View source for Epilepsy Case Study: A Queen's University Neuromotor Function Project

== Case Presentation:  ==
A 61 year old South Asian male came into clinic with balance and coordination complaints stemming from a switch in his epilepsy medication. The patient was diagnosed with epilepsy at age 16 after having multiple seizures without a cause. He has been on medications since this diagnosis for the past 45 years and has not had any major issues with seizures since. However, he reports suffering from an acute exacerbation of the seizures approximately 11 months ago, experiencing 4 of them in the span of a few months at this time. This coincided with a period of increased stress in his life, due to challenges at work and in his personal life. As a result of this spike in seizures, he ended up switching medications from the valproic acid he had been taking for decades to a newer drug, lacosamide, in order to try and restabilize his condition. He reports that the seizures have now been nullified, but his balance and coordination have subsequently worsened in response.  

He now states that his ability to walk, get around the city, and function effectively at work, have all been impaired since switching to the new medication. He does not want to change medications again, given that the seizures have been eliminated, but he does hope to improve the aforementioned impairments and get back to participating in his regular daily activities. 

=== Subjective: ===

===== History of Presenting Illness: =====
Mr. Gee was diagnosed with epilepsy at the age of 16 after having multiple seizures from unknown causes. He was successfully able to medically manage his seizures for the past 45 years but recently suffered a spike in the frequency of them approximately 11 months ago.  He experienced 4 seizures within a period of months at this time, leading him to change his anti-seizure medication from valproic acid to lacosamide, a newer drug. This switch was successful at eliminating the seizures, but seemed to trigger a vast array of balance and coordination impairments that have left Mr. Gee quite fearful and apprehensive of movement. He decided to come into our clinic for guidance surrounding these balance issues in particular.  

===== Past Medical History: =====
Patient’s epilepsy had been managed primarily through valproic acid AEDs for the last 45 years and was fairly stable. He reported having only a handful of seizures during that time span that were all quite minor. A key point of note is the fact that he mentioned most of the seizures arose during or following periods of stressful events in his life.

===== Current Interventions: =====
Medically manages his epilepsy with Lacosamide based treatment

Not currently exercising as he is worried about reaggravating his seizures and worried about losing balance/potentially falling

===== Medications: =====
Lacosamide Vimpat 200 mg/day - an Anti Epileptic Drug (AED) used in patients with generalized seizures as a mono-therapy <ref>Hoy S. Lacosamide: [https://link.springer.com/article/10.1007/s40263-018-0523-7 A Review in Focal-Onset Seizures in Patients with Epilepsy]. CNS Drugs. 2018 May;32(5):473–84.</ref>

===== Health Habits: =====
Patient does not smoke and reports drinking alcohol on occasion, approximately 3-4 drinks a week. He reports that his drinking is very tied to his mood, stating that he will drink a lot more whenever his depressive symptoms worsen. He reports not participating in any sports or routine physical activity since switching to the new medication due to the aforementioned issues with his balance that come as a side effect of these drugs <ref>Goldenberg M. [https://pubmed.ncbi.nlm.nih.gov/20689626/ Overview of drugs used for epilepsy and seizures: etiology, diagnosis, and treatment]. P T. 2010 Jul;35(7):392-415.</ref>. He was an avid bowler before switching to the new medication and would like to get some confidence back so that he can resume this activity with his friends.

===== Social History: =====
Mr. Gee works in human resources at a local manufacturing company 5 days per week. His responsibilities were changed 11 months ago to more tedious, repetitive assignments that often have very short-term and strict deadlines. He was expecting a promotion this fiscal year but was just informed that it is not coming due to company-wide restructuring. He has a wife and 2 middle aged children who live minutes away from him. He has a few friends but hasn’t been socializing with them much recently as he is fearful that he may fall and embarrassed of his poor coordination.  

===== Prior Functional History: =====
Patient was very active in his youth, prior to his epilepsy diagnosis. He played competitive soccer from the age 11-16 and would train his body extensively during this time. He was also quite active over the past 45 years while medically managing his epilepsy with valproic acid. He had a high activity tolerance and was able to perform all basic [[Activities of Daily Living|activities of daily living]] (bADLs) and instrumental activities of daily living (iADLs) with ease. He participated in a weekly bowling league with his workplace colleagues over the past 20 years and ended up winning the championship 5 times.  

