Rheumatoid Arthritis and Fibromyalgia

Why Does Fibromyalgia Occur in Rheamatoid Arthritis – a Neurological Perspective

Rheumatoid Arthritis and Fibromyalgia

When working with a large number of patients with chronic pain and illness, you begin to notice patterns in relationship to certain illnesses. One of the more common trends I see today is the association between having an inflammatory illness like rheumatoid arthritis along with widespread body pain like fibromyalgia.

Rhumatoid arthritis and fibromyalgia share some commonalities in that they disproportionately affect women more than men, are associated with flare ups of increased pain intensity, and are chronic illnesses with no cure. Although they are separate and distinct health issues, it seems that if you have an inflammatory illness like rhematoid arthritis, 10-15% of these patients are likely to report the widespread body pain of fibromyalgia. Let’s see if we can break this phenomenon down.

Rheumatoid Arthritis and Inflammatory Illnesses

Rheumatoid arthritis falls into a class of inflammatory disorders where flare ups of inflammation can create damage to joints throughout the body. The pain from these flare ups can be debilitating, and the damage done to the joints can be quite severe when left untreated.

CanStock Photo

Notice the deformity of the thumb and index finger on the right hand. CanStock Photo

The damage to these joints is caused by an autoimmune reaction. Autoimmune disease is a condition where the body’s own defenses inadvertently create harm to the body itself. In the case of rheumatoid arthritis antibodies can build up in the joint spaces and cause other immune cells to create an inflammatory reaction in the area. This is where people can feel the heat, swelling, and pain that is known to occur in flare ups.

Patients with rheumatoid arthritis tend to have arthritic flare ups affect joints like the hands, toes, and neck. However, they are also more prone to wide spread pain in other regions not associated with arthritic breakdown. Why would pain exist in an area that is not associated with inflammation and destruction of the joint?

Chronic Pain: Central  Mechanisms

Pain is an extremely complex phenomenon. We generally think of pain having a direct relationship to tissue damage. When we get a cut, sprain an ankle, or break a bone we expect that pain will occur because of the injury. Therefore it’s not surprising that the pain and destruction from a rheumatoid arthritis attack to be very painful.

However, we also know that pain can occur long after an injury has healed, and even in the absence of injury whatsoever. This is what happens in patients with the widespread pain of fibromyalgia. People with fibromyalgia often have nothing to point to as a cause of their pain. It’s an enigma that makes chronic pain syndromes so frustrating because they have no test or image to prove why they feel so poorly.

Many suspect that this widespread body pain may be from dysfunction at the level of the central nervous system. In normal circumstances, the brain has a few ways of controlling how much pain it will feel.  This ensures that our bodies don’t overreact to normal everyday stimuli and interpret as painful.

One mechanism is by pain inhibition. Pain inhibition involves the brain using it’s own pharmacy of pain killing chemicals to stop a pain signal from going up the spinal cord.

Pain can be inhibited by chemical pathways inherent in the brain.

Studies on patients with rheumatoid arthritis have shown that the brain’s ability to inhibit pain becomes compromised leading to an increase in pain with normal stimulation. [Source]

Pain Inhibition broken

When your brain has difficulty inhibiting pain, then you begin to feel it in places where there’s no injury

Another way that the brain can modulate pain is through a concept known as the pain gate. The pain gate operates on the idea that pain has to hit a certain threshold for it to be consciously perceived in the brain. In this way, it allows the brain to ignore things that aren’t causing much damage or risk.

In a perfect system, you would only feel pain when you have actually created injury or are under imminent threat of injury. However, this appears to be another mechanism that gets disrupted in chronic pain patients. When people have chronic pain, it probably means that the gate that is meant to block most of your pain is letting everything in.

Pain Gate Theory

 Does Rheumatoid Arthritis Break This System Down?

The main treatment for inflammatory arthritis focuses on managing inflammation. Most patients with this type of arthritis will take a wide variety of anti-inflammatories that cover a wide spectrum. They include drugs that specifically target the inflammation associated with RA like Trexall, immune modifying biologics like Humira, and go all the way down to non-steroidal anti-inflammatories like ibuprofen.

In many of these cases, the inflammatory pain of arthritis is under control by these drugs, yet the widespread body pain persists. We don’t really know how or why these inflammatory disorders can lead to pain sensitization, but studying other acute pain conditions may give us some clues.

Studies done on patients with acute pain from a traumatic injury and post-surgery pain issues. When someone suffers from the pain of a major injury, the neurons associated with the pain response start to fire more frequently to guard against the area of injury. This is only supposed to be a short term response to significant injury, but in some cases these changes become persist through a phenomenon known as plasticity. When these spinal cord neurons stay hypersensitive, it means that a person’s nervous system will become hypersensitive to the pain response. [Source]

While inflammatory arthritis isn’t necessarily an injury in the classic terms, make no mistake that inflammation can create a significant amount of tissue damage when it goes unchecked.

Making Your Nervous System Less Sensitive

If the nervous system can be made more sensitive by persistent pain, can it work in the opposite direction? A lot of the research on pain has been focused on targeting these mechanisms which has lead to a higher usage of opioid medications. The obvious problem is that opioids are highly addictive and has become a major public health issue.

There is a growing need for non-pharmacologic interventions to address these chronic pain issues, and fortunately there are some that can be really effective. In cases of chronic pain, the best approach is one that addresses a person from a mental and physical standpoint rather than chasing after a holy grail treatment.

When you look at the pain gate theory image, you can see that the factors that impact your pain threshold include brain and spinal input which exercise and chiropractic adjustments can play a major role. Things like memories, emotions, expectations, and attention are all factors that can be changed with neuropsychological therapy. Out of that entire list, everything except your genes are modifiable factors.

Our approach to chiropractic is focused on the head and neck, which has been shown in at least one study to improve long term outcomes in patients with fibromyalgia syndrome when combined with exercise and cognitive based therapy. You can read more about that in a previous article below:

Fibromyalgia and the Atlas

Conclusion

At the end of the day, there is no cures for rheumatoid arthritis or fibromyalgia yet. There may not be cures for years to come. However, many people with these illnesses can see their quality of life improve by addressing some of the neurological consequences of the disease.

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Dysautonomia and PCS

Dysautonomia – A possible cause of post-concussion syndrome

Dysautonomia and PCS

With concussion being a dominant topic in sports medicine, we have seen a large spike in research dollars being spent to study the effects of brain injury. Despite our increased knowledge, when someone has concussion symptoms for longer than 30 days, there still isn’t great consensus as to why these people develop persistent symptoms and what is causing it to happen.

The symptoms of post-concussion syndrome (PCS) are what make the illness difficult to understand. The primary symptoms of PCS include:

  • Persistent headache
  • Dizziness
  • Loss of balance
  • Difficulty with concentration/brain fog
  • Nausea
  • Impaired or slow cognitive activity

The symptoms are vague and non-specific. In medicine, there’s a tendency and a desire to have a condition be linked to one very specific piece of anatomy. That way you can treat the diseased organ and cure the illness.

The reality is that a head injury is likely disrupting multiple body parts simultaneously. The higher centers of the brain aren’t the only things that get scrambled during a concussion. A concussion is likely damaging multiple areas in the brain along with the inner ear organs, the neck, the jaw, and the eyes.

Since every head injury is unique in terms of velocity, direction, and magnitude, it means that each person’s head injury is likely to impact their anatomy in individual ways. This is where you can have a lot of variation in how someone with post-concussion syndrome looks symptomatically.

Another struggle is that different body parts can create similar symptoms. An injury to the neck can cause a feeling of vertigo just like an injury to an inner ear organ. An injury to the neck can also cause headaches symptoms just like the eyes or the vessels in the brain.

Some doctors are looking at another potential cause of persistent concussive symptoms called dysautonomia.

