll just take a quick blood sample’ and I have to say ‘oh I will need to come back tomorrow for that’, which is embarrassing and also time wasting. Thus my interest in the use of something as simple as different body positions in order to treat this – as that is something that I can do, as needed, just contort myself, throw some shapes, and feel better! The idea of these positions is not new – putting you head between your legs if you feel faint, lying down (I can still pass out flat on my back but at least I don’t end up requiring stitches!), however this paper suggests that vasovagal syncope can be successfully treated by these maneuvers – which, if true, would be the miracle cure I have been looking for.

Case Report

This paper was published in 2006, and I only came across it very recently and by accident. However, they claim to use novel maneuvers as well as high tech methods for the testing of the effectiveness of these maneuvers on a person undergoing syncope. At first I was disappointed that it’s taken me 15 years to find this out, but then I read it.

The work presented is a case report, and is based on the findings from just a single person – so personally I think it is over-reaching to suggest that this would work for everyone, just based on that. We learn that the subject is a 26-year-old male with a ‘history of syncope’ – this history is actually pretty limited IMO, with his first experience occurring at 15 (when he was ‘spanked on his buttocks’ – TMI?), again he had an episode at 21 during a blood draw, and his third was, it would appear quite close to this study, during a dental visit. So let’s think about this – this work is based entirely on the results from one patient, who has experienced this condition a total of three times in 26 years. Obviously there might have been other factors – maybe he has been totally avoiding corporal punishment/doctors/dentists in those 26 years? It is impossible to know, but IMO this is not a huge problem for this guy – I had probably experienced 3 times those episodes before starting primary school at 5. But this is not a competition – I just question if he is the most appropriate patient to use, and if a n=1 is sufficient to make the claims they do.

So they tested the subject’s vitals, his blood pressure was 120 (systolic)/ 80 (diastolic) – which (occurring to Google fits just within the range of ‘normal’) - and he seemed to be pretty normal and healthy otherwise. They used a Transcranial Doppler (TCD) to measure the cerebral blood flow velocity (66 cm/s), peak systolic velocity (97 cm/s), diastolic velocity (37 cm/s), a pulsality index of 0.89, and a pulse of 72 bpm. They then stuck him with a needle and watched what happens – unsurprisingly he started to feel dizzy and at 10s post needle stick (presyncope) his systolic blood pressure was ‘unobtainable’. I am not all that sure what they mean here – that he has no systolic blood pressure? Is that possible and still be alive? I know from my own experiences that syncope results in a sudden drop in blood pressure, so maybe this means they were not able to get a reading with their equipment – it might be below the lower limit, or that they were unable to get a cuff on him. The TCD shows a decreased presyncope cerebral blood flow velocity (46 cm/s, -20cm/s on his previous reading), peak systolic velocity (75 cm/s, -22cm/s), diastolic velocity (19cm/s, -18cm/s), a pulse of 58 bpm (-14bpm) and an increased a pulsality index of 1.19 (+0.3). After 20s post stick the patient was so dizzy that he had to lie down, and the TCD scan is shown in Fig. 1C – however they do not describe the data displayed in the chart, but it is apparent from the comparison with Fig. 1A that something drastic has happened. Based on these finding they diagnose the patient has suffering from vasovagal syncope due to a blood-injury phobia.

The patient was then invited back for repeated venipuncture (which from what they describe seems to be for the explicit purpose of initiating syncope but also potentially acts as desensitization therapy – but they do not mention this) and the testing of four different physical maneuvers, which are based on various arm- and leg-tensings, standing, sitting, bending and squatting positions. They present that this time the patient felt faint after 30s and his systolic BP dropped from 120mm Hg to 70); on the next occasion his BP drops only to 80 after 30s and dizziness is felt at 50s; and in the final session there was no decrease in BP or fainting. The patient was then instructed to continue with practicing the maneuvers at home. Then comes the kicker – the patient was also prescribed ‘25-mg alprazolam and 10-mg propranolol twice daily’. Alprazolam is the active ingredient in Xanax (which is the brand name), a powerful benzodiazepine – which ‘is used to treat anxiety and panic disorders’ (WebMD). 25mg is a huge dose – the pills come in 0.25, 0.5, 1 and 2mg – so I feel this this is potentially a typo – and that they actually gave him 0.25mg, twice a day, which is a standard starting dose; WebMD states that the maximal dose if 10mg/day. Propranolol is another drug used for anxiety and belongs to the group of medicines known commonly as ‘beta blockers’. The final line of the Case Report tells that after this treatment the patient was able to undergo a ‘dental procedure without fainting’.