===== Current Functional History: =====
After switching medications, Mr. Gee reports feeling very clumsy and imbalanced. This led to decreased confidence with activities like driving long distances, climbing stairs, grocery shopping, and bowling which he tends to refrain from in order to avoid embarrassment or hurting himself. As a result, his activity tolerance has decreased substantially due to his overall deconditioning. He is still quite independent but remains partially restricted in iADLs.  

===== Family History: =====
Mr. Gee does not have a family history of epilepsy, however, there have been clinical diagnoses of depression on Mr. Gee’s paternal side, including his father, grandfather and uncle.

=== Co-morbidities: ===
Based off of the information that was gathered from the subjective history, a number of [[The Flag System|yellow flags]] were noted. These findings combined with the fact that depression is a common comorbidity in epilepsy patients, led us to administer the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) <ref name=":0">Friedman E, Kung H, Laowattana S, Kass S, Hrachovy A, Levin S. [https://www.sciencedirect.com/science/article/pii/S1059131109000661 Identifying depression in epilepsy in a busy clinical setting is enhanced with systematic screening. Seizure]. 2009;18(6):429–33.</ref>. The NDDI-E is a questionnaire containing 6-items that is validated for screening epilepsy patients for depression  <ref name=":0" />.  He scored 16/24 which is considered positive for depression. Although we may suspect that Mr. Gee may have depression, he has not been formally diagnosed and this it is not within the scope of physiotherapy to diagnose him. Therefore we may want to refer him to a specialist to gain a more accurate clinical picture (as later discussed in the discussion). 

=== Objective: ===
<u>Observation:</u> patient displays no visible deformities or abnormalities while in static position. Was able to walk into the clinic independently, although at a slightly slowed and controlled cadence combined with an apprehensiveness to movement across uneven surfaces and tight corners. Displayed intact cognition and was able to answer all questions with no issue. Mood was noted to be worth mentioning as the patient seemed quite down and low on energy throughout the assessment. 

<u>AROM:</u> U/E and L/E WNL

<u>[[Muscle Strength Testing|Manual Muscle Testing]]:</u> (only lower extremity)

Scores of 4+/5 bilaterally in hip flexors, extensors, abductors, and adductors 

Scores of 4/5 bilaterally in knee flexors and extensors 

Scores of 4/5 bilaterally in ankle dorsiflexors and plantar flexors

==== Problem List (Based on the [https://www.physio-pedia.com/International_Classification_of_Functioning,_Disability_and_Health_(ICF) ICF Model]): ====
<u>Body structure & function:</u> Patient reports having balance impairments and clumsiness as a result of his switching to his new AED.

<u>Activity Problem:</u> Patient struggles with his ability to walk when he is navigating various "complex" environments.

<u>Participation Problem:</u> Patient's balance impairments are affecting his willingness to participate in social activities like his workplace bowling league
==== Outcome Measures: ====
<u>The Sharpened [[Romberg Test|Romberg]] (SR)</u>

Based on the problem list, Mr. Gee’s most pressing functional issue was his balance. Due to the patient’s age and overall independence, the SR with eyes open will be used to assess static balance as it was used in Fife et al. <ref name=":1">Fife T, Blum D, Fisher R. [https://pubmed.ncbi.nlm.nih.gov/16675199/ Measuring the effects of antiepileptic medications on balance in older people].] Epilepsy Research. 2006;70(2):103–9.</ref> to assess balance in older adults with epilepsy who take AEDs.  

* Initial Findings: Mr. Gee held the Tandem stance for 13 seconds.

<u>[https://www.physio-pedia.com/Activities-Specific_Balance_Confidence_Scale Activities-Specific Balance Confidence (ABC) Scale]</u>

Based on the problem list, Mr. Gee’s main activity based issue is related to his ability to ambulate in various environments, including walking around his house, parking lots, shopping malls and uneven surfaces. To assess this, the ABC Scale will be used, which is a patient reported outcome measure assessing a patient’s confidence in various walking and non-walking based activities and can also serve as a predictor of falls. As highlighted by Camara-Lemarroy et al. <ref>Camara-Lemarroy C, Ortiz-Zacarías D, Peña-Avendaño J, Estrada-Bellmann I, Villarreal-Velázquez H, Díaz-Torres M. [https://pubmed.ncbi.nlm.nih.gov/28033546/ Alterations in balance and mobility in people with epilepsy]. Epilepsy & Behavior. 2017 Jan;66:53–6.</ref> this has been utilized for elderly patients as well as those with epilepsy. 