Dysautonomia – A Fight Between 2 Super Systems

Dysautonomia is a condition where the brain loses normal control of the internal organ systems of your body. Dysautonomia can show up in organs like the digestive system, bladder, glands, and pupils. Classically, these disorders show up in the cardiovascular system by affecting your heart rate and blood pressure.

Autonomic Nerveous System Chart

The autonomic nervous system is compromised in patients with dysautonomia

The most common disorders linked to dysautonomia are:

  • Multiple sclerosis
  • Fibromyalgia
  • Postural Orthostatic Tachycardia Syndrome (POTS) – an illness characterized by rapid heart beat to 150-200 bpm at rest
  • Neurocardiogenic syncope – a disorder characterized by unpredictable fainting attacks.

When people have these disorders then the broken function of the nervous system causes people to feel dizzy, in a fog, extremely fatigued, light headed, and anxious. When you read those symptoms on paper (or screen) it doesn’t sound like much, but the way those symptoms persist can drive someone mad.

People don’t just have a brain fog, they are scared and frustrated that their brain won’t allow them to focus and accomplish a task.

People don’t just have fatigue, they have an inability to socialize and be effective at work and at home because of exhaustion.

People don’t just have dizziness, they are worried about driving and being in open spaces because their body is betraying them.

People don’t just have a rapid heart beat, they have fear and anxiety that this next attack could put them in the emergency room.

Having dysautonomia whether it’s an illness on it’s own like POTS, or part of another illness like MS can make life much harder and depressing, because treatment for the illness is really limited.

Post-Concussion Syndrome and Dysautonomia

Going back to post-concussion syndrome, we discussed how the illness can be extremely frustrating because doctors and scientists have had a hard time coming to a consensus as to where the symptoms are coming from.

Some doctors and scientists are presenting an interesting theory that cases of post-concussion syndrome may be a manifestation of dysautonomia.

One of the first studies to look at this phenomenon was done in 2016 on young patients with persistent concussion symptoms. The study involved a test called the head-upright table tilt test. You can check out the full study here:

Orthostatic intolerance and autonomic dysfunction in youth with persistent postconcussive symptoms: a head-upright table tilt study

Image credit to Stickman Communications

Image credit to Stickman Communications

This test is used to diagnose feinting conditions but is also a hallmark test for POTS. The study showed that 24 out of 34 PCS patients had findings on the test indicating a form of dysautonomia. 10 Patients had syncope while 14 patients had POTS.

Even more interesting was that when the patients with POTS stopped having PCS symptoms, they also stopped having a reaction to the table tilt test when re-examined.

Another 2016 study showed that patients who have a history of concussion show a decreased ability to modulate their heart rate and blood pressure at rest indicating a loss of autonomic control. This was happening in patients without any overt signs or symptoms of dysautonomia.

Valsalva maneuver unveils central baroreflex dysfunction with altered blood pressure control in persons with a history of mild traumatic brain injury

Then you also have a wide range of studies looking at how concussion can impact your heart rate variability which is an increasingly utilized biomarker for autonomic nervous system activity.

HRV Studies

A dysautonomic theory of post-concussion syndrome can also help explain some of the unusual symptoms that may arise after a head injury. While it’s easy to understand how a PCS patient can have persistent headache and dizziness, there are a lot of people who will have a concussion or whiplash and start developing persistent gut issues and sensitivities to foods. Dysautonomia as a culprit helps to make better sense of this phenomenon.

What Does This Mean for Treatment?

Dysautonomia is a condition that is not well recognized by many physicians and there aren’t many choices for effective treatment options. In dysautonomia, the brain is having a terribly hard time making sense of its environment.

There’s some interesting work going on utilizing balance and vestibular exercises and graded cardiovascular exercise to help the brain recover from injury, but I’ll cover that on another day. Today I want to talk about the veins in your neck.

Dr. Michael Arata is an interventional radiology specialist in Southern California. I heard him speak at a conference in 2015 where he talked about the effect that the veins in your neck could have on your autonomic nervous system. It’s been an interesting and controversial theory that has been tied to illnesses like multiple sclerosis where dysautonomia is a hallmark of the illness. When the large veins in the neck become narrowed or occluded, it can cause abnormal fluid movement in the brain leading to venous reflux, congestion, and neuroinflammation in the brain.

Dr. Arata even published 2 studies that demonstrating that a procedure that uses a balloon to open these veins was able to create changes in the autonomic function of patients with multiple sclerosis including heart rate variability and blood pressure control.

Transvascular autonomic modulation: a modified balloon angioplasty technique for the treatment of autonomic dysfunction in multiple sclerosis patients.

Blood pressure normalization post-jugular venous balloon angioplasty

But that wasn’t the most interesting part of his presentation. During his talk, he talked about the concept of the atlas vertebra creating compression on these vascular structures. He even used an imaging technique called a venogram to show this happening in his patients:

Dr. Arata shows images of a venagram to show how atlas rotation can disrupt the internal jugular vein

Dr. Arata shows images of a venagram to show how atlas rotation can disrupt the internal jugular vein

It’s because of this phenomenon that Dr. Arata actually refers some of his patients for upper cervical correction so that they can influence this part of the autonomic nervous system.

If dysautonomia is a primary symptom generator in PCS patients, then the impact from a potential neurovascular insult like an craniocervical displacement should be considered especially considering the mechanism of injury includes a blunt force to the head.

An Personalized Approach to Post-Concussion Syndrome

Patients with post-concussion syndrome with signs of dysautonomia likely have multiple systems that must be addressed to regain normal functionality. In addition to dysfunction in multiple systems is the idea that each person will have a varying tolerance to different therapies.

In truth, no single therapy is likely to fix someone with persistent post-concussive symptoms and dysautonomia. These patients need to improve their tolerance to exercise with gradual increased load (especially if they’re an athlete). They also need vestibular rehabilitation so that their brain can move the head and eyes normally again. There’s no disputing the necessity and usefulness of those treatment strategies.

However, if we are concerned about the chronic effects of head injury and the ability to improve fluid movement through the brain, then we have to consider the impact that trauma has on the structural alignment of the neck and the neuroinflammatory consequences that these injuries can leave behind.

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Medication Overuse Headaches

Combating Medication Overuse Headaches

Medication Overuse Headaches

Medication overuse headache (MOH) is a very common manifestation of chronic headache patients. It is one of the unique instances where a once effective way of controlling an illness will actually perpetuate the illness further as the body adapts to a chemical intervention. This condition is unique to patients with chronic daily headache disorders and various chronic pain syndromes like fibromyalgia.

The most frustrating part about MOH is that you may do better for a long period of time because of a medication, but as the effectiveness of the medication wanes over time you may actually experience the headache worse than before.

It’s a situation that can cause despair as medications are generally the treatment of choice for all headache conditions. If your body has become resistant to all of the available medications, what can you do next?

Why Is Your Medicine Making Your Head Hurt?

People with chronic headaches will generally have 7-10  headache days per month. For better or for worse, there are a wide variety of medications that can help knock a headache out or prevent them from occurring. It’s not unusual for a chronic headache patient to have  a cocktail of drugs that they have to take on a daily basis.

The problem with a frequent medication regiment in chronic pain conditions is that the cells of your body almost always have an adaptation to to make itself more resistant to the medications’ effects. This can happen even if you’re taking your medications correctly as prescribed by your doctor.

The headache that results from MOH is often called a rebound headache. As the effect of the medication wears off, the headache returns rapidly which can create a need for another dose of medication. In this way it becomes a cycle of struggle as the effects of the medication start to decline faster and the rebound headaches become more persistent. When this occurs, the chronic headache patient can become the chronic daily headache as the headaches will begin to occur greater than 15 days per month. Because of the reliance on these medications, medication overuse headache has become the 3rd most common headache disorder, and the most common cause of migraine-like symptoms.

