Parkinson’s Disease, the Gut-Brain Axis, and the Craniocervical Junction

Parkinson’s Disease is a devastating and complicated neurodegenerative disorder. Many people have become familiar with Parkinson’s Disease due in part to advocacy and awareness campaigns from watching the progression of celebrities like Mohammed Ali and Michael J. Fox. As a whole, people have come to know that Parkinson’s Disease is tied to the masked face appearance, tremors, dementia, and a slow shuffling gait, but there’s so much more to the illness than most understand.

Parkinson’s vs Parkinsonism Disorders: A Complete Clinical Picture

Parkinson’s Disease falls into a class of disorders called Parkinsonism. Parkinsonism basically describes the chief movement problems seen in PD patients including the rigidity, tremor, slowness, and balance/gait problems.

However, not everyone with these signs and symptoms have Parkinson’s Disease. Some patients may have adverse drug reactions causing dopamine depletion, some may have a severe breakdown of their autonomic nervous system called multiple systems atrophy, and others may have Parkinsonism following a series of strokes called vascular Parkinsonism. Some are easier to treat than classic PD, but others may actually be worse and less responsive to treatment.

Parkinsonism is characterized by a resting tremor, a stooped forward posture, and a shuffling gait

People are usually diagnosed with classic PD when other causes have been ruled out. Because of this, brain imaging studies like MRI are typically negative in PD patients. Many classic PD patients will also have digestive symptoms before the movement disorders become present (This will be an important point later on) in addition to sensory problems like a loss of smell . Finally, most classic cases of PD will show improvements in their movement when placed on dopamine medications like levodopa.

 

Pathology of PD. New Research on the Gut-Brain Connection

 

Conventional Parkinson’s Disease treatment sees the substantia nigra/basal ganglia as the area of damage and needs treatment.

In the classic view of Parkinson’s Disease, the region of the brain affected is called the basal ganglia. The basal ganglia plays a critical role in voluntary movement, movement planning, thinking, eye movements and emotion. It is an incredibly complex region of the brain that shows very pronounced symptoms when this area is damaged. In fact, most things that we consider movement disorders occur because of problems in the basal ganglia. This includes dystonia, Huntington’s Disease, Tourette’s syndrome, torticollis, and more.

What is often forgotten is that the basal ganglia is one of the most interconnected regions of the brain. While we all know that everything is connected as a pleasent euphemism, this is very literally true for the basal ganglia. It affects cognition, emotions, and especially movement, the basal ganglia is involved. That’s why it can cause such a wide variation of problems from hitting a small region of the brain.

But that’s not all. Parkinson’s is now generally accepted as a disease of abnormal protein aggregation similar to Alzheimer’s Disease, Chronic Traumatic Encephalopathy, and Mad Cow Disease. The protein that is malfunctioning is called alpha-synuclein, which is present throughout the brain but when it misfolds, it can damage neurons and spread to neighboring tissues. While Parkinson’s is associated with these protein aggregates in the substantia nigra, studies have shown that alpha-synuclein can be found throughout the brain and even in peripheral nerves.

Where is this rogue protein coming from? Some recent studies have suggested that Parkinson’s disease may actually originate in the gut. Multiple studies have shown that alpha-synuclein is present in the intestines of PD patients before the onset of neurological symptoms. A 2016 study in the journal Cell showed that mice bred to produce alpha-synuclein only expressed PD-like disease processes in the presence of gut bacteria producing metabolites that stir up neuroinflammation in the brain’s glial cells. The same study showed that if the gut bacteria from human patients with PD when injected into a mouse will produce PD-like symptoms.

Graphical representation of how gut bacteria can influence PD in a rat model. From the journal Cell, Dec 2016
http://www.cell.com/cell/fulltext/S0092-8674(16)31590-2

 

Another compelling study published in Neurology in 2017 showed that patients who had a surgery to remove the vagus nerve in humans with ulcers is associated with a protective effect against Parkinson’s Disease. The authors noted that the vagus nerve may be the route that the rouge alpha-synuclein proteins make their way from the gut to lower brainstem and up to the substantia nigra.

A more complete view may require taking a step back and understanding the relationship between the gut microbiome and the vagus nerve. Studies have shown that composition of your gut bacteria, and that gut bacteria can use the vagus nerve to create cognitive and emotional changes. There’s also evidence that vagus nerve activity can be measured through heart rate variability. These measurements can predict changes in PD and can be improved through interventions like electrical stimulation and exercise.

Most importantly for us, vagal nerve responses give us the most likely mechanism for how some patients with PD can improve by addressing the neck.

The Craniocervical Junction and PD

So how can a chiropractic intervention possibly improve a patient with Parkinson’s? Based on conventional theories on Parkinson’s, the substantia nigra and the dopamine producing neurons in this part of the brain has to be the target for treatment and therapy. As much as I love chiropractic as a profession, there’s nothing that I am doing that is going to magically make substantia nigra neurons grow back to life again.

One of the intriguing things that brought me from a traditional form of chiropractic to an upper cervical and neurological approach was the way that this form of chiropractic seemed to produce good results with people who had neurodegenerative disease like Parkinson’s Disease. Getting the chance to help people gain some aspects of their quality of life when conventional medicine just didn’t provide much was something I’ve always appreciated about chiropractic.

I was drawn to a study by an Upper Cervical Chiropractor named Erin Elster who wrote up case studies on dozens of patients with PD. The study looked at 81 patients with PD or multiple sclerosis and monitored the patient response to upper cervical care over time. In the Parkinson’s group, there were 37 patients and 23 out of the 37 patients experienced an improvement in at least half their symptoms. These symptoms ranged from musculoskeletal symptoms like posture and pain to more neurologic problems like tremor and balance.  Out of those 23 patients, 16 of them experienced a substantial improvement where all of their symptoms showed either improvement or resolution.

Back in 2011, I documented some similar improvements in a 67-year-old female patient with Parkinson’s Disease who was having problems with repetitive falls and tremors that was causing difficulty with basic activities of life and work. Within 6 months, the number of falls reduced significantly while tremor and rigidity were noticeably improved. You can read about my early thoughts on this in the original case study here.

