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.

Ask our Doctors a Question

 

A Gentle approach to chronic pain

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 predator

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: 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

 

 

CCJ-and-headache

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

 

 

A Letter to My Patients – A Doctor’s Migraine Experience

A letter to my patients

 

To all of my patients and those soon to be,

In my 7 years of practice, I’ve had the honor of taking care of many of you when you have suffered from a variety of terrible health conditions. Thank you for putting your trust in myself and my staff.

Don’t worry, this isn’t a farewell letter. I’m not going anywhere anytime soon.

This is a letter to let you know that for all the trust you have placed in me to take care of you, I don’t think I was serving you to the very best of my abilities.

Don’t worry, it’s not because of a lack of training or ability to give a great atlas correction. I will always stand by my work there.

It’s because until recently, I don’t think I was able to truly understand what many of you have felt on a daily basis. It wasn’t until I got a taste of the throbbing pain and the nauseating sickness of a migraine that I could feel a deeper sense of connection to what some of you have felt for years.

Throughout my life I’ve always been fairly healthy. I’ve had some of the headaches, stomach aches, and shoulder injuries but these problems came and went without much assistance from other doctors. Even my introduction into chiropractic was less about treating any pain or symptoms, it was really about correcting the structure of my spine so I could experience what it was like to have optimal structure and better health.

Last month I got sick for the first time in several years. I can’t even tell you the last time I had a cold. I got hit with a terrible fever for 24 hours after a light workout. I came home to a feeling of chills followed by a long night of sweats and a 103.5 degree fever.

After a restless night of sleep, I noticed that I still didn’t feel quite right. I went into the office the next day in a daze that I couldn’t shake. That afternoon, the headache hit. My head started pounding and just the normal light and sounds of the office seemed to overwhelm my senses. I was nauseated and the only thing that seemed to be less terrible was just to put my head down and close my eyes.

I made it back home and just lied down in the dark. I didn’t want anything to drink, and I didn’t want any dinner (which if you know me, then you know this has to mean that I was in bad shape). It was too late to see my chiropractor, and anti-inflammatories didn’t really budge the pain.

All I could do was close my eyes, endure, and wake up tomorrow with the hope for a better day.

The next day I got to wake up feeling a little hung over, but after getting an adjustment from my chiropractor I bounced back to my normal self pretty quickly.

A lot of people don’t get to have that luxury, and I feel for them.

I’ve always known intellectually that living with chronic pain and illness must be a terribly difficult existence. However, it’s difficult to feel that struggle until you’ve experienced a taste of it for yourself.

I will always strive to improve my skills as a clinician to deliver the best care I possibly can to my patients. And even though I’ve often praised for my bedside manner, I think this short but temporary bout with the debilitating feeling of a migraine will make me a better and more compassionate doctor for you all.

Sincerely,

 

Jonathan Chung, DC

 

TMJ and neck

Why Pain Can’t Tell You Where You Need Treatment: A TMJ Case Study

TMJ and neck

Jaw pain/TMJD is a very frequent problem we see in the office. It’s so frequent that I spend one day each week inside of a dental office in West Palm Beach doing consultations with a great local area dentist that specializes in pain syndromes of the jaw.

Most of the patients that see us with jaw pain have already seen a variety of jaw specialists. They’ve had MRI’s done, mouth pieces made, and various therapies done on the area of pain.

The problem of course is that pain, especially chronic pain, does a poor job of telling us what is wrong with you. Chronic pain is complex. Chronic pain is misleading. Chronic pain is also a poor locator for pathology.

Identifying the Pain Source

One of the common questions asked during a case history is to highlight or point to the area where you feel pain. It can be useful sometimes when pain patterns are reflecting specific nerve roots, and it also gives a general vicinity for a doctor to examine more closely. For most cases of chronic pain, examining the area of injury often leads to dead ends. There’s no damaged tissue to treat or remove that’s likely to explain why someone hurts.

Patients with TMJ pain frequently seek the treatment of these specialized dentists, and most of them do really well when in the right hands. However, sometimes jaw pain isn’t truly a problem in the jaw. Sometimes it’s a pain problem somewhere else in the body.

I recently took care of a patients who were was referred by another chiropractor. The patient had been to 6 different jaw and mouth specialists but could not get any form of relief from treating the jaw.

When we examined the patient, we didn’t pay much attention to the jaw itself. The patient already had imaging and tests done to their mouth already, so I wanted to spend my time elsewhere.

We found that the patient had poor motion in their shoulder and neck area on the right side. They were also showing a large amount of forward head posture characteristic of anterior head syndrome. Surprisingly, the patient’s jaw seemed to move pretty well. There wasn’t the clunky abnormal opening and closing of the jaw that you would usually see in a TMJ where the jaw displays a large side to side movement. From my view, the patient’s jaw movement looked really great, but the patient’s neck was moving poorly.

Correct the Neck and Pain Self-Resolves

We did our normal protocols with this patient. We did a gentle NUCCA correction to the patient’s neck. We post-x-rayed the neck to verify a neck improvement, and then we waited. You can see the x-ray results below.

Pre and Post X-ray shows a small shift, but an almost perfect correction.

Pre and Post X-ray shows a small shift, but an almost perfect correction.

3 days after her first appointment, we had our first follow-up appointment scheduled. The patient had gone 3 consecutive days without any jaw pain at all for the first time in 2 years!

Pretty good, but would it last?

3 months later, we re-examined the patient. The patient was now going 1 month between appointments because it would be important to see if the patient could go that long a distance between appointments without pain. The jaw was still moving normally, but now their head and neck could move in all ranges of motion smoothly. The patient also stopped showing a persistent right tilt of their head.

Most importantly, the patient could now talk with no restrictions, and had no more food limitations on what she could eat. For all intents and purposes, she became a normal teenager again.

Final Thoughts

Now if we had kept on trying to treat the jaw and identify pathology in the jaw, would she still have gotten better?

It’s hard to say, but after 2 years of doing every jaw therapy under the sun, it just seemed to make sense to look at other pieces of anatomy.

The complexity of chronic pain often means that we can’t look at things linearly. We have to know that someone has pain in one region, but we also have to think about all the different anatomy that shares a connection with the part of the body that hurts. This doesn’t mean that every person with chronic jaw pain will get better from a neck adjustment, because that’s not true either.

It means that we have to take care of people and see them for what they are globally instead of treating them as an object with a specific piece of meat that hurts today.

 

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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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