Research has shown that this can occur regardless of the type of medication you take. It’smost frequently associated with prescription migraine medications, but it has been documented to occur in people taking over-the-counter drugs like ibuprofen. Hard pain meds like oxycontin may be used by headache patients without a doctor’s prescription, and these can tend to accelerate the process to MOH because of the way that opiods sensitize your brain.

You can read more about how pain pills can make your pain worse in this article I wrote last year:

Research: Can Pain Pills Cause More Pain Over Time?

How to Beat Medication Overuse Headaches

The easy answer is to stop taking your medications for a while because….

you can't if you dont

If you don’t understand this meme, then ask someone who is younger than 30. I promise it’s funny.

Unfortunately, biology isn’t that simple, especially if you have chronic pain.  Are there side effects to stopping a daily medication? Will you experience worse pain when you stop taking the drugs? How will you cope with the pain if you can’t take any meds? How long will this take before you can make the meds work again?

Chronic headache patients need effective non-pharmacological methods to deal with the pain of headache physiology.

One specific target for drug-less treatment of headaches is by correcting dysfunctions in the neck.

In many cases, headaches syndromes can be a result of a secondary effect of a shift in at the top of the neck. This is why chronic headache patients are some of my favorite people to see in practice because a gentle correction of the neck  has allowed us to have a very high success rate with chronic headache syndromes.

While addressing the cervical spine may not address the cause of  a medication overuse headache, it may help fix the primary source of a patient’s headache condition so that taking the medication becomes less necessary. The most common comment I get from headache patients is when they tell me that they’re taking less ibuprofen since they started getting their neck better.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

Within 2 weeks of neck corrections with the NUCCA procedure, the vast majority of our headache patients experience relief in either the frequency or intensity of their daily headaches.

Not All Neck Adjustments Involve Cracking

A lot of people are scared about having their neck worked on by a chiropractor. The general portrayal of a neck adjustment by viral Youtube videos can make it seem scary.

While chiropractic adjustments have a tremendous track record for safety, the bottom line is that a lot of people just don’t want their neck cracked because the sound and the motion make them really uneasy. This leads to patients tightening up their neck and bracing which can make a neck manipulation hurt in the hands of a chiropractor that is not skilled.

That’s one of the big reasons why I’ve used the NUCCA procedure throughout my career. The NUCCA procedure involves a very light pressure to correct the neck as opposed to a high velocity manipulation. By using the NUCCA procedure, the doctor is able to measure and control how much force goes into the neck, and if we have corrected the underlying dysfunction. All of this happens without the popping, twisting, or cracking of the spine.

Not all patients with headaches are good candidates for the NUCCA procedure. Only patients with a subtle shift in the top vertebra called the Atlas will benefit from the NUCCA correction. A thorough history and examination will help us determine if the Atlas is causing a problem and if it’s something that can be fixed.

 

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The Anatomy of Vertigo

The Anatomy of Vertigo

the anatomy of vertigo

 

Part III of my Anatomy of… Series. If you want to check out Part I and II, the links are below:

The Anatomy of a Headache

The Anatomy of a Pinched Nerve

Let’s talk about vertigo. Technically a diagnosis of vertigo should be confined to a sensation of spinning or rotation in the absence of movement. However, for purposes of this conversation we will discuss the wide range of vestibular disorders that are often described as dizziness or vertigo.

When people say they are feeling dizzy it usually means that they have a feeling of being in motion without actually being in motion. It could be the feeling of swaying like a boat, feeling drunk or woozy, feeling a sense of fogginess, or even just really light headed.

It’s not unusual for people to feel these sensations periodically after having too much to drink or after a wild ride on a roller coaster. However, if you have these sensations chronically without a precipitating event, then you likely have chronic vestibular dysfunction.

Chronic vestibular dysfunction is challenging to diagnose and treat. It can be a secondary effect of a different diseases like multiple sclerosis or it can be a primary vestibular disorder like positional vertigo. Either way, these conditions can be related to the following pieces of anatomy:

 

The Semicircular Canals

When it comes to a true sense of vertigo where you or the world appear to be spinning, then the most likely culprit are these tiny little tubes in your inner ear called the semicircular canals.

The semicircular canals are inner ear organs that tell us what direction our head is moving

The semicircular canals are inner ear organs that tell us what direction our head is rotating.

These tiny little tubes in your ears are roughly oriented into in the main directions of movement of your head. When you bend your head forward or backward, turn, or bend to the side these little tubes give powerful signals to the brain to let you know where your head is moving in space.

These canals are lined with tiny hair cells called cilia which are your receptors for balance. The canals are also filled with a fluid called endolymph. When your head moves, this fluid moves inside the canals and stimulates these hair cells.

These organs are almost hard wired to movement of your eyes, so that when you move your head in one direction, your eyes reflexively move the opposite way.

What Can Go Wrong?

The most common problem to affect these canals is called benign paroxysmal positional vertigo (BPPV). In this condition, little tiny crystals in the otolith get dislodged and jump around in the semicircular canals. These crystals will move the hair cells in the canal causing them to fire without the appropriate head movement.

When that happens, your inner ear is firing like your head is moving in one direction when it is not actually moving. This causes a sensory mismatch in which the canals almost always win. Therefore your ears tell your brain your head is moving, and your eyes will start moving inappropriately to match it, and now the world is perceived as spinning.

The Otolithic Organs

The otoliths are a pair of small swellings in the inner ear called the utricle and the saccule. Like the semicircular canals, they are lined with small hair cells that become stimulated by the movement of fluid and crystals as the head moves. For ease of understanding, the utricle is a more horizontal structure and detects side to side motion of the head, while the saccule is more vertically oriented and detects up-down movements.

These play a huge role in the brain’s perception of gravity. As a chiropractor, this plays a huge role in what we do. One of the first signs of a problem in these little organs is the presence of head tilt. Over time, this head tilt can start causing neck pain and headache.

The otoliths monitor straight motion of the head and neck

The otoliths monitor straight motion of the head and neck

What Can Go Wrong?

The otolithic organs are not understood as well as the semicircular canals. The crystals that cause BPPV are dislodged from the utricle and they may play a role in otolithic disorders.

When the otoliths are involved, you are less likely to feel the “spinning” type of vertigo, but more likely to have a sense of tipping over, walking off balance, or feeling like you’re rocking on a boat. The otoliths are also likely to be implicated in motion sickness.

This can also lead to abnormal head tilts, blurry vision, neck pain, and headaches. You can read more about that here:

Is Head Tilt Driving Your Brain Crazy

The otoliths are susceptible to toxicity from certain medications and various enviornmental toxins. When substances affect the inner ear, it can cause ringing in the ears and balance disorders. Substances like certain antibiotics, heart medications, aspirin, diuretics, chemotherapy compounds, and more. One of the most common compounds I see that is ototoxic includes neurontin. A common drug used to treat chronic pain and neurological disorders.

The otoliths can also be prone to traumatic head injury, but we’ll get more into that shortly.

The Vestibulocochlear nerve

The vestibulocochlear nerve is a specialized nerve called a cranial nerve. This nerve travels from your inner ear to the brain stem. This nerve is linked to specialized receptors that transmits sound and balance information from the inner ear so that your brain can process it.

Whenever you your otoliths or semicircular canals sense movement, the hair cells of the inner ear fire and travel down the nerve towards the brainstem for processing.

The vestibular cochlear nerve carries hearing and balance signals from the ear to the brain.

The vestibular cochlear nerve carries hearing and balance signals from the ear to the brain.

 What Can Go Wrong?

Because this nerve transmits both sound and balance information, damage to this nerve can compromise both your sense of hearing and balance.