In the instance of Mr. Gee, however, there aren’t as many activity limitations with specific aspects of gait, but instead a general apprehensiveness of movement which is especially pronounced in various more “complex” contexts, including his house, stairs, across a parking lot, and or uneven surfaces. As such, even though the Tinetti is a well validated measure for this population, it would not accurately highlight Mr. Gee’s activity limitations, thus making it more difficult to create goals and meaningful interventions. 

* The patient completed ABC scale produced a final mean of 54.38% across the 16-item scale. Compared to normative values for elderly adults, any score of lower than 67% indicates a risk of falls that is based on the patient’s own confidence in their ability to navigate various environments <ref>Lajoie Y, Gallagher SP. [https://pubmed.ncbi.nlm.nih.gov/14599700/ Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers]. Arch Gerontol Geriatr. 2004; 38(1): 11-26.</ref>.

{{pdf|Completed ABC Scale.pdf|Abu Gee's Completed ABC Scale}}

<u>Quality of Life in Epilepsy Inventory</u>

Based on the patient's complaint regarding his participation limitations after switching medications, the Quality of Life in Epilepsy Inventory 89 item version (QOLIE-89) was chosen to be administered. This outcome measure is able to assess seizure related worry, health discouragement, medication effects, and work/driving/social functioning with a high degree of validity in epilepsy patients of varied demographic characteristics <ref name=":2">Devinsky O, Vickrey BG, Cramer J, Perrine K, Hermann B, Meador K, et al. [https://pubmed.ncbi.nlm.nih.gov/7588453/ Development of the quality of life in epilepsy inventory]. Epilepsia. 1995;36(11):1089–104.</ref>. This scale has been validated thoroughly in North American epilepsy patients so it will provide a detailed picture of the specific participation related domains our patient is facing impairments within  <ref name=":2" />'''.''' The scale is split into 17 subscales that each correspond to unique health concepts. Each of these subscales is scored from 0-100, with higher scores corresponding to better [https://www.physio-pedia.com/Quality_of_Life?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal quality of life] ratings. An overall score is obtained using a weighted average of the sub-scale scores, and is also in a range between 0-100 with 100 representing a higher quality of life <ref name=":2" />.

* Based on the QOLIE-89 scoring system, our patient scored lowest in the domains of emotion related role limitations (0/100), work/driving/social function (22.3/100), social isolation (20/100), and social support (31.3/100). He also mentioned feeling very socially isolated in the subjective interview, noting that he is particularly upset about not being able to participate in his workplace social bowling league since starting his new medication. We will thus try to tailor our interventions to these specific areas in order to help Mr. Gee regain confidence in his ability to participate in more social situations, such as his cherished workplace bowling league.

{{pdf |AbuGeeQolie89_scored.pdf|AbuGeeQOLIE-89}}

=== Clinical Impression: ===
<u>Diagnosis:</u> After assessing Mr. Gee, we have observed that he has impaired balance, fear of movement, and has yellow flags surrounding social interactions. The impaired balance was indicated from the SR as he held the tandem stance for 13 seconds (normative for his age is 29 seconds). The fear and difficulty with movement was indicated by Abu’s score on the ABC scale, achieving a mean score of 54.38% (<67% indicates risk of falls due to confidence with activities). Finally, the yellow flags surrounding social interaction were not only attributed to the subjective interview but also to the results of the QOLIE-89, specifically the domains of emotion related role limitations, work/driving/social function, social isolation, and social support.

<u>Prognosis:</u> In terms of prognosis, many factors go into play in attempts to determine this. Some supporting factors that may shorten the length of Abu’s rehabilitation include his supportive family, the current stability of his seizures, his meaningful goals, and the fact that he came to physiotherapy for help. Some factors that may lengthen the time needed to achieve his goals include the stressors in his life (work/finances), many of the yellow flags (that are not currently being addressed), and his low intrinsic motivation. With this being said, it is hard to determine a specific prognosis as many of these factors can change day by day, however we believe that within 3 months, Abu Gee should be able to return to his participation in bowling.