Reduction in Symptoms Related to Parkinson’s Disease Concomitant with Subluxation Reduction Following Upper Cervical Chiropractic Care

I’ve had the pleasure of seeing several patients with Parkinson’s Disease get pretty similar results over the years with one even having a 70% reduction in tremor activity and improved gut symptoms.

If we aren’t affecting the damaged substantia nigra, then how is a chiropractic intervention providing improvements in PD symptoms? One idea is that chiropractic adjustments may help drive better compensation in movement planning by the way that adjustments can increase activity of the cerebellum. This way, if the basal ganglia can’t control your movements, then the cerebellum can help make up for it a little bit.

There’s also a theory of neurodegeneration that involves changes in cerebral spinal fluid and venous drainage that applies well to multiple sclerosis, but no evidence currently exists that a mechanism like this would create parkinsonism.

But the thing I’m most interested in is that gut-brain connection we discussed earlier.

The vagus nerve and it’s connection between the brain and gut is growing area of interest for a small subset of chiropractors. We know that we can use heart rate variability (HRV) as a way to measure the activity of the vagus nerve and we know that chiropractic has some preliminary studies showing it has a positive impact on HRV.

The craniocervical junction is particularly unique because of it’s proximity to the the brain stem and key neurovascular structures that may influence the vagus nerve. Strains, fixations, misalignments, and malformations of the skull and neck can impact the way the brain processes important neurological information and indirectly impact the home of the vagus nerve nerve in the brainstem.

Additionally, top bone in the neck called the Atlas also has a capacity in some patients to compress the internal jugular vein which has the capacity to wreak havoc on the vagus nerve by causing a condition called dysautonomia. Studies have shown that severe forms of dysautonomia do produce Parkinsonism via multiple system atrophy, and some PD populations can show characteristic signs of dysautonomia.

While all of these is very much hypothetical, if we know we are impacting HRV, then it is plausible that every time we touch the upper neck, we are potentially affecting the vagus nerve and those very important bacteria in our guts.

Closing Thoughts

But I won’t say that results with Parkinson’s Disease are typical. I’ve taken care of some  patients with PD who get no improvement at all. A lot of this depends on the nature of the person’s illness, how far along in the disease process the patient is, and other factors that can dictate the brain’s ability to adapt.  It’s a progressive and challenging illness no matter how you spin it.

However, Parkinson’s Disease is an illness that can have devastating effects on someone’s quality of life as they age. At best we are decades away from a meaningful cure, and in the meantime we need to explore safe options that can meaningfully improve someone’s quality of life for all too fleeting moments that their brains are mostly in tact.

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Ringing in the Ears is a Pain in the Neck

Tinnitus and Neck

Tinnitus is a problem where patients perceive sounds in the absence of sound stimuli. It afflicts between 10-15% of adults, but can be a severe hindrance in about 2% of the population. While tinnitus is classically thought of as a ringing sensation in the ears, there’s a wide variance to what patients perceive. Some describe it as a hissing, sizzinling, whooshing, or clicking.

The cause of tinnitus is known and well established in patients with hearing loss or those whose ears have been subject to noise trauma like loud music or blasts. However many patients experience tinnitus that can come out of the blue without a known cause. There is a growing amount of evidence that points to the neck as a unique source of ringing. Some have identified this type of tinnitus as cervicogenic somatic tinnitus (CST) and is estimated to make up almost 40% of all tinnitus cases.  

How is My Hearing Related to My Neck?

It seems strange that a problem in your neck can interfere with normal hearing, but researchers have been trying to identify why people with tinnitus can get improvement from things like chiropractic or physical therapy interventions. A study in the journal Medical Hypothesis looked at the neurological connections between the neck and the hearing organ of the ear. 

The authors showed that the nerve roots from all of the cervical spine all travel through the spinal cord and travel to the brainstem where your senses can integrate with some of the cells responsible for hearing. Cervical spine dysfunction has also been associated with blood flow problems, and some authors have hypothesized that dysfunction in the top vertebrae in the neck may affect blood flow to the brainstem and inner ear organs. When blood flow to these areas are compromised, then dysfunction from the ear can occur.

Problems like structural shifts in the neck or arthritis can agitate these sensory nerves and affect some of the brainstem regions that modulate your sense of hearing. This may be the reason why some patients can have ringing in the ears that lingers after things like whiplash and head injuries in sports even when there’s been no damage to the ears. 

 

The neurological pathways that tie the neck to the hearing centers in the brain. Graphic from Bressi et al in Medical Hypothesis. 2017

The neurological pathways that tie the neck to the hearing centers in the brain. Graphic from Bressi et al in Medical Hypothesis. 2017

Fortunately for many, research is also showing that addressing the neck can improve tinnitus in patients with some of the most disabling symptoms. A 2016 study in the journal Manual Therapy showed that treating the neck can lead to substantial improvements in up to 53% of patients with severe tinnitus.

Another study in 2018 showed that using both auditory and somatosensory stimulation can induce long lasting changes in the loudness and intrusiveness in tinnitus compared to just using one or the other.

Upper Cervical Chiropractic and Ear Problems

An interesting but little known fact is that chiropractic emerged in 1895 as a treatment for deafness. D.D. Palmer is credited with creating the chiropractic profession, and first performed an adjustment on a janitor with hearing loss named Harvey Lillard. It’s unclear what the circumstances of this first adjustment, but what is known is that Palmer thought he stumbled on the cure for deafness.

It’s obvious that chiropractic is not a cure or treatment for hearing loss otherwise our offices would be filled with the deaf and hard of hearing. However, current neuroscience research has helped us understand how several patients with hearing disorders like tinnitus can get relief from a neck procedure like the Atlas correction.

While it may not help every person with tinnitus, a thorough history and examination may be able to help us figure out if we can get that bothersome ringing out of your ears.

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Plasticity: How It Can Ruin or Restore Your Health

 Plasticity

Healthcare often goes through phases where certain buzzwords will take a dominant place in the minds of marketers and consumers looking for the next big thing to change someone’s life. That’s how the ideas behind terms like ‘wellness’, ‘detox’, ‘gluten-free’, and ‘keto’ get taken and raised like a banner that will change the face of healthcare. An interesting one that I’m seeing catch some steam in recent years is a term that chiropractors and neuroscientists have been using for decades called ‘neuroplasticity’.