This nerve is susceptible to inner ear infections, tumors, and neurodegeneration. Illnesses that cause labyrinthitis or acoustic neuritis can make you feel dizzy and off balance through the inflammatory response.

The Brainstem

The brain stem is the most primitive part of the brain responsible for most life sustaining processes in the body. It is also home to the cells that form the specialized cranial nerves like the vestibulocochlear nerve we just discussed.

The Brainstem is the most primitive part of the brain, but governs most of the life sustaining processes for the body.

The Brainstem is the most primitive part of the brain, but governs most of the life sustaining processes for the body.

The brain stem also acts like a central processor of a computer. It takes a lot of the inbound information from the body and filters it down into a signal that the brain will how to use it. This is especially important for your balance system.

A specific area of the brainstem called the vestibular nuclei are responsible for coordinating the signals coming from your eyes and ears. When your head moves, the inner ear sends signals to these brainstem cells which will help move the eyes. This way your head movement and eye movements are purposeful and coordinated.

What can go wrong?

The brainstem can be injured by strokes and traumatic injury. Dizziness is one of the primary symptoms of stroke and concussion because of the way they hit the brainstem. That means your inner ear can be healthy or in tact and your world is spinning and off balance because the part of the brain that is supposed to make sense of all of this is injured.

These patients often struggle worse with their balance symptoms because they don’t play by the same rules as the previous types. The balance issues may be unrelenting or unpredictable because the central control system is compromised. A central cause of vertigo is likely the culprit in cases of migraine associated vertigo.

These cases of vertigo are of central origin and usually require treatment or therapies that are a lot different from those that affect the semicircular canals, otoliths, or vestibular nerves.

The Neck

The neck is a really common but under appreciated cause of vertigo. Because the neck holds our head up, it provides a lot of feedback to the brain about where the head is in space. The contraction of your neck muscles tell your brain if your head is pointing up, down, left, or right. Additionally, your spine is loaded with millions of tiny little sense organs or cells called mechanoreceptors.

These receptors fire in response to the way that muscles and joints are loaded. When they fire, it helps the brain decide on the quality and accuracy of movement

The neck is a common but underappreciated source of vertigo

The neck is a common but underappreciated source of vertigo

What can go wrong?

Injuries, misalignment, or degeneration of the the spine can alter the way these mechanoreceptors fire. If your brain is getting poor or inaccurate feedback from the neck, then it causes a sensory mismatch with the eyes and inner ears. This sensory mismatch is at the core of vertigo and balance disorders.

Many of these cases respond favorably to chiropractic adjustments or other types of manual therapy. In fact, a diagnosis of cervicogenic vertigo is usually based off the fact that vertigo resolved because of a treatment to the neck.

It’s a challenging condition to diagnose because it’s a rare condition where the treatment often dictates the diagnosis.

Don’t Leave Your Doctor’s Office with a diagnosis of vertigo

A lot of people leave a doctor’s office with dizziness and come back with a diagnosis of vertigo. This is an utterly useless diagnosis. They’ve basically taken the fact that you said you have dizziness, and gave it a latin name. You can read more about that here:

Vertigo is NOT a Diagnosis

You have to figure out what anatomy is causing your condition. While vertigo looks and feels similar no matter what anatomy is causing it, the way that it needs to be treated can vary greatly.

Vertigo and balance disorders are tough conditions to treat medically because drugs do a poor job selectively targeting these very different pieces of anatomy. Many of these cases have a mechanical and neurological cause, and can be rehabilitated using mechanical and neurological strategies.

If you see a doctor who is not caught up on current strategies to rehabilitate balance disorders, then you might be leaving a doctor’s office thinking that your balance problem is untreatable.

The first step to addressing vertigo is to identify the anatomical cause, and then getting you to the right professional who is equipped to manage this debilitating condition.

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Is Cardio Useless

Is Cardio Useless? Your Brain Says No

Is Cardio Useless

 

As of the timing of this post, I consider myself primarily a weightlifter when it comes to fitness. If you follow my social media posts on Instagram, Twitter, and Facebook you’ll mainly see photos and videos of squats, snatches, cleans, and other movements that involve heavy barbells.

A popular trend in fitness is to condemn forms of exercise called steady-state cardio, which is your classic endurance exercise like long distance running, rowing, cycling, etc. Critics will say steady-state cardio is ineffective for putting on muscle mass and strength as well as a negligible effect on weight loss so it should be discarded as a form of exercise.

Whenever gym bros start talking about cardio

Whenever gym bros start talking about cardio

All of those things are pretty accurate. Cardiovascular exercise has a marginal effect on strength and hypertrophy, and in the absence of diet no form of exercise really promotes weight loss. But this doesn’t mean that cardiovascular exercise is useless. The effect that cardiovascular exercise has on your brain can be life changing.

Cardio and Neurogenesis

Neurogenesis is a term that scientists use to describe the growth of new neurons. For decades it was a widely held belief that all of the brain cells you are born with are the ones that you will have forever. In more recent years, scientists have identified parts of the brain that do produce new brain cells on a regular basis……just a lot more slowly than something like your skin.

One particular region in the brain that is well known to undergo neurogenesis is called the hippocampus.

This little chunk of brain is one of the few areas that can produce new neurons regularly.

This little chunk of brain is one of the few areas that can produce new neurons regularly.

 

The hippocampus is a piece of our brain that is associated with the formation of memories and in learning. It’s been well established in rat studies that neurogenesis happens in this part of the brain, and exercise enhances this process. [Source] But that’s just a rat study. Does this actually happen in humans?

While we can’t put humans on a treadmill for 30 minutes and cut out their hippocampus, there are studies that imply that neurogenesis happens in humans after cardiovascular exercise too [Source]. These studies have showed that exercise improves memory scores, increases the size of the hippocampus, and produces higher amounts of brain derived neurotrophic factor which is the chemical compound associated with neurogenesis.

That’s pretty amazing stuff! This is the type of stuff that helps to explain why people that exercise regularly have a lower risk of dementia. It also helps us understand how exercise can help combat things like ADHD and other brain related disorders.

Does Weight Training Have the Same Impact?

Scientists who did the study on rat brains found that aerobic exercise had double the amount of neurogenesis as sedentary rats. They also found that rats who did resistance exercise had very little effect on the rat brains, even though the rats got physically stronger. Source

Now we have to take that with a grain of salt because:

  1. Rats aren’t people.
  2. The way that the scientists “strength trained” the rats is by tying a weight on their tails and making them climb with it. Not a terribly good comparison to men and women who voluntarily lift weights recreationally.

The biggest take away from this study is the way that aerobic exercise seems to pump up that brain derived neurotrophic factor which may be a key to making your brain grow and heal.

While the effects of weightlifting on neurogenesis hasn’t been studied yet, there is compelling evidence that suggests weight training is beneficial in people with early stages of memory loss. Resistance training has been shown to improve general cognitive performance ¹, improve blood flow to memory areas of the brain ², and save seniors with memory problems money ³.

All Exercise Is Beneficial

At the end of the day, all kinds of exercise is beneficial for different reasons. We have developed a stronger understanding for how cardio can benefit the brain, and there is data that shows that weight training also gives the brain a boost.

There’s no need to shame someone’s exercise of choice. There are so many people that don’t move at all, that anything that a person can do to be active and move regularly will provide them a substantial benefit.

Now if you’re a fitness junkie already, then taking a balanced approach and incorporating something you usually avoid is a great recipe to get the maximum benefits of exercise.

If you are someone that lifts weights 4 days a week without fail, then maybe taking a 2 mile run or row would be a great addition to your weekly regiment. If you run daily and never do strength, then you should definitely look into resistance training to supplement your cardiovascular fitness.

Your brain thrives on exposure to new things.  Beyond some nice looking muscles and better heart health,, the biggest benefit of exercise is making your brain better.