=== Intervention: ===
'''<u>Balance</u>''': 

<u>Short-Term Goal: Increase SR time to 17 seconds by the end of the first month of treatment</u> 

Intervention: Following the American College of Sports Medicine (ACSM) (2014) guidelines for balance training in older adults, Mr. Gee will be prescribed static balance exercises that alter his base of support and challenge his balancing abilities without inducing a fall or near fall. As per the [https://allactive.co.uk/wp-content/uploads/2016/04/Balance-exercises-for-older-adults-AllActive-Information-Guide.pdf AllActive Information Guide] <ref name=":3">[https://allactive.co.uk/wp-content/uploads/2016/04/Balance-exercises-for-older-adults-AllActive-Information-Guide.pdf Information guide] - allactive [Internet]. Amacsports Ltd; 2015 [cited 2023 May 11]. Available from: <nowiki>https://allactive.co.uk/wp-content/uploads/2016/04/Balance-exercises-for-older-adults-AllActive-Information-Guide.pdf</nowiki></ref> based on the ACSM (2014) guidelines, the following three exercises will be performed 2-3 times a day, 2-3 days a week, for as long as possible (up to 15 seconds). The support of a chair can also be used if needed. These exercises include: feet apart standing, semi tandem standing, and tandem standing. 

<u>Long-Term Goal: Increase SR time to 25 seconds by the end of 3 month of treatment</u>
[[File:Figure 1 Toe Standing Exercise .png|thumb|'''Figure 1.''' Toe Standing Exercise   <ref name=":3" /> ]]
Intervention: In the case that Mr. Gee has met his short term goal, he should be more than ready to progress his exercises. The next exercises will start to minimize the size of the patient’s base of support by decreasing the amount of contact that his feet have with the ground. These exercises will follow the same parameters as the previous intervention as per AllActive Information Guide  <ref name=":3" /> and are as follows: single-foot standing, toe standing, heel standing.  

In the case of an adverse event such as a fall during any of his exercises, education on the importance of not going to the point of a fall or near fall would be provided and the need for regression of his exercises would be assessed. Next, the patient can start to do his exercises by a more stable surface such as a kitchen counter. Additionally, his kids could be educated on proper guarding during exercise and could come over to Mr. Gee’s house while he exercises to help him in the case that he experiences another fall. 

'''<u>Walking</u>''':  

<u>Short-term goal : Improve patient’s ability to walk in complex environments, as captured by a score of 58% on the ABC scale in 1 month</u>

To address activity limitations in ambulation in various complex environments, Mr. Gee’s intervention program will be focused on ambulation exercises that are aimed at improving his dynamic balance. This intervention will follow the [https://allactive.co.uk/wp-content/uploads/2016/04/Balance-exercises-for-older-adults-AllActive-Information-Guide.pdf All Active Information Guide] <ref name=":3" /> which is based on the ACSM guidelines from 2014. In general, this intervention will require the patient to adhere to the program for 2-3 days per week at an intensity that is highest but does not cause any fall or near-fall states. These exercises will become more difficult as the patient’s base of support (BoS) will be progressively challenged, causing the patient to adjust their positioning such that their centre of gravity (CoG) falls within the BOS, preventing them from falling. This will mimic the type of demands that are placed on Mr. Gee in the activity of walking, specifically within the aforementioned “complex” environments (i.e. walking in a crowded mall, walking on uneven surfaces). Furthermore, practicing these sorts of maneuvers will improve Mr. Gee's confidence in these environments, which will be represented by improvements on the ABC scale.
[[File:Side-step.jpg|thumb|'''Figure 2.''' Sideways Walk Exercise for Dynamic Stability  <ref name=":3" />]]

* Exercise 1 - Sideways walk
* Exercise 2 - Backwards walk
* Exercise 3 - Heel-to-toe-walk - forwards
* Exercise 4 - Heel-to-toe-walk - backwards
* Exercise 5 - Heel walking

<u>Long-term goal : Improve patient’s ability to walk in complex environments, as captures by a score of 70% on the ABC scale in 3 months</u>

* progression of exercises depending on the needs of the patient


''Note: Instructions for exercises mentioned can be found in [https://allactive.co.uk/wp-content/uploads/2016/04/Balance-exercises-for-older-adults-AllActive-Information-Guide.pdf All Active Information Guide]''

<u>Adverse Effects</u>

If Mr. Gee experienced an adverse event, such as a fall, his treatment program would have to be adjusted. Specifically, this can be done by simplifying the given exercises to an earlier progression and continuous patient education. Mr. Gee would have to be reminded of the importance of maintaining a safe intensity to these exercises. 

