Neurocardiogenic Syncope

Question:

I am starting a client with Neurocardiogenic Syncope. I did read a lot of information about it, but I was wondering if you knew of any specific exercise protocols?

Answer:

Syncope (fainting) is one of the most common medical ailments encountered in clinical practice. The two main causes of syncope are cardiac arrhythmias and neurocardiogenic (vasovagal, vasodepressor) syndromes. In both of these conditions, blood circulation to the brain is reduced, resulting in temporary loss of consciousness. Among the arrhythmias causing syncope, tachycardias (fast heartbeats), particularly those of ventricular origin, rather than bradycardias (slow heartbeats) are more often the culprits. You need to make certain your client has been diagnosed with Neurocardiogenic Syndrome and does not have syncope due to cardiac arrhythmias (get the physician’s clearance!). In the case of arrythmias, your client will likely need a medically supervised program and will not be cleared for a regular training environment.

In most patients with any evidence of previously known heart disease, it is likely that their syncope is related to a cardiac arrhythmia, usually ventrical tachycardia (VT). All cardiac arrhythmias can be effectively controlled if proper diagnosis is made with the help of cardiac electrophysiologic studies. In general, if a slow heart beat is the problem, it can be treated with a pacemaker. If rapid beating is discovered, the treatment will vary depending on the nature of the fast rhythm.

In an individual with neurocardiogenic syncope, the reduction of blood return triggers a miscommunication between the heart and the brain. Just when the heart needs to beat faster, the brain sends out a message that the heart rate should be slowed down and that the blood vessels in the arms and legs should dilate. These actions take even more blood away from the central part of the circulation where it is needed. As a result, the individual feels lightheaded or may faint because not enough blood is getting to the brain. Fainting is helpful in that it restores a person to the flat position, removing the pooling effect of gravity on the blood and allowing more blood to return to the heart. Following the lightheadedness or syncope, most individuals feel tired and their mental abilities are somewhat foggy. Neurocardiogenic syncope occurs in predisposed individuals in the following settings:

• After prolonged periods of quiet upright posture (such as standing in line) 
• After being in a warm environment (such as in hot summer weather, a hot crowded room, a hot shower or bath)
• Immediately after exercise
• After emotionally stressful events (having blood drawn, being scared or anxious)
• Some individuals get symptoms soon after eating, when blood flow has shifted to the intestinal circulation during the process of digestion.

Individuals that are prone to neurocardiogenic syncope manifest a spectrum of symptoms ranging from fatigue, vague lightheadedness, recurrent dizziness, near fainting, palpitations, nausea, unexplained sweating, joint or muscle aches and, the most dramatic, "the faint." Some people may only have one or more of these symptoms but never progress to fainting. Prolonged fatigue after a modest amount of physical activity is occasionally seen. This post-exertional fatigue can last 24 to 72 hours and interferes with many daily activities.

Neurocardiogenic syncope is most often treated with a combination of increased salt and water intake in conjunction with drugs that regulate blood pressure. It is important for patients to recognize potential triggers and heed warning signs. Treatment can broadly be divided into two categories.

The first step in treating this problem is to increase fluid intake. We cannot stress this enough. Patients who drink fluids regularly throughout the day seem to do better than those who don't take this task seriously. If low salt intake is an issue, it is recommended to increase in the amount of salt clients to add to their food. For some individuals with mild symptoms, an increased intake of salt and fluids may be all that is needed. Most of those with chronic fatigue syndrome and more severe symptoms require one of several medications in addition to the increased salt and fluid intake. The increased salt and fluid intake continue regardless of which of these medications is added. To be successful, though, the increased salt intake must be accompanied by a sufficient increase in the intake of water and other fluids (minimum of two liters of fluid per day).

Where practical, advise your client to avoid circumstances that might bring on symptoms.

• Shop at non-peak hours to avoid long lines.
• Take shorter showers and baths and aim for a cooler water temperature.
• Avoid saunas, hot tubs and lying on a hot beach.
• Avoid standing still for prolonged periods in hot environments, and on very hot days.
• Flex leg muscles and shift weight when standing still, or better still, walk around.
• Avoid alcohol because it leads to dilation of the veins and arteries, and this can steal blood away from the central circulation.
• Reduce caffeine intake.

Certain postures and physical maneuvers are helpful in raising blood pressure when sitting for a prolonged time, mainly by helping to use contraction of the leg muscles to pump blood back to the heart and by compressing the abdomen to reduce the amount of blood that pools in the intestinal circulation. The helpful maneuvers to suggest to your client include:

• Standing with one's legs crossed
• Squatting
• Standing with one leg on a chair 
• Bending forward from the waist (such as leaning over a shopping cart) 
• Sitting in the knee-chest position 
• Sitting in a low chair 
• Leaning forward with hands on the knees when sitting 
• Elevate the head of the bed slightly by 10 to 15 degrees, a position that appears to help the body retain fluid at night rather than lose fluid into the urine.
• Waist-high support hose can prevent some of the excessive pooling of blood in the legs (knee-high support socks may not work as well).

Exercise is important in regaining the effects that fitness brings in counteracting neurocardiogenic syncope. Because exercise can initially make symptoms worse, it must be done carefully at first. Some common sense things to consider for exercise include:

• Make certain that you have a physician’s clearance.
• Focus on a well rounded program of endurance, strength and flexibility that is based on the person’s beginning ability, just as you would any client.
• For endurance exercise, consider a recumbent bike (seated exercise) in case of dizziness. 
• For strength training, consider using exercise machines (seated and supported) instead of free weights or body weight. 
• Avoid exercise at extreme temperatures, especially heat.
• Recommend indoor exercise in a controlled environment. 
• Advise your client to wear waist high support hose under work out clothes.
• Make sure clients avoid steam rooms, saunas and heated therapy pools. 
• Carefully watch the client’s hydration level before, during and after training.
• Suggest a sports drink that replaces (contains) sodium.
• Avoid exercises that could put your client at risk of a fall if dizziness or fainting occur (balance balls, free weights, “standing” cardio machines). 
• Provide a good warm up to get the blood moving.
• Provide an extended cool down and don’t let the client rush away until heart rate has returned to normal and the body has had time to adjust after exercise.
• If your client has a dizzy or fainting episode during training, immediately have him or her lie flat on the floor until it passes.
• Watch for fatigue and stop if the client is more tired than usual.
• Be aware of the possibility of extreme fatigue during or after even a mild or moderate exercise session.
• Educate your client about the benefits of exercise for his/her condition as well as other chronic diseases. 
• Do not leave your client unattended until you are certain he or she is ready!
• A circuit training program (to build both strength and endurance) that uses selectorized equipment (with stretching done in between sets) might be a good program to “graduate” the client to after you have gradually worked them into a consistent exercise routine.

References:

1. Comprehensive Cardiovascular Group. “Neurocardiogenic Syncope.” Madison, Wisconsin. http://www.hrtcare.com/neurosyn.asp