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Migraines and Concussions

Why Concussions Hit Migraine Patients Harder

Migraines and Concussions

 

The vast majority of people who suffer concussive injuries will recover without any chronic symptoms. However, about 15% of people who suffer concussions will go on to have post-concussion syndrome, where they will experience headaches, dizziness, and cognitive problems beyond 30 days after an injury. These symptoms can be debilitating, and some people can experience the effects of these head injuries for years later.

A lot of research has been done to identify people who are at higher risk of developing post-concussion syndrome. The most significant risk factor for this is having multiple concussions, but that’s a rather obvious one. The more concussions you’re exposed to, the greater the opportunity to have chronic symptoms. However, research has pointed to one specific risk factor that seems to contribute heavily to post-concussion syndrome in the athletic population. That risk factor? A history of migraine headaches.

Migraines and Concussion: a terrible duet

Post-traumatic headache is one of the hallmark symptoms of post-concussion syndrome. These headaches look a lot like migraines because of the wide range of neurological symptoms that concussions can cause.

It’s no secret that concussions can cause terrible headaches in people, but many people don’t know that having a history of migraine headache is a risk factor for worse outcomes in post-concussion syndrome. ¹ ² ³

This is important for a couple of reasons:

  1. If you know someone with migraines is at a higher risk for post-concussion symptoms we can be better prepared to see appropriate specialists in the event of a concussion.
  2. We have a better understanding for why sports like girls’ soccer are more susceptible to concussive injuries and can be more prone to chronic post-concussion syndrome.
  3. Because understanding the common physiology in migraines and concussion can help us identify effective treatments for one of its most debilitating symptoms.

Migraines, Post-Concussion Syndrome, and the Neck

Treatment for headache symptoms in migraine and post-concussion syndrome are pretty similar. Amitriptyline, propanolol, and topirimate. These medications target receptors in the brain that can become overactive and underactive during a migraine attack.

Most research is focused on finding effective drugs to treat headaches, but this treatment philosophy ignores the fact that the headaches from a migraine or concussion can often stem from dysfunction of the cervical spine.

When the neck is compromised the muscles and nerves that surround the upper neck can become areas of concern for the headache patient. The muscles at the top of the neck transmit information to the brain about where the head is in space.  Studies have shown that these muscles can be tied to chronic headache symptoms. ¹ Some studies have even shown that cutting these muscles can lead to headache relief.¹

You can read more about these troublesome little muscles on a previous article I wrote here:

Is This Small Neck Muscle Driving You Mad?

 

The muscles in the deep part of the neck have been implicated in headache disorderrs

The muscles in the deep part of the neck have been implicated in headache disorderrs

 

Additionally, the nerves in the top of the neck are important transmitters of pain. The C1, C2, and C3 nerve roots in the neck are linked to the trigeminal cervical nucleus which is an important relay center for pain in the head. Branches off the C1 nerve like the suboccipital nerve have been targets for nerve blocks in migraine patients with good success.¹

 

The nerves in the upper neck play a major role in headache physiology

The nerves in the upper neck play a major role in headache physiology

 

These mechanisms are important because research has shown that whiplash and concussions can have a significant impact on these anatomical structures. ¹ ² ³

Concussions Worsen Cervical Spine Problems

So here’s the main issue. Many (but not all) migraine issues can be tied to the neck. More than 80% of the migraine patients that come into our office get a tremendous improvement in the frequency of their migraine attacks just by fixing biomechanical issues in the neck, and there is some research that supports it. ¹

When someone has a biomechanical issue in their neck, then a major blow to the head like a concussion can make these neck problems worse. Several studies are starting to show that there are some interesting similarities with what happens in a whiplash and what happens in a concussion. The fact is that the amount of force that it takes to cause a concussion FAR exceeds the amount of force it takes to create a mild whiplash injury.

Whiplash and Concussion

The force required to sustain a concussion far exceeds the forces necessary to cause a whiplash

Obviously not every force over 5 g’s causes a whiplash and not every force over 100 g’s causes a concussion. Otherwise we’d all be walking around with with severe neck injuries every time we got off a roller coaster. There are factors involved like neck strength, timing of muscle bracing, and previous injuries that affect our susceptibility to these forces.

My point is that if you have sustained a concussion, then the probability of you also suffering an injury to the neck is really really high.

If you were a migraine patient before the concussion and the migraine was stemming from your neck, then the odds of that neck injury becoming worse and making the healing process after a concussion is much higher for you than most others.

If you had a small biomechanical issue in your neck that was contributing to your migraine headache symptoms, then the force of a concussion is going to injure the ligaments and muscles that were already compromised! This is addition to the way that concussions knock out your vestibular and ocular systems which are also known contributors to headache physiology.

Addressing the Neck

So what does this mean for you?

  1. If you are an athlete and have a migraine headache problem, you should get your neck checked and rule out any biomechanical problems in the upper cervical spine. Fixing these issues will likely address your migraines, and may provide some protection from head contact.This is even more true for female athletes than male athletes. Women suffer from migraine headache issues at a much higher rate than men, and this can be a contributing factor to the increased rates of concussion we see in girls’ soccer.
  2. If you play contact sports, getting your neck stronger may provide protection from concussive injury. Again, this applies even more so to female athletes because women will tend to have smaller neck muscles than men. Weight training and specific neck exercises is a safe and easy way to possibly mitigate this risk.
  3. If you have a history of neck injury from whiplash and concussion, make sure you’re seeing someone with expertise in addressing the cervical spine. People with traumatic neck injuries may not respond well with vigorous treatment methods and may regress with too much force applied to injured tissue.

 

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head tilt

Is Head Tilt Driving Your Brain Crazy?

Is Head Tilt Driving Your Brain Crazy?

 

A lot of people are starting to recognize the role that posture plays in overall health. Things like text-neck has made it’s way to major publications like the Washington Post, and the perils of slouching have been written about ad nauseum.

I won’t get into that today, because I think there’s a problem that is a lot more important but gets far less attention. Most doctors will ignore this, but chances are it’s a major contributor to headache, balance disorders, vision problems, and overall brain health.

Today we’re going to break down your head tilt.

Cute for Puppies and Sorority Poses, Bad for Patients with Neurological Issues

First we should clarify a couple of things. When we discuss head tilt, we’re not talking about the tilt that comes on when you intentionally tilt your head for a photo. If you are intentionally creating a momentary head tilt, it’s not a big deal. There’s no such thing as a bad posture if you are willfully and intentionally trying to create a specific shape with your body in gravity.

We only classify postures as negative when your body is doing something that it is not intending. If I ask you to stand up as straight as you can and your head tilts to side, it paints a much different picture of your brain than if I asked you to purposefully hold your head to the side. An inability for you to create a straight upright posture suggests that you have a deficiency in your brain’s ability to control your muscular system. You can read about that in greater detail here:

Why Your Posture Isn’t That Important

So what’s the big deal if your head tilts to the side?

It’s a sign that your brain is perceiving the world around it incorrectly.

If your brain is getting wrong information from your senses, then it can’t produce the right response to the world around it.

It doesn’t sound like a big deal when we’re talking about posture, muscles, and bones, but let’s apply the same idea to some of your other senses:

  • If you have a problem with one of your eyes, how will that affect your ability to catch a baseball?
  • If your ears are hearing a high pitched noise all of the time when everything is quiet, how will that make you feel?
  • If your skin is constantly itching, but you have nothing on your skin that is irritating it, will you keep scratching?

All of these are examples of your brain perceiving the environment incorrectly and they all lead to specific conditions from a lack of depth perception, tinnitus, to neuropathic itch. When left for a long time, these conditions can have a significant impact on your enjoyment of life.

So what are the consequences of a chronic head tilt?