I remember hearing and reading about the concept of plasticity about 15 years ago as an undergraduate student going through neurobiology courses. It describes the concept that the brain uses to strengthen the neural connections that it uses often and to weaken the connections that it doesn’t use, in order to adapt itself to the environment. The concept is really profound in people that have experienced strokes. Strokes cause brain cells to die which means those brain cells are not likely to ever grow back. So if the part of the brain that helps to move your leg suffers a stroke, then you may see that person develop a limp.

A lab grown example of neurons enhancing their connection to each other

A lab grown example of neurons enhancing their connection to each other

If the brain was hardwired and you lost the “leg” portion of the brain, then the function of that leg would stay permanently impaired for life. However, that’s not really what we see in real life. Often times, an area of the brain that is affected by stroke may die and become damaged, but the brain can re-organize itself and use other parts of the brain to help regain some of the function in that leg. This is some of the rationale behind the improvements in rehabilitation seen in patients stroke patients undergoing occupational therapy, physical therapy, and chiropractic.

This idea is called plasticity, because it implies that the brain is NOT rigid and hardwired like we once thought, but it is softer and can be re-modeled to fit the needs of that person.

The Popularity of Plasticity and The Perils of Hype

The idea of plasticity made a leap from scientists and doctors to the general public when Dr. Norman Doidge wrote a New York Times Bestseller called:

The Brain that Changes Itself – Norman Doidge

The book details some amazing feats of healing and adaptability displayed by the human brain. A patient with damage to the balance organs in her ears and felt like she was perpetually falling was taught how to regain her balance by using a tongue sensor. It also shares the story of a woman who was born with just one-half of a brain who has grown to be normal in almost every way. The stories are powerful and moving. They really make you feel like your brain is really capable of almost anything.

From that idea, great ideas have been developed to rehabilitate people with brain injuries and phantom limb pain, and even to teach the blind to see with their tongues. It has also left the field littered with loads of products and services who have hijacked the term to describe brain training tools that allegedly prevent Alzheimer’s or improve memory. It’s also come into the realm of many self-help gurus who distort the science and terminology of plasticity as a way to manipulate sales for their books and consulting services.

While plasticity is a real phenomenon and has some very strong real world applications, we have to guard ourselves from promoting false claims and false hope.

How neuroplasticity can help or hurt your recovery

Neuroplasticity is not a hippie woo term that requires a special chant or mindset in order to derive the benefits. It doesn’t require a self-help book, special chants, or a special exercise to make things work.

Focus Builder eye movement exercises are one of the tools that can be used to build neuroplasticity

Focus Builder eye movement exercises are one of the tools that can be used to build neuroplasticity

Plasticity in its simplest form is the idea that the neural pathways that fire together repeatedly get stronger, and neural pathways that don’t get used start to fade. To throw a cliche out there, plasticity is about practice making perfect, or more realistically practice making permanent.

The more that your body uses a neural pathway the better it becomes at doing that task. That’s how a novice guitar player can fumble around miserably when first learning an instrument despite intense concentration can start to play almost effortlessly with a couple of months of daily practice with good coaching/direction. The muscles of the fingers didn’t change much in any meaningful way, but brain that that was coordinating the movement of those fingers are finely tuned to the timing and precision required of those movements.

It also means that if that same novice guitar player developed bad habits while learning the guitar, that those habits will persist even as they are able to play more songs and riffs. The more that he practices poor technique and sloppy finger movements, the more his brain will use those same techniques because he is getting better at doing something poorly.

What does that mean for you as a patient? Let’s use one example

When you get injured, your body produces pain as a response to injury. Pain serves as an alarm system to slow you down and prevent further injury. That’s why you move a little slower, limp, or walk awkwardly when you throw your back out. After an injury has healed, some patients have developed plasticity in the neural pathways that were triggering pain. This process of sensitization of the peripheral and central nervous system can cause these patients to feel pain even after the injury has healed. Even worse is when this causes plasticity in the pathways that hold your spinal muscles in a certain way that reflects your pain and makes certain movements more painful.

The damage to your body has healed, but plasticity helped the pain to persist. No bueno

This same property of the nervous system can be used to help you recover and heal as well. By understanding which parts of the brain are functioning poorly or damaged, a guided program of treatment can be developed to help the brain recover or compensate appropriately. 

So we take that same patient who has developed plasticity in pathways to create chronic pain, then other pathways can develop plasticity to beat the pain. This is one of the emerging concepts in chiropractic research that suggests that adjustments create plastic changes in the brain that may help change muscular activity or abolish the pain response. 

When done in combination with a well crafted and designed exercise and rehabilitation program, the tools available to create plasticity in the brain is only limited by the ingenuity and creativity of the doctor, and the determination of the patient to execute their plan of care.

But this isn’t just exclusive to pain. These plastic changes may help you use your muscles a little bit more efficiently for your next big lift. It may help your brain organize itself to find better balance. It may also create changes in the systems of your brain that regulate heart rate and blood pressure too!

 

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Homocysteine and Migraines – What Does It Mean?

Homocysteine and Migraine

 

Headaches are very common and almost everyone has experienced one at one point in their life. They can be painful and disabling, which cuts into your focus, productivity, and quality of life. Headaches come in different types such as tension, cluster, and migraine. The migraine type headaches are the third most common disease in the world and effect about 14.7% of the worlds population. That’s around 1 in 7 people who will experience a debilitating headache that will put that person down for the count, locked up in a room with the lights off, and a trash can near by. It is not a pleasant way to spend your day.

When you have a migraine you look for any way to get rid of them. People have asked what’s the relationship of homocysteine to migraines after hearing about methylation problems in the body.

Homocysteine is an amino acid found in the blood, but if found in high amounts has been shown to cause inflammation leading to an increased chance of stroke or cardiovascular disease. Migraine headaches are severe throbbing or pounding headaches that usually occur on one side of the head. People may experience a sensitivity to light, sounds, and smells. Some experience nausea or vomiting. Some migraine patients experience what is called an aura before the onset. An aura is a visual disturbance, such as a blind spot or flashing light.