Discussion:

The discussion suggest that this is the ‘first report of TCD findings in a patient with syncope induced by blood-injury phobia’, they continue to discuss the potential use of TCD for management of this condition, list other names for syncope and typical symptoms, and then the available treatment options. They suggest that ‘avoiding the trigger event’ should be included (IMO this is not a ‘treatment’), as well as maintaining a ‘central fluid volume’ (drinking water, e.g. not being dehydrated – which they didn’t explore in their case study but I guess they could extrapolate from the normal BP), and, most importantly, changes in body position. They claim that there ‘is no evidence for the efficacy in drugs preventing syncope, including beta-adrenergic blockers’ – and they quote a reference for this – which does suggest that beta-blockers are not useful. However, despite this they still prescribed their patient propranolol – a beta-blocker! They also prescribed alprazolam, which is not included in the article they reference, and is also not a beta-blocker – but their catch-all sentence that the drugs-don’t-work suggests that there is no use in treating patients with this drug either. They then go on to describe the effects of leg crossing and muscle tensing on the body – in terms of heart rate, BP, and fainting, and suggest that the maneuvers that they described ‘should be recommended for treatment and subsequent prevention of vasovagal syncope due to blook-injury phobia’.   

My take on their data:

As I mentioned at the beginning of this review, I am not a medical doctor, but based on my own experiences with this condition I do feel like I am, at least somewhat, qualified to comment on this work. I read this paper in the hope of finding a magic cure – and, I guess, I should have known better – magic cures do not exist, sadly. As a scientist I know we always feel that case studies, based on a single patient exhibiting atypical symptoms, are often not terribly robust. But I feel here that this is not even that, it is based on a single patient exhibiting typical symptoms.

I feel that the title is very misleading, as is much of the discussion – where they give the impression and advocate so very strongly for the treatment being the result of their physical maneuvers alone. In the abstract the only treatment that is described is the maneuvering, nothing about the anti-anxiety meds or desensitization. The case study details that he is ‘treated’ by the BP rising body positions which the authors are so keen on, but this is in combination with desensitization based on the number of needle-sticks he receives during the course of their study, and the drugs he is prescribed, however these other two ‘treatments’ are very much down-played. In the discussion they discount the effectiveness of drug treatments (despite prescribing their patient this very drugs), and briefly mention desensitization but say that physical body positioning is more effective. Based on my experiences (also an n=1, but if that’s good enough for them, it’s good enough for me) I suggest that it is a combination of all these ‘treatments’ which allow their patient to undergo his dental procedure without fainting. All four of the authors are MDs, and two also are PhDs – I really think they should know better!       

Things I liked:

  • The pics of the TCD data was very interesting; I know from my smart watch that when I am suffering from ‘an episode’ my heart rate drops very quickly and can go down to less than 45bpm, which means I am either in bradycardia or an elite athlete/ninja.
  • Figure 2 is nice and clear.

Things I didn’t like:

  • Being misled, nearly everything presented here is misleading.
  • The error in the dose of alprazolam – 10mg is the max dose/day, but they have written 25mg, twice a day.
  • The lack of acknowledgment to the effects of the desensitization and drug treatments in the treatment of their patient.
  • The purpose of publishing this data, in this way – why are they so insistent on their ‘physical maneuvering’ as being the only effective treatment? They could have presented it, as it was, and still have published this report.


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