The Physiology of Head Tilt

How your brain decides to hold the head up involves a lot more neurology than most people expect. Generally speaking, we think about head tilts being a result of tight muscles pulling the head out of place. When we use this model, treatments become a matter of rubbing one muscle and stretch another and the head will be straight again.

For better or worse, the way the brain moves the head is WAY more complex than that. Your brain decides where to put your head in space based on the interplay of your inner ear organ, your eyes, and the small muscles of your neck.  Here’s how it works:

Normal Head Tilt Reaction

So this is what happens when the system is working okay. When the system works, you can tilt your head when you choose to, but your brain will bring your head back to the normal upright position after it has achieved its purpose.

We see this system break frequently when someone has injuries like whiplash or concussion. The impact of these injuries disrupts normal function of all three systems. It scrambles the inner ear which distorts your eye movements. It also wreaks havoc on the muscles and ligaments of your neck.

What Happens When Your Head Tilt Breaks?

This is why the biggest problems associated with whiplash and concussion injuries are balance and vision issues. You can’t keep your perception of the world straight if your eyes, ears, and spine are giving you inaccurate information about gravity!

When your head and neck get scrambled by a hit and you disrupt these 3 systems, your body takes on an abnormal head posture which can make the other systems work inappropriately. One of the first things I’ll ask someone during a consultation is to sit up as straight as they can, and I’ll look at where they put their head in space. Very often they look like this:


Abnormal Tilt Reaction

 

 

But let’s be honest here; you don’t really care if you have a head tilt, crooked eyes, and tight muscles if it’s not causing you any pain or discomfort right?

Here’s the thing, your body can compensate like this for a little while. But if you’ve ever had to rely on a back up system before, you probably know that backup systems aren’t ideal and they’re more prone to glitches and failure. Your body is the same way with its own back up systems. They will get you out of a pinch for a short time, but they will eventually fail. Or even worse, you may suffer another injury while you are compensating and have even more damage to the brain.

So as your back up systems start to fail and your eyes and neck aren’t working normally you will start to have problems like:

  • Dizziness
  • Feeling off balance
  • Neck and back pain
  • Headache
  • Nausea

Why? Because if your eyes don’t move well, then it leads to difficulty reading or tracking targets in space. If your neck doesn’t move well, it causes pain and headaches. If you have all three systems saying different things, your brain has no idea how to determine it’s sense of balance.

Your Brain Hates Mismatches

Your brain hates it when its sensory organs give it conflicting information causing sensory mismatches. It hates it more than your significant other hates it when you walk out of the door with a brown belt and black shoes.

Your brain hates sensory mismatches even more than your significant other hates this fashion faux pas

Your brain hates sensory mismatches even more than your significant other hates this fashion faux pas. Image Credit to http://www.houseofmarbury.com/can-wear-black-brown/

All kidding aside, these sensory mismatches are the main trigger for the balance issues that can make people miserable. When you combine that with the fact that the balance system shares connections to your autonomic nervous system, then it gives us an understanding for why balance problems can really wreak havoc on our stress response system.

The abnormal movement of the eyes and head are also likely to create persistent headaches and pain in your joints and muscles from abnormal loading patterns.

When your head tilts, all of your spinal system starts to act screwy

When your head tilts, all of your spinal system starts to act screwy

While the symptoms can be bad enough, the biggest concern is the impact that these maladaptive patterns have on the functioning of the brain as a whole. If you can’t orient your world properly, then the parts of your brain that are responsible for normal function start to degrade while the parts of the brain that are producing these abnormal patterns get stronger. This persistent abnormal head pattern can change the way blood flow and oxygen get to various parts of the brain and lead to further problems with thought, focus, and movement.

If we want to make a real impact on the health of your brain, then we have to allow the brain to stop compensating and get your head on straight again.

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equestrians-and-concussion

Are Equestrians More Resilient to Concussive Injury Than Everyone Else?

equestrians-and-concussion

 

Concussions, Balance, and the Equestrian Advantage

Concussions are a hot topic in professional football, but it’s something that horse lovers have been familiar with for years. A 2014 paper in published in the Sports Health medical journal showed that almost 50% of competitive riders will have experienced a concussion during their life while riding. Surveys have also shown that helmet usage amongst equestrians is extremely low with estimates ranging from 9%-25% of riders opting to ride without head protection.

The sudden deaths of high profile professional football players have made the complications of head trauma a hot button topic in sports and medicine. Concussions are considered a mild traumatic brain injury, but the truth is that a brain injury of any sort is anything BUT mild.

While most people will recover from the effects of a concussion within 7-10 days, approximately 15% of patients will experience symptoms beyond 30 days. When these concussive symptoms persist,  the patient will likely receive a diagnosis of post-concussion syndrome or PCS. The symptoms of PCS include:

  • Headache and migraine
  • Vertigo or loss of balance
  • Brain fog/difficulty with concentration
  • Memory dysfunction
  • Dysautonomia and fatigue

Pro-Riding and Pro-Brains. Not Mutually Exclusive

There are risks to all sports, and as an athlete you have come to accept those risks as part of the game. Additionally, if you have been involved with riding for a while, it’s easy to accept head injuries as an inevitable part of the sport, and the truth is that most people will recover in a week or two.
It’s a common thread with sports doctors to say that sports like riding are too risky for the developing brain. The truth is that concussions shouldn’t be something that scares you from playing your sport. Getting into sports like riding are the most effective ways for people to stay active and fit throughout your life.

I try to teach my riders 2 important concepts:

  1. If you get an injury, make it an injury of performance. Take the right steps to prevent injuries of negligence or careless behavior like not wearing a helmet.
  2. Know what to do after a head injury so that you can ensure maximum brain health and recovery.

 

Taking Care of the Concussed Brain – Performance Over Pathology

When talking about the long-term health consequences of head injury, it’s best NOT to get your stance from places like Will Smith’s recent film, Concussion. The brain illnesses discussed in that movie are pretty rare, and apply to very specific types of athletes.

However, that doesn’t mean that concussion is free of long-term consequences. Studies of athletes with a history of concussion have shown slightly slower cognition and reaction time 30 years later, even if there are no symptoms of head injury. Studies of previous football players have shown that athletes with a history of concussion are more likely to have back and leg injuries after retirement because of the way concussions affect control of your own joints.

Here’s where getting the right treatment after concussion can make all the difference in the world for an equestrian athlete. While most athletes aren’t overly concerned about something abstract like brain health, athletes are VERY interested in anything that can affect their performance on the field or rink.

The Equestrian Advantage

While equestrians are at a higher risk of head injury than most sports, the unique features of equestrian sports may help confer protection from some of the chronic problems associated with concussion.

From a neuroscience perspective, horseback riding requires a tremendous amount of work from the parts of your brain that control balance. Your sense of balance is made up of a delicate interplay between your inner ear (vestibular system), eyes (ocular), and joints (proprioception). Your brain takes information from these 3 systems and paints the image in your mind of where you are in space.

The 3 super systems that maintain your balance

The 3 super systems that maintain your balance

When you ride a horse, your body is constantly bobbing in a way that far exceeds the normal force of walking. Your brain has a magnificent system in place to help keep your vision in focus even though your head is moving all over the place. If this system gets corrupted, then really simple movement makes us feel off balance or dizzy. In other cases, this system also affects our emotional control and cause headaches.

The brain, like any other part of the body gets stronger and adapts the more that you use it and challenge it. Between simple riding, jumping, and dressage, equestrian athletes have to challenge their vestibular system more than almost all people, including many athletes. That means that many equestrians are likely to have a stronger sense of balance than most people, and research is actually starting to demonstrate that1. The effects that horseback riding has on balance or so strong that they are even being suggested for the treatment of balance problems in the elderly2 and in stroke patients3.