Homocysteines are a major player in chronic inflammation.

Homocysteines are a major player in chronic inflammation.

The question being studied is, “does an increase in homocysteine in the blood directly relate to an increase in migraines?” There have been a lot of studies to answer this question and the results appear to be conflicting. On one side, many studies show no significance between the two. On the other side, some do show significance that an increase of homocysteine in the blood does correlate to an increase in migraine headaches. There seems to be no sound conclusion when it come to levels in the blood.

However, a study out of Headache tested homocysteine levels in the cerebrospinal fluid (CSF) in the spine and showed a very significant increase. It showed that migraine patients with auras had a 376% increase in the CSF and patients without had a 41% increase. What this means is an increase of inflammation in the CSF for people with migraines.

What is Special About Cerebrospinal Fluid

CSF also acts an a cushion and protector of the nervous system. It should flow normally through out the system without being stagnant. In recent years, CSF has been identified as a fluid that helps to remove waste products from the brain’s normal metabolism, and that failure in CSF movement from things like lack of sleep may contribute to the pathology of Alzheimer’s disease.

Why Is CSF Important to Us?

Sometimes when a segment in the spine shifts out of place it can not only put pressure on the disc, nerves, and bloods vessels around that segment, but it can also effect the flow of CSF through that area. When this happens this can cause CSF in areas in the head and spine to be stagnant because a segment has shifted out of place affecting the normal flow. When the CSF is stagnant you can have a pooling where it can collect homocysteine causing inflammation.

As a structural chiropractor that focuses on the craniocervical junction, the interaction between the neck and cerebrospinal fluid is an important area  of interest. A study by the Upper Cervical Research Foundation showed that a correction of the atlas vertebra shows significant improvement in migraine symptoms and potential changes in venous drainage patterns. This allows things to function better, including the CSF to flow better.

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What Happens To Your Brain When You Move Your Head?

brain with head movement

A lot of you are familiar with my work on the relationship between the neck and concussions. It used to be something of a fringe concept that neck injuries could be related to some of the symptoms of a concussion, but research on the topic has exploded in the last 10 years. It’s not such a secret anymore.

Recently I had a great conversation with a physical therapist with similar research interests named Dr. Eric Jorde. He brought up a really cool paper that I’d never read about the biomechanics of the brain during normal head movements. You can check out the paper in the link here (fair warning: Lots of math involved):

Quantitative Imaging Methods for the Development and Validation of Brain Biomechanics Models

I’ll be honest. I didn’t understand a lot of what the paper discussed because it talked about the techniques they used to image the brain during movement. However,  some of the videos they shared in the supplementary materials are stunning and really help us understand why concussions can happen with violent movement of the neck.

Brain Movement and Head Movement

Let’s take a quick look at this gif of the brain on a tagged MRI.

Movement of the brain with a simple head turn.

Movement of the brain with a simple head turn.

 That’s amazing! Look at that grayish stuff covered in a grid pattern. That stuff is the brain inside of a skull as the head turns normally. Does it remind you of anything? It reminds me of a plate of jello when you set it on a table for the first time.

Look at that jello jiggle

Look at that jello jiggle

It gives us a good reminder of a couple of concepts.

  1. The brain really is a soft semi-gelatinous organ that can deform and reform it’s shape pretty easily
  2. The brain isn’t a static structure. Normal head movement causes very conspicuous movement of your brain even with the surrounding barrier of cerebral spinal fluid.

You can take a look at some videos taken directly from the study at the end of this article.

If the Brain Moves with Normal Head Motion, What Happens When I Really Hit My Head?

So the whole purpose of this study is to get an idea on how the brain may be moving when exposed to head trauma. If just normal movement of the head is creating substantial brain movement, then we can begin to imagine what happens when someone takes a hard blow to the head. Many people associate a concussion with a contusion-type of a trauma….like a bruise.

However, some of the hardest hit parts of the brain from a concussion are not the part of the brain that hit the skull. Many times, the most compromised structures from a concussion are some of the midline parts of the brain like the midbrain and brainstem. This is because that soft gelatinous tissue will experience a SHEAR type of strain from the way the brain moves!

Even forces below the threshold usually required to cause a concussion may be creating excessive movement of the brain and injuring some of the delicate wiring that allows our minds to work. That means that hits to the head, or really rapid head accelerations from things like whiplash may be creating damage to the brain even in the absence of a full blow concussion. Why? Because whiplash injuries are known to create shear forces into the spine, but the brain can also experience some of this as well, but likely at a much smaller amount than a full blown concussion.

Even a force like a whiplash may move the brain enough to cause injury to the brain's axons

Even a force like a whiplash may move the brain enough to cause injury to the brain’s axons

Knowing how the brain moves when the head moves does help to explain why youth and high school athletes can show signs of brain changes in a season of football even without a concussion [1,2]. It can also help explain why some NFL players can have a degenerative brain disease like CTE even if they had no history of a reported concussion.

This is also the reason why that helmets probably aren’t enough to make contact sports safe for athletes long term. You can stop the head from hitting the ground with a helmet, but you can’t stop the brain from sloshing around and deforming when the helmet gets hit.

Conclusion

We can’t fully prevent head injuries from happening to people, but the more that we know about how the brain moves when you move, the more we can do to help make sports and life safer for everyone.

Tagged MRI of rotation

Tagged MRI of flexion

Magnetic Resonance Elastography

 

A Cervical-Vestibular Approach to Dysautonomia: 2 Case Studies

Dysautonomia Case Studies

Thanks to the readers of our blog, our office has become a place where patients with dysautonomia are seeking care with the hopes of improving their quality of life. Many patients with dysautonomia often struggle with widespread body pain, dizziness, brain fog, and headaches to go along with their primary symptoms of feinting, persistent light headedness, or rapid heart rate.

Today we’re going to breakdown the success we’ve had with 2 recent patients with dysautonomia.