Based on the ACSM published in 2014, the appropriate intensity of exercise is one where there is no fear/likelihood of falling. As such, we would remind Mr. Gee to pay attention to his level of exertion and any emerging feelings of instability. If Mr. Gee feels like he is becoming unstable and or likely to fall, we would advise him to take a break and resume the exercises/walking after a period of rest. These pointers would also be transferable to his preventing complications in his daily life and improving his confidence in ambulating in “complex” environments.

<u>'''Social Engagement:'''</u>

<u>Short Term Goal: improve QOLIE-89 sub-scale scores by 10 points in the domains of social isolation, social support, and work/driving/social function by the end of 1.5 months of treatment</u> 

Intervention: . 

* Teach him how to ambulate with the walking poles using a 2-point step-through gait pattern
* Teach him how he can use the poles to assist his sit-to-stand

The goal will be to use the gait aid to reduce his balance related worries in order to make him feel more confident about ambulating in a variety of different social situations, thus reducing his fear of movement while also improving his functional mobility.

<u>Long Term Goal: patient will be able to bowl a full game within his workplace bowling league every week without having any balance concerns by the end of 3 months of treatment</u> 

Intervention:  

* Patient education regarding the value of exercise for improving balance and coordination related side effects linked to his new AEDs. 
** Will use empirical research evidence to decrease or eliminate Mr. Gee's fear when it comes to exercise and his ability to perform it due to his current condition<ref>Pimentel J, Tojal R, Morgado J. [https://pubmed.ncbi.nlm.nih.gov/25458104/ Epilepsy and physical exercise]. Seizure. 2015;25:87–94.</ref>,  and to illustrate the beneficial effects exercise can have on depression-related symptoms <ref>Kvam S, Kleppe CL, Nordhus IH, Hovland A. [https://pubmed.ncbi.nlm.nih.gov/27253219/ Exercise as a treatment for depression: A meta-analysis]. Journal of Affective Disorders. 2016;202:67–86.</ref>. 

The overall goal will be to utilize the educative nature of the physiotherapy profession to provide accurate, detailed information to Mr. Gee that will make it easier for him to buy in and carry out the static and dynamic balance training interventions mentioned above. 

<u>Possible challenges:</u>

* possibility of patient getting overwhelmed that may not result to active participation. 
* As someone who has been fearful of movement for nearly a year, the patient may exhibit resistance to activity change.
* re-occurrence of seizure. 
** If this were to happen, we would change the theme of our education to focus more on the general triggers of seizures  and how interventions such as better quality of sleep more exercise, and stress coping mechanisms can help combat them <ref>Alanis-Guevara I, Peña E, Corona T, López-Ayala T, López-Meza E, López-Gómez M. [https://pubmed.ncbi.nlm.nih.gov/16098815/ Sleep disturbances, socioeconomic status, and seizure control as main predictors of quality of life in epilepsy]. Epilepsy & Behavior. 2005;7(3):481–5.</ref> <ref>Pappa A, Kottaras A, Lytras D, Iakovidis P, Tsimerakis AF, Chasapis G. [https://www.medicinepaper.net/archives/2021.v3.i2.B.219 The effect of different physiotherapy approaches on the treatment of epileptic seizures]. International Journal of Advanced Research in Medicine. 2021;3(2):82–4.</ref> <ref>Privitera M, Walters M, Lee I, Polak E, Fleck A, Schwieterman D, et al. [https://einstein.pure.elsevier.com/en/publications/characteristics-of-people-with-self-reported-stress-precipitated--2 Characteristics of people with self-reported stress-precipitated seizures]. Epilepsy & Behavior. 2014;41:74–7.</ref>.