No Symptoms No Problems In Concussion Patients

So why is that important for a concussion? Most people associate concussion with your ability to think, but concussions actually have the strongest and most immediate impact on this balance system. When people suffer with concussions, you’ll often see that their ability to stand still and walk is affected even if they don’t have any cognitive symptoms at all. The brain hates when the balance system is broken. Overtime, as balance issues fail to get fixed, it spills over into problems leading to vision disturbances, headaches, and brain fog.

One of the things that I notice in my experience with equestrian patients is that many won’t show signs of head injury in their normal daily activities, due to their strong sense of balance. When your body feels like it has a good sense of balance, some of the cognitive and pain symptoms from a concussion don’t impact you quite as badly. This is a great thing in that a head injury won’t cause an obvious deficiency in your quality of life.

However, many times this is due to a compensation strategy by the brain. When you suffer a concussion, the parts of the brain that control the eyes, cognition, balance, and movement become compromised. When the brain suffers damage to one area, then other areas of the brain will start to work harder to perform the duties of the damaged region. This is driven by a concept called neuroplasticity. This is what allows blind people to have a heightened sense of hearing, or deaf people to have a more focused visual sense.

As a rider, a concussion may damage the regions of the brain that control neck and eye movements, which can be detrimental to your balance. However, your balance system from the inner ear is so strong that it can take over the task of keeping you upright without much of a hitch. Even though you feel good and your balance seems strong, there’s only so long that the brain can manage these compensation strategies before it starts to fail.

Compensated Performance = Suboptimal Performance

 So now we’re going to bring it all back together.

When you suffer a concussion and parts of this comprehensive balance system breaks, many equestrians are fortunate enough to bounce back without prolonged symptomatic consequences because of a well-trained balance system in the brain.

The problem is that our brain is designed to work with contributions from all of our sensory systems. If we partially lose a system like proprioception from the joints and the inner ear system works overtime, then we will gradually lose more and more function from the joint position system. It won’t affect us immediately, but it may start to show up as back pain and knee injuries later on in life. If we lose some of our visual sense, then things like double vision or blurry vision can become long-term consequences.

You can even perform simple tests to see if some of your balance systems are not working well. Something as simple as standing with your eyes closed vs standing with your eyes open helps to see if your inner ear and joint position sense are working. If you start having difficulty concentrating while reading, your ocular system may be compromised.

The good news is that the same plasticity that helps us compensate is what allows us to develop strategies to rehabilitate the brain when we know which system is compromised. A thorough structura and neurological exam can help ensure that your brain does not just survive after a concussion, but to get it back to thriving again.

  1. Kim SH, Lee C, Lee I. Comparison between the effects of horseback riding exercise and trunk stability exercise on the balance of normal adults. Journal of Physical Therapy Science. 2014 Sep; 26(9): 1325-1327
  2. Kang K. Effects of mechanical horseback riding on the balance ability of the elderly. Journal of Physical Therapy Science. 2015 Aug; 27(8): 2499-2500
  3. Kang K. Effects of horseback riding simulator exercise on postural balance of chronic stroke patients. Journal of Phhysical Therapy Science. 2013 Sep; 25(9): 1169-1172.

 

trigeminal neuralgia

Unraveling Trigeminal Neuralgia

trigeminal neuralgia

[8 minutes]

Unraveling Trigeminal Neuralgia

​Most of you have probably never heard of trigeminal neuralgia (TN). It’s a pretty rare disorder that affects about 4-5 people per 100,000. If you or someone you love has ever had it, then you know that this illness can be associated with the worst pain that a human being can experience. The constant and persistant pain is so debilitating that TN has been called “suicide disease” because an estimated 25% of sufferers will take their own life.

​Today we are going to breakdown the anatomy of this devastating disorder, and how we can help.

​The Anatomy of Facial Pain

Trigeminal neuralgia can seem very simple on the surface. The name of the disease stems from the nerve that it attacks called the trigeminal nerve. The trigeminal nerve is one of twelve specialized nerves that come from inside the skull called cranial nerves. As the trigeminal nerve exits the brainstem, it sends branches all throughout the head and neck. Here is a short list of the things connected to the trigeminal nerve:

  • ​Sensation on the surface of the head and neck (especially pain sensation)
  • Sensation in the teeth and gums
  • The meninges
  • Major jaw muscles

​You can see how the nerve spreads and some of its major branches here:

The Trigeminal Nerve

The three main branches of the trigeminal nerve are the opthalmic branch (v1), maxillary branch (v2), and the mandibular branch (v3).

​While trigeminal neuralgia is a very specific illness with a set diagnostic criteria, the cells that form the trigeminal nerve have been implicated in pain issues that include migraine headache and jaw pain (TMD). This is because there is a bundle of cells in your spinal cord that act as a relay station for all pain perception in the head and neck called the trigeminal cervical nucleus.

In the most simple terms, if you were to go to a dentist and had your gums poked, it would fire a receptor called a nociceptor. This nociceptor travels through the trigeminal nerve, into the spinal cord, and up into the brain where it perceives that signal as pain.

Using this idea, scientists have tried to identify lesions along the trigeminal nerve in people with trigeminal neuralgia that consistently set off the pain response. It’s been suspected that an artery near the brainstem can pulse and compress the trigeminal nerve roots. These pulsations explain why patients can feel waves of shock like pain, with brief moments of relief in between.

There is also evidence to suggest that inflammation or trauma in the brain or spinal cord can make the brain more sensitive to the pain response. This is known as central sensitization.

It’s important to know this because knowing if the problem is from a peripheral lesion like an artery warrants a much different treatment than a condition where the pain is mediated from a central location.

Treatment Options

Peripheral Lesions

Most cases of true TN are resistant to anti-inflammatory medications.  When anti-inflammatories fail, they are treated with anti-convulsant medications like Tegretol or Neurontin. These medications can be effective for some, many patients find the side effects (dizziness, brain fog, balance problems) of these medications to be intolerable.

For patients with a peripheral lesion like artery or vein compression, there are surgical options. If patients have a confirmed compression of the trigeminal nerve roots by an artery, a surgery called micovascular decompression can be used to move the offending artery off of the nerve. The surgery has a very high success rate for a large number of TN cases, but it is also is a major surgery which requires cutting through the skull, and has risks that come with neurosurgical procedures.

Other procedures like Gamma Knife radiation can be performed to damage the trigeminal nerve so that it does not transmit the pain signal to the brain. This procedure has been less effective than decompression, and also may require additional procedures.

While these procedures can be great options for TN as a result of a displaced artery, it is unlikely to help those whose symptoms are not part of the peripheral nerve. Some forms of TN may be a brain related issue.

Central Disruption – A Brain Processing Problem

Problems in the peripheral nerve structure are easy to understand. You have delicate nerve tissue that hates to be compressed and you have an offending structure that is rubbing or compressing the nerve roots. When you remove the offending structure, then the nerve problem goes away. In a way, a peripheral lesion is similar to the way that a herniated disc causes the pain from a pinched nerve.

But what if you have this face pain but there’s no sign of a rogue artery pressing against the nerve? The problem may be with processing of pain rather than an offending lesion.

While peripheral problems are easy to understand, central problems can seem more abstract. When the brain and spinal cord aren’t working properly, you can’t do a blood test or look at an MRI and definitively say “This is why you have pain in your face”. In order to test this idea, you often have to perform functional tests which test how your body feels different stimuli.

Central disruption is more of a problem of too much or too little.

What I mean by that is that neurons in the brain can fire too often while other important nerves may not fire enough. When the firing of these nerves is out of balance, then the brain perceives things incorrectly.