Case 1

This patient started with us back in June 2017. She got hit with dysautonomia after coming back from a trip where she had a bout with malaria. She’s had times where the her dizziness and fatigue were so bad that she had to be pushed in a wheelchair to get around. Her heart rate is consistently over 100 beats per minute with routine standing. When she came to our office her biggest problem was that whenever she stood up from seated, she would start to get dizzy, feel feint, and sometimes black out. This made it difficult for her to go to church, take a shower, and other really basic activities of normal living.

She showed dysfunction in her neck at the atlas vertebra and some past history of whiplash. She also had a large amount of difficulty just following moving objects with her eyes alone and it made her vision blur repeatedly.

We started by performing a correction of her Atlas and after her first visit she was able to go from seated to standing without having her vision go dark and pass out.

As her cervical spine maintained the correction, we began doing exercises for her eyes and vestibular system to help her brain orient itself to the environment accurately again.

As she performed the exercises more frequently, she was able to track moving objects better and she was able to tolerate standing for 15-20 minutes without feeling tired or feint.

You can see her in her own words below.

Case 2

After case 1 got really great improvements, she referred her mother to our office to see if we could help her in a short amount of time. Case 2 also had dysautonomia throughout her life. She had it many years ago and was frequently dizzy and had difficulty with standing and fatigue. She went into remission for a number of years when the symptoms started to come back. She also got into a car accident which seemed to intensify the symptoms again. She flew in from North Carolina to be seen and evaluated.

We knew we would only be able to work with her for a week at a time so we opted to do some more intensive care seeing her for multiple sessions in a day initially. Fortunately, being fast responders to NUCCA corrections seems to be a family trait.

We identified problems in the upper neck as well, and while her eyes were not moving as poorly as case 1, she had some issues tracking objects certain head positions would cause vertigo.

After her initial visits, she was able to maintain better balance and bend forward without getting dizzy. She also started to notice improvements in pain throughout her body.

On her third time visiting, she was able to jump and move with significantly less feeling of imbalance.

 

How Does This Work for Dysautonomia Symptoms? 

 So why does cervical and vestibular work seem to help with dysautonomia? It seems that some cases of dysautonomia can be tied back to an inability of the brain respond appropriately to gravity. Many primary dysautonomia cases  like POTS have a postural component to it (hence Postural Orthostatic Tachycardia Syndrome). When the body moves into different positions in gravity, an inappropriate response occurs such as an extremely rapid heart rate or a blood pressure that tanks.

This is relevant because the cervical spine and your inner ears are really big players in how your brain recognizes gravity. If one inner ear senses more gravity than the other, then your brain is going to think that it is tilting or turning when you are really just sitting straight. If the joints of the neck are malfunctioning, then you are going to have abnormal muscle patterns that also provide a misrepresentation of where the head is in space.

Vestibular and cervical problems will also cause your eye movements to become dysfunctional too, causing blurring and other visual problems.

This is exactly what we see in a lot of people with concussions too, which is why some researchers are saying that the dizziness and visual problems we see in concussed patients may be a problem with dysautonomia too. Read more about that here:

Dysautonomia and Concussion

While dysautonomia is pretty rare and presents with numerous complexities, taking a cervical and vestibular approach to some cases may make a big difference in getting someone’s life back.

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A Gentle Approach to Chronic Pain

A Gen

Breaking the Chronic Pain Cycle of Fibromyalgia

                  Chronic pain takes many shapes and forms, but we know that it has a huge social and economic burden. The Institute of Medicine reports that roughly 116 million, or 30% of the population suffer from pain lasting a year or longer. Although chronic pain isn’t a life threatening issue, it’s certainly a problem that has a dramatic effect on the quality of someone’s life. After taking care of hundreds of people with conditions like fibromyalgia, I know that these people experience quite a toll both physically and emotionally.

NUCCA requires a specific angle to achieve a desired correction angle.

NUCCA requires a specific angle to achieve a desired correction angle.

                  Perhaps the worst part about fibromyalgia is that there is no known cause or cure. It’s basically invisible to any blood tests or MRI studies, and most of the drugs available are for pain control. People with fibromyalgia may often be depressed, have anxiety, and have a sense of isolation because they don’t feel that their friends and family understand their struggle. This often compounded by the fact that their doctors have told them that the pain is psychosomatic, or just in their minds because no tests can reveal an underlying disease process.

                  In recent years, fibromyalgia has become one of the most published topics in medical journals. As a result, we are starting to develop an understanding of the disease on a deeper level to know that it’s certainly NOT just in the patient’s mind. Research is pointing to problems within the central nervous system and tiny blood vessels in the skin as likely causes of the deep body-wide pain. But what does this mean in terms of treatment?

                  For most people, drugs that target the nervous system like Lyrica or Gabapentin are the first line of treatment and many have had success. However, some patients can be sensitive to drug reactions, or their bodies may develop a high tolerance for the dosages. In cases like these, many patients start to seek out alternative therapies like acupuncture, reiki, and homeopathy.

                  Traditional chiropractic has also been a source of relief for many people seeking help with chronic pain. However, many people with the chronic pain of fibromyalgia can feel apprehensive about seeing a Doctor of Chiropractic because manipulations can seem too rough for someone who can barely stand to be touched.

Not All Adjustments are Built the Same

                  In chiropractic, there are dozens of techniques and approaches to correcting the spine. Some are heavy handed and require a lot of force, but others are very gentle and rely more on precision. It’s not to say that one is better than the other, but some are just designed for specific patient populations in mind.

                  In my office, I attract many patients with fibromyalgia, trigeminal neuralgia, and TMJ problems that are Secondary to a Structrual problem in the neck called Atlas Displacement Complex. Most of these people are afraid to be touched, and gravitate to a lighter approach. This type of condition requires a precision type of adjustment called an Atlas Correction. This type of adjustment is so light, that most people often wonder if I even touched them, and then they start to feel their body change. Currently, only about 1000 doctors in the country are trained in this type of care.