'''<u>Technology-Based Intervention:</u>'''

One innovative technology-mediated tool that may be used to help reduce Mr. Gee’s anxiety and fear of movement would be [[Virtual Reality|virtual reality]] (VR). A scoping review, observing the use of VR to treat anxiety disorders, found that it can be a valuable tool for simulating environments that clients with anxiety disorders have difficulty being in <ref>Donnelly MR, Reinberg R, Ito KL, Saldana D, Neureither M, Schmiesing A, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8742249/ Virtual reality for the treatment of anxiety disorders: A scoping review]. The American Journal of Occupational Therapy. 2021;75(6). doi:10.5014/ajot.2021.046169</ref> . This may provide benefits in terms of enhancing patient outcomes. This suggests that introducing Abu into stressful situations (such as participating in social situations with colleagues or being in a busy mall) could expose him to this environment in a controlled way. This exposure (when graded properly) may provide benefit to Abu when dealing with this in real life. 

=== Discussion: ===

Three health care professionals that Mr. Gee could be referred to are an Occupational Therapist, a Social worker, and a Psychiatrist.

An [https://www.physio-pedia.com/Role_of_Occupational_Therapist_in_a_Rehabilitation_Team Occupational Therapist (OT)] would be able to help Mr. Gee in his care by collaborating to come up with cognitive and organizational tools that can help him return to his functional ADL’s. An OT would be able to support Mr. Gee by gaining a thorough understanding of what is meaningful to him, and ways to gain back confidence in completing tasks outside of his comfort zone (in a safe way). This would help to complement our PT intervention and provide prognostic support. 

A [https://www.physio-pedia.com/Rehabilitation_Team_Members#:~:text=Social%20Worker,-Social%20workers%20work&text=The%20aim%20of%20social%20work,quality%20of%20their%20own%20lives. Social Worker] would help Mr. Gee in his care by helping to address some of the major stressors in his life. This includes his financial troubles and retirement plan. This would help Mr. Gee’s mental health by giving him a better idea of ways to navigate this next stage of his life, managing this extra stress by giving him ways to work through these issues. It would help give Abu better peace of mind and confidence that he can support his family. 

The Psychiatrist would help play a role in better understanding his depressive symptoms and help form a potential diagnosis in regards to this. They would also be able to provide further benefit in finding a well suited treatment to help with Abu’s mental health status. See below for a sample referral to a Psychiatrist for Abu. 

<u>Sample referral to a Psychiatrist:</u>

''Mr. Abu Gee is a 61 year old man came into my clinic with balance and coordination complaints stemming from a switch in his epilepsy medication. The patient was diagnosed with epilepsy at age 16 after having multiple seizures without a cause. 11 months ago, he experienced an acute exacerbation of seizures that coincided with a period of increased stress in his life, due to challenges at work and in his personal life. As a result of this spike in seizures, he ended up switching medications from the valproic acid he had been taking for decades to a newer drug, Lacosamide, in order to try and restabilize his condition.'' 

''Upon further assessment, Mr. Gee reported that he periodically has depressive symptoms that lead to decreased motivation to complete ADL’s and socialize. Along with this, he stated that he has a family history of depression (including his father, grandfather, and uncle). Due to the information gathered in the subjective history that lined up with several yellow flags, we ended up administering the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). He scored 16/24 which can be interpreted as positive for depression.'' 

''I think that it is important you are aware of this information and I believe that Mr. Abu Gee would benefit from your expertise. Feel free to contact me if you would like to chat or need any additional information.''

=== Self Study Questions: ===
1.What is a common comorbidity seen in patients with epilepsy? 

a) Parkinson’s Disease

b)Eating Disorders 

c) Depression 

d)Multiple Sclerosis 

2. In the case that your patient experiences an adverse event such as a fall or near fall while performing prescribed exercises. What change(s) to your treatment plan could you implement as the therapist? 

a)Simplify the exercise 

b)Provide more/sturdier supports for the patient to use as balance aids during their exercises 

c)Educate friends/family on proper guarding techniques and encourage that they help your patient while they perform their home exercise program 

d)All of the above 

3. What is a common side effect of Anti Epileptic Drugs mentioned in this case study?

a)Impaired balance 

b)Acne 

c)Heart palpitations 

d)Trouble swallowing

Correct answers: 

# c)
# d) 
# a) 

=== References: ===
<references />
 [[Category:Queen's University Neuromotor Function Project]]
[[Category:Case Studies]]