Pain experienced in the head and neck can be dictated anywhere along these pathways

Pain experienced in the head and neck can be dictated anywhere along these pathways

The pain pathways of the head and neck converge into an area of the spinal cord called the trigeminal cervical nucleus. So if you have a pain in the head, face, or neck, all of the pain sensing fibers are going to enter into this region which is found in the spinal cord around the level of the first 3 neck vertebrae.

Our perception of pain is dictated by the multiple factors that include the current environment, memory of past pain, genetics, expectations, and our attention. The trigeminal cervical nucleus, thalamus, and somatosensory cortex have a system determining if the brain should pay attention to a painful stimulus. This is what allows people to feel pain differently.

That’s why  our favorite athlete can ignore the pain of a broken leg in order to complete a task. It also allows us to perceive danger if we step on a nail in the dark.

When this system malfunctions, then the trigeminal cervical nucleus is allowing too many pain signals to get through to the brain. When it allows every painful stimulus to get to the brain, then the brain is constantly bombarded with pain signals even if that signal is harmless.

Symptoms of facial pain can be a result of too much firing from the trigeminal cervical nucleus.

That’s what allows a cool breeze to the face, brushing your teeth, or scratching an itch on your face can be wrongly perceived as a painful stimulus that sends them cascading toward miserable facial pain.

When it comes down to it; your brain is perceiving the environment incorrectly because it is letting too much pain stimuli through the pain gate.

This is the cornerstone of the Gate Theory of Pain below.

Pain Gate Theory

 

The good news about a central pain response is that your pain threshold can be changed by several factors as listed in the diagram. While we can’t change our genetics, we can change almost every other factor on that list. From a treatment perspective, there are numerous things we can do to change brain and spinal cord input so that pain output decreases.

Fixing the Neck to Fix the Brain

Chiropractors that focus on the upper neck have found a large amount of success in helping patients with trigeminal neuralgia and other facial pain syndromes. A quick search through chiropractic literature shows a dozen case studies detailing the improvements of patients with facial pain syndromes (including my own here if you want to read it link here).

Obviously these are just case studies and can’t tell you much in themselves(I’ll save my rant on the politics of chiropractic research later. How is there not a formal study on trigeminal nerve issues and chiropractic by now?), but there is a logical rationale that helps explain how the neck can affect facial pain and why 75% of our trigeminal neuralgia patients get substantial improvement.

Let’s look at that graphic and highlight some important components:

Pain Gate Theory

 

Brain input and spinal cord input play a big role in the sensation of pain. A big part of brain and spinal cord input comes from the top 3 nerves in the neck.

When the head and neck shift, brain and spinal cord input get altered in ways that can impact the trigeminal cervical nucleus. In our office, we find that this is particularly common when the Atlas vertebra rotates or twists out of position.

Atlas Rotation

When this shifting occurs 3 things happen:

  1. Torsional forces occur in the spinal cord potentially impacting the trigeminal cervical nucleus
  2. Compressive forces may occur along the vessels that can affect movement of spinal fluid and blood in the head.
  3. Aberrent input into the brain from asymmetry of spinal positioning leading to dominance of nociception (pain) into the brain.

When the neck shifts in this manner, it doesn’t always cause trigeminal nerve issues, but it is tied to other problems like headaches, neck pain, cervicogenic vertigo, and more.

It brings us back to a fundamental principle: upper cervical chiropractic is not about treating a specific condition. It’s about improving the function of the brain and nervous system.

When we correct the structure of the neck, we are looking to decrease these damaging forces into the spinal cord and veins and improve the symmetry of firing into the brain.

The atlas on the left is almost 4 degrees twisted. The Atlas on the right is at just 1.5 degrees.

The atlas on the left is almost 4 degrees twisted. The Atlas on the right is at just 1.5 degrees.

Because if we can play a role in making the brain more resilient, then it has the best chance to make itself resistant the the pain you may experience in your day to day life.

Talk to Dr. Chung

 

Sitting rise test

Can This Simple Movement Predict Your Risk of Death?

Sitting rise test

 

When you go to see a doctor for your annual physical, you are there for 2 main reasons:

  1. To identify any disease processes that may be hiding underneath the surface so that a potentially deadly illness can be caught and treated early (cancer, heart disease, brain illness, etc)
  2. To have routine tests done that can help you gauge your overall level of health and fitness to prevent chronic illness (pulse, blood pressure, blood sugar, cholesterol, etc)

These routine exams and tests are generally unremarkable while we are young and healthy, but they become a lot more meaningful as we age, and our risk for illness increases. When we think about your risk of death, we generally think about our blood pressure, cholesterol, and blood sugar numbers.

All of those numbers are important, and certainly help predict your risk of dying from cardiovascular and metabolic disorders in the future. However, one of the things we see in the aging population is a gross loss of mobility and strength. You can see it in the way that many older people move. Walking is slow and cautious. Bending and picking up things from the floor become an extraordinary challenge.

From an evolutionary perspective, a lack of mobility and fitness can drastically affect your survival value. While elder adults can be wise and crafty in their survival skills, this lack of fitness can make you less likely to catch/produce food, escape danger, and become a burden on a migrating group of hunter gatherers.

But does that still carry over into today’s world where we aren’t being chased by tigers or migrating across a continent? The scientific eviduce seems to say yes. Strength and cardiovascular fitness have repeatedly been shown to be protective from your risk of death from all causes. [Source 1, Source 2]

 Movement and Strength Are Signs of an Efficient Nervous System

Movement and strength are important markers to the functionality of the nervous system. Remember that your brain is built to move your body to acquire and maintain resources for survival. When we examine people neurologically we are looking at things like their posture, balance, gait, and muscle strength because it gives us an idea about the functionality of their brain.

Just think about what happens with things like MS, Parkinson’s Disease, and stroke. They affect our ability to move, but they are not strictly a muscular problem we are looking at. They are brain problems!

To put it simply, if you can’t perform some of the basic movements of a human being, it suggests that there are deficiencies within the brain.

Sitting/Rising Test (SRT)

In 2014 the European Journal of Preventive Cardiology published a study that suggests that a simple movement test can predict risk of death in middle aged and elderly individuals.

2076 people were studied between the ages of 51-80 and were tracked from 1997 – 2011. Subjects performed a test called the Sitting/Rising Test(SRT). The test is really simple. The subject sits on their bottom and stands up and are asked to perform the test without using their hands, knees, or sturdy objects. Each time that a hand, knee, or assistance is used, a point is given. The total points are subtracted from 10 and an overall score is assigned.

Check out the infographic below:

Image Credit http://www.easternhealth.sg/Pages/NewsDetails.aspx?ProjectID=1649

Image Credit http://www.easternhealth.sg/Pages/NewsDetails.aspx?ProjectID=1649

Having a score of 8-10 is associated with a high protection from death of all causes regardless of age, sex, or body mass index. Every point below was associated with a 20% increase in death from all causes within the next 6 years. A score of 4 or more generally meant you could function independently, while less than that indicates a need for assistance.

What It Doesn’t Mean

So here’s the thing. This test correlates with your risk of death, there is no causation behind this and dying. The fact that you can’t do this exam well doesn’t mean you’re going to die from some horrible illness. It also doesn’t mean that simply practicing this test so that you can do it well is going to magically decrease your risk of death. We are looking at correlations not causations here.

This test is a functional indicator of your strength and basic neurologic fitness. Being able to do this means that your muscles have appropriate strength to move your body through space, and that your brain has good control of your body movements. It’s an indicator that you are fit and have good enough balance to not hurt yourself.

Rather than focusing on practicing this movement, you should be focusing on getting stronger and having better body balance. It means that maybe you should add some weight training to your weekly routine 3 times per week. It means maybe you should take a conscious movement practice like yoga or Tai Chi to improve your balance.

Remember, you’re not doing these things to prevent death. You are doing these things because it helps you to navigate through the challenging parts of life that much easier.