                  This approach is effective because of the spine’s influence on the central nervous system. When the top of the neck shifts abnormally and moves improperly, the nerves firing into the brainstem become distorted. In this way, the brain is like a computer that relies on spinal positioning to operate normally. When there are garbage signals going into the brain, then garbage signals come out in the form of pain. This phenomenon in fibromyalgia patients creates a condition called central sensitization. This is the reason why people with fibromyalgia can feel excruciating pain from a light touch. It’s not that there’s a physical injury, but the nervous system is getting scrambled signals and is primed to experience pain.

Your nervous system can act like a computer. If poor information comes in, then poor information will come out.

Your nervous system can act like a computer. If poor information comes in, then poor information will come out.

                  This is NOT designed to cure you. The cure lies in the fact that the body is capable of healing itself. When you remove interference to the body’s self-healing ability, I find that people can return to a level where life is livable again. By breaking the pain cycle through the nervous system, you can impact the way stress affects the body and the immune system. By no means is this a cure all, but it can be a great catalyst to being steered back on the path towards a normal life. I’ve seen numerous patients who’ve been able to go from disability to working or resuming exercise again in a matter of months.

One of the greatest joys of doing this type of work is giving people a glimmer of hope. So many people are convinced that they have to live in pain, or have been told that the problem they’re having is all in their head. In my office, I’ve helped hundreds of people recover from chronic pain with this gentle procedure. However, it’s not for everyone. Only people with a problem in their Atlas can receive this type of care, and that requires a detailed Upper Cervical Chiropractic Examination to identify the problem. Sometimes a little bit of hope is all a person needs to start healing again.

How to Spot a Personal Injury Predator

How to spot a predator

Outline

  • The famously dirty personal injury industry
  • When profit leads to failed patient care
  • How to spot predatory practices

Personal injury (PI) is an famously dirty industry. When people think about PI, you usually think about ambulance chasing attorneys taking up local billboards, radio, and television commercials. In a state like Florida where just the act of a car crash can make you eligible for $2500 of personal injury protection at minimum, and many eligible for $10,000 of coverage from their insurance company, it has opened the door for many avenues of scams and unscrupulous activity.

Common fraud activity include people paid to stage accidents, forced referrals from tow truck companies, enticing victims with cash payments to go to certain clinics, and more.

Attorneys get a bad rap (some of them deserve it), but when it comes to your health after an accident it may be the doctor you choose that could be the biggest threat to your health and your money.

When Profit Leads to Failed Patient Care

While attorneys get most of the blame for a corrupt delivery system, unethical practices by healthcare providers have contributed to the problem.

There is an unspoken trust between medical providers and the public to always practice with the best interests of the patient in mind. While doctors will try their best to insulate themselves from getting too involved with the business side of medicine, the personal injury business has made it difficult to practice strictly based on clinical findings.

Health providers face pressure from patients and attorneys to help build a case for larger settlements. New doctors have large student debts to pay on top of trying to support their families. No one is trying to harm the patient, but it’s easy to see how money can muddy the waters of patient care.

So many patients are subjected to unnecessary imaging and procedures because of pressure from attorneys and patients to pad the medical bills and build a case for lawsuit. MRI’s are so widely prescribed for personal injury cases because the findings can show greater injury despite the fact that the correlation between imaging findings and pain are surprisingly weak.

Many patients with no pain have abnormal MRI findings, but these images can unreasonably scare and confuse patients about the real causes of their pain. Image Credit: Adam Meakins https://thesports.physio/

Many patients with no pain have abnormal MRI findings, but these images can unreasonably scare and confuse patients about the real causes of their pain.
Image Credit: Adam Meakins https://thesports.physio/

In some cases, offices and facilities have become places that exclusively see injured patients for the sake of billing thousands of dollars from insurance with little regard for appropriate management. Their only goal is to increase their billing as high as possible until the injury benefits are exhausted, and the patient is released from care regardless of whether they received the care they need.

This not only robs patients of benefits that may provide them with appropriate care from other providers, but it also causes take money out of the pocket of consumers as insurance premiums rise to pay for these unethical practices.

So what’s a person supposed to do? Here are some thoughts:

  1. Ask About the Expected Services and Fees Involved: When patients have the expectation that insurance will be paying for their services, they rarely ask about what services will be performed and the cost of these services.This might be okay if you have private insurance, but in capped payment systems like personal injury protection, doctors may be prescribing the same tests and procedures for all patients to get the bill to rise as fast as possible.Transparency in costs helps to control spending. If you knew that your x-rays were going to cost $500 of your own money, you’re a lot less likely to get it done unless you felt like it was necessary.If a doctor or staff is elusive about their fees and services saying things like “Oh don’t worry about that, your insurance will cover it.” Then press them on it. You will eventually get the explanation for their billing, and see if what they say and do actually matches up.

    Treat your insurance dollars like they are your own dollars, because when benefits start to run out and you’re not better, you may ultimately end up paying yourself.

  2. Check Your EOB’s and Your Statements: Insurance companies will send you an explanation of benefits to show patients what was billed for and what they paid for those services.In shady practices, you may see billing for services you’ve never received before. Patients who have never had an ultrasound machine touch them will see ultrasound in their billing. Patients who do a few arm circles may see a bill showing that 30 minutes of exercise is on the bill.This is a crime, and it’s called fraudulent billing, or just fraud for short. In the most extreme cases, you may see dates of service billed for days you know that you were never in the office.
  3. Are You Getting the Same 3 things Done over and over with no results?: Doctors who care about their clinical outcomes will design treatment plans based on your specific injury and how well you are responding to care.A sign that you are in a injury mill type practice is if you are being scheduled for the same treatments multiple times per week with no regard for how you are responding to care. This usually looks like getting electric stimulation and ultrasound placed on you by staff, a chiropractor manipulating your spine, and some vague recommendations for exercises. This is done 3-5x per week and the treatment doesn’t change despite the fact that you don’t feel any better, and sometimes continue to feel worse.Good practice is to triage your case based on the severity of your injuries. If you have a severe acute injury, you may need medical management from patches, meds, or injections so that you can feel functional as you go towards physical rehabilitation. Good practice also involves getting you to an appropriate specialist if you are not improving in a timely manner.

    When offices are not paying attention to whether the patient is getting better from their treatment, then it is a sign that they are trying to max out your benefits as quickly as possible.

  4. Are you being coerced to seeing certain doctors?:  Patients are always in control over what doctor they wish to see. If you have a comfort level with a certain doctor, then you always have the ability to find out if that doctor accepts personal injury claims.Some PIP schemes are set up to funnel patients into specific doctors’ offices for reasons that are not about helping the patient. At times people can be pushed into these offices by attorneys or patient runners saying they have to see a certain doctor for the purposes of the case. Some schemes will even go out and give patients financial compensation to go to specific offices which is outrageously illegal.This is a sign that there is an illegal kickback system involved that is built to just get maximum reimbursement from the PIP system.

Predatory PIP Practices Hurt Us All

So what’s the big deal if a practice is trying to max out your insurance money? After all, if you as a patient aren’t paying the bill then why should you care?

The truth is that these types of practices hurts us all. It hurts attorneys who are trying to build a business ethically in a dirty system that will spend more to get an advantage. It hurts doctors who treat patients for the best clinical outcome who may see insurance reimbursement go down to combat fraud. 

Most of all, it hurts us all as people who want to trust attorneys, doctors, and the insurance company. As a doctor, you’ll usually expect me to trash insurance companies for cutting payments, but in terms of PIP many times it’s just a response to fraudulent or unethical billing practices. Insurance companies raise premiums on us all when fraud gets out of hand, and in some cases it makes it really hard to get insured at a reasonable rate after an accident lawsuit. 

I have no sympathy for a multi-billion dollar industry, but I can certainly see why the system is built the way it is when I observe some of the scams that are run by people that are supposed to be the gate keepers of patient health.

This industry may be too far beyond repair and reform, but maybe it can get a little bit cleaner when patients are informed enough to call it out.

 

Dizziness: Misdiagnosed and Mistreated

Dizziness: Misdiagnosed and Mistreated

 

Dizziness is Hard to Diagnose

When people have dizziness as a complaint, it can be one of the most commonly misdiagnosed and mistreated conditions around. The challenge is that dizziness is a symptom that can be associated with lots of different conditions. Here’s a short list of conditions associated with dizziness:

Primary dizziness: Dizziness as a primary disease entity

  • Positional vertigo (BPPV)
  • Meniere’s disease

Secondary dizziness: Dizziness as a result of another problem

  • Stroke
  • Migraine
  • Concussion
  • Tumors
  • Medications

On top of that, dizziness means something different to different people. Does your dizziness feel like spinning? Rocking? Feeling off balance? Light headedness? Sometimes the feeling of dizziness can be hard to describe because you just feel disoriented and lost in space.

All of these factors are important to help a doctor get the right diagnosis.

It means that a doctor has to take a good health history, perform the right bedside tests, and order the appropriate diagnostic testing to find out the cause of your dizziness. Without knowing what’s causing this feeling, then administering the right treatment can be a lucky guess at best, or make you more dizzy at worst.

It’s no wonder that people who have chronic vertigo and other balance issues often see their primary care doctor, neurologist, ENT, physical therapist, acupuncturist, and more looking for answers on how to get their world to stop moving.

Dizziness is Even Harder to Treat

Another challenge with dizziness patients is that medications don’t really do a good job of making the world stop moving. Many patients with chronic dizziness are placed on anti-depressants, anti-anxiety meds, and drugs for nausea. The problem with that is that the patient may not be as nauseated, but their brains are not responding to their environment appropriately.

Dizziness after spinning on a bat is easy to explain, but what if the world is spinning when you're standing still?

Dizziness after spinning on a bat is easy to explain, but what if the world is spinning when you’re standing still?

 Dizziness can also be treated by positional maneuvers like the Epley maneuver and head shaking exercises like gaze stability. Both are extremely effective when they are used appropriately, but can be useless if it’s performed on the wrong patient with the wrong diagnosis.

That’s why it’s so important to know what’s really going on with a patient. Many clinics will take any person with dizziness and just do some of these maneuvers even though the maneuvers may not be appropriate for the patient’s specific condition. In order to help a patient recover, we have to examine them closely to make sure that we have the right information to begin care.

Case Study: 

Recently we had a patient come in with dizziness and had been seeing an ENT for treatment. She was having problems feeling off balance for a while and it was made with head turning sometimes. She wasn’t experiencing a spinning type sensation, but just a sense of feeling out of sorts.

The doctor diagnosed her with benign paroxysmal positional vertigo or BPPV. It’s arguably the most common form of vertigo and is usually easily treated with a positional maneuver called the Epley maneuver. The doctor performed Epley and gave her some alternative maneuvers that she could do at home whenever she felt dizzy.

The problem was that the maneuver wasn’t changing anything. She tried doing the maneuvers for several weeks with no change. When she followed up with the doctor, the doctor told her there wasn’t anything else he could do and that some cases don’t respond.

Fortunately the patient found her way to our office through a referral from one of our patients who got really great results with balance problems

BPPV usually causes a spinning sensation that is really short lived. In many cases, doctors can diagnose BPPV with a test called the Dix-Halpike maneuver. You can look at this test below. If you have BPPV your eyes will start moving making a fast oscillating movement called nystagmus.

It’s this nystagmus when the inner ear moves the eyes that creates a feeling of spinning.

When this patient came in, we did a thorough history and found out that her “vertigo” didn’t have any spinning at all. She just felt disoriented and off balance. We performed the Dix-Halpike test and she had her eyes stayed solid.

So now we knew that she probably didn’t have BPPV, and that’s why the Epley maneuver didn’t work that well for her. It was time to figure out what other anatomy might be causing her problem.

We did a test called the smooth pursuit neck torsion test. It’s a test developed from patients who had dizziness after whiplash. It’s an indicator that the neck might be causing the eyes to move abnormally. You can see that test here below. In patients with neck problems, the eyes will start jumping instead of staying smooth.

Now that we knew the neck could be a problem, we started addressing the neck using the NUCCA procedure for structural correction.

Within 2 visits, the patient’s dizziness was about 80% gone. We have more work to do to help the neck heal, but with some time I think this patient will get back to normal.

Find the Cause, Deliver the Solution

So this isn’t an indictment on another professional. Lots of ENTs keep their focus on infections of the ear, nose, and throat. An ENT with a neurology background would probably have found the same thing and recommended physical therapy or chiropractic care.

The lesson here is that dizziness is complicated, and one treatment won’t solve all forms of dizziness. For any condition, we have to spend time with our patient, listen to their history, examine them thoroughly, and we can find a game plan to help them get back to normal.

Talk to Dr. Chung

 

 

The Craniocervical Junction and Headache Disorders

CCJ-and-headache

 

  • Chronic headaches come in different types
  • The neck and headache disorders
  • The craniocervical junction, NUCCA, and migraines

Headaches disorders are among the most common conditions that people seek treatment from a doctor. While most people will experience a headache of some form,  there are those who develop chronic and repetitive bouts with headaches of different types.

Each headache has unique characteristics that help to make an effective diagnosis for effective treatment. However, when we look at the reality of a daily patient interaction, we see that people with these headache disorders can have traits that overlap. (Remember this point because this is something I’ll come back to later)

That makes these headaches  extremely burdensome on the patient, but it can also be challenging for a doctor or therapist to find effective solutions. The chronic use of medications has led to the emergence of medication overuse headaches as the third leading cause of chronic headaches in the United States.

Medication overuse headaches were once classified as rebound headaches because of the way headaches could come back with a vengeance after the pain-relieving effects of a medication wore off. It became re-classified in part due to the alarming number of patients showing a regression in their headache symptoms after prolonged and frequent use of medication. While the physiology of this disorder is widely unknown, it does show characteristics of physical dependency as seen with drug withdrawals.

As drug therapies become less effective for this subset of headache patients, there has become a growing need to identify non-pharmacologic strategies to help patients with headache disorders. For many of these patients, a possible solution might lie in the neck.

The Neck and Headache Disorders

Headaches caused by a neck problem are usually classified as a subtype known as cervicogenic headaches. People with cervicogenic headaches are usually those with chronic headache along that is associated with neck pain, whiplash, or a resistance to most medications.  Studies on chiropractic and cervicogenic headaches are mixed, but it is mostly accepted that these types of headaches can be responsive to traditional spinal manipulation [1].

The study of these headaches has helped us understand the neurology behind head and neck pain in general. There’s a lot of really sensitive anatomy in your neck. Structures ranging from the muscles, ligaments, joints, nerves, arteries, and nerves. Things like whiplash, concussion, and even sub-concussive head injuries can damage some of these structures causing pain receptors to fire into your brain stem.

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 disorders

That’s where things can get a little bit screwy. The area in the brain stem that gets pain signals from the neck also receives pain signals from the head and face too! When nerve fibers from different parts of the body converge onto one location called the trigeminocervical nucleus (TVN), it allows for 2 things:

  1. It allows dysfunction in what part of the body to be felt in other parts of the body. It’s like when you have a pinched nerve in your back but you feel it in your leg, or when someone has a heart attack, they may feel it in their left arm.
  2. It allows the opportunity for treatments in one part of the body to have the ability to reduce pain in other areas. i.e – targeting TMJ and the neck to help with head pain

But What About Neurovascular Headaches Like Migraine?

Neurovascular headaches are those attributed to problems in the blood vessels in the head or brain. Migraine and cluster headaches are the main classes of chronic neurovascular headaches.

From a basic science standpoint, the neck still seems to be a problem area for migraine patients. We also know that patients with migraine also tend to have overlapping pain in parts of their neck too. However, from a clinical research standpoint, most studies on treating the neck in migraine patients have been underwhelming.

Findings like these challenge my beliefs because while I know the research says that treating the neck is not likely going to get you far, the results in my practice seem to dispute that.

The Cranialcervical Junction and Headaches

As an office focused on upper cervical chiropractic, we often see headache patients who have chronic and treatment resistant headaches. They’ve usually been through multiple rounds of different medications and have bounced around through various specialists from renowned neurologists, to local chiropractors.

Despite seeing these patients with significant challenges, our success rate in chronic migraine headache is pretty high. About 85% of our patients with a primary complaint of migraine headache reported a favorable outcome after 8 weeks on a progress exam.

 

How I imagine Brad Pitt would react if he had chronic migraines and didn't anymore

How I imagine Brad Pitt would react if he had chronic migraines and didn’t anymore

Of course I wish everyone got better, and I spend a lot of time reading and going to seminars trying to get answers for the other 15%. We just have a high degree of confidence that even some of the most challenging headache cases seem to do well when we address the upper neck.

If so many people get relief in our office, but clinical trials on chiropractic show limited effect, then what gives?

The big thing is that I don’t practice the same way that most chiropractors practice. Our office uses precise x-rays of the top of the neck called the craniocervical junction and we use very low-force techniques like the NUCCA procedure to address the neck. We also take pre and post x-rays to verify that we’ve changed the way the head sits on top of the neck.

  • Maybe previous chiropractic studies didn’t use techniques that accurately identified the problem area in the spine?
  • Maybe the way the spine was manipulated was not well suited to the specific patients?
  • Maybe the adjustments used didn’t actually show a structural change in the craniocervical region? It’s hard to say.

However,  a small 2015 study on patients suffering from chronic migraine headaches showed that the correction of the atlas vertebra using precise upper cervical methods showed a reduction in headache days and high patient satisfaction.

Obviously we can’t generalize these findings to every migraine patient because there was no control group and migraine studies have a high rate of placebo, but this is clearly something worth studying more.

Is It Worth It?

So I can’t tell someone if getting their atlas corrected is going to be worth it. For many people, the prospect of having far fewer headaches is worth any price. For others, you may have become so used to having headaches that you have learned to live with it and don’t mind the pain.

What I can say is that getting the atlas corrected through the NUCCA procedure is a really safe way to address some of the real anatomical and physiologic causes of many headaches.

The only things I can say for sure are this:

  1. If your atlas is a major cause or contributor to your headache syndrome, we’ll know it pretty quickly as you will likely respond to this within a few weeks.
  2. We will do everything in our power to help you find solutions to this disabling secondary condition, even if it means we have to refer you to another provider that is better equipped to help.

 

Talk to Dr. Chung