Get to Know POTS

Postural Orthostatic Tachycardia Syndrome or POTS is a form of #dysautonomia.⁣

It used to be a rare diagnosis that often left many patients (especially women in child bearing years) left with a diagnosis of a psychiatric disorder or hysteria.⁣

Thanks to increased awareness of the phenomenon and accessible ways to test for it at bedside, we now know it is something that is actually fairly common, especially as it presents with other illnesses.⁣

Fundamentally, POTS is a miscommunication between the brain and the body’s organ systems. This miscommunication can happen in different ways and thus have different types of PoTS.⁣

Most commonly, there appears to be a loss of sympathetic nerve activity to blood vessels in the legs. This causes blood to pool in the lower body, and the heart has to compensate for less blood flow by pumping faster, but less efficiently.⁣

We now know that POtS can also be associated with low blood volume and hyperactivity of the sympathetic nervous system. Recent evidence also suggests a strong autoimmune relationship, as more PoTS patients are testing positive for various autoantibodies.⁣

While most therapeutic approaches focus on treating peripheral findings in POts, functional Neurology has found that a rehabilitation strategy focused on central decompensation can actually help many PoTS patients get their life back.⁣

In addition to the forms of POTS we see on paper, I think we will find greater evidence for dysfunction at the level of the Brainstem to be a major contributor to POTS physiology which allows for a dynamic rehab strategy. In fact, this rehab strategy is that different from what we do for concussed patients!⁣

#neuroscience #neuroplasticity #POTS #fibromyalgia

The Beautiful Brainstem

The Beautiful Brainstem


The brainstem is arguably the most important area of the brain in terms of keeping us all alive. Most medically educated people know that the Brainstem is tied heavily towards our ability to breathe and maintain heart rate.⁣

But the Brainstem does so much more! It’s a bottleneck point for neural transmission the entire body, so lesions of the Brainstem can impact any other part of the body.⁣

When we look at the function of the Brainstem, we usually separate the anatomy into 3 regions.⁣

• Midbrain⁣
• Pons⁣
• Medulla⁣

By knowing the function of each region, we can examine a patient and get a sense for any possible dysfunction, especially when we evaluate a patient’s cranial nerves.⁣

A patient with impaired ability to move their eyes up and down may have midbrain dysfunction. A patient with issues with their face/jaw may have a problem at the Pons. A patient with nausea signs and balance problems likely has issues in the medulla.⁣

By understanding these issues, it can help us see if a patient has a serious , life threatening issue that needs special tests or referrals. It can also help us design rehab for patients if these issues aren’t pathological.⁣

Either way, looking at the anatomy and physiology of the Brainstem can create a sense of awe, as you understand that this small chunk of brain is responsible for so much of what makes us alive.⁣

Chronic Pain Structurally Changes our Brain

Chronic Pain Structurally Changes our Brain

Our brains are made up of gray matter and white matter. ⁣

Gray matter is made up of pools of neurons that are responsible for specific tasks.⁣

White matter is made up of axons which carry the information from our neurons to another region of the brain or body.⁣

When we look at how chronic pain changes our brains, multiple MRI studies have shown that size of gray matter in our brains decrease. This is observed in parts of the brain that are associated with the painful body region, but it also affects other areas of the brain that affect us emotionally and cognitively.⁣

We don’t necessarily know the exact implications of this, but it’s been suggested that decreased gray matter may be associated with decreased functionality of those brain regions. This is mostly driven by aging research where decreased gray matter is associated with declining cognition.⁣

This may be a mechanism for how chronic pain can have downstream affects on cognition, autonomic function, and depression.⁣

The good news is that these changes in gray matter are actually reversible!⁣

Studies have shown that when pain is reduced or eliminated, some of these brain changes actually start to increase again.⁣

We know that pain has a functional purpose in the acute phase, but chronic pain can be quite detrimental.⁣

While we can’t always rid someone of pain, having the ability to reduce pain and the consequences of pain is really important. It’s also really important to develop emotional and cognitive strategies to best manage painful syndromes as well.⁣

Autoimmune Disease and Chronic Pain

As a chiropractor, I encounter a lot of patients with a variety of pain issues. In school, we learned to recognize a lot of the skeletal changes that can happen in a patient with #rheumatoidarthritis and #ankylosingspondylitis so we had some training with autoimmune disease.⁣

However, it wasn’t until my wife was diagnosed with lupus where I really learned how tricky these illnesses can be, and how important it is to investigate a patient’s history for autoimmune disorders.⁣

Being able to recognize these diseases early is so important to the patient’s future health. Had we known that lupus was the source of my wife’s joint pains, we would have treated way earlier, and avoided the catastrophe that resulted in a one month hospital stay.⁣

This has taught me to really investigate a patient’s history and exam much more thoroughly than ever before.⁣

We want to know if your family has a history of inflammatory disease. If your pain comes with redness and swelling. If multiple joints are affected by “flares” of pain.⁣

As soon as we identify these signs, we immediately start having patients request bloodwork and work with a rheumatologist to get the inflammatory disease treated.⁣

This doesn’t mean that chiropractic or rehab can’t help the autoimmune patient, because it can be extremely helpful! Tools like exercise, adjustments, cold laser, and vagus nerve stimulation can be powerful adjuncts for the arthritis patient.⁣

Sometimes it is helpful enough where the patient’s pain is improved despite an active autoimmune process which may not be a good thing in the long run.⁣

If we want to “correct causes” then we don’t want to delay something that could be life altering later on.⁣

Concussions and Helmets

Concussions and Helmets

A lot of time and resources have gone into methods to reduce concussion in sports. There’s a lot of speculative stuff out there, but most of it has yet to be proven in a meaningful way.⁣

The biggest myth is that newer generation helmets can protect against concussion in football. The evidence on this is really poor. ⁣

The problem is that a helmet was never really intended to prevent a concussion. It was meant to protect against skull fractures!⁣

Our helmets do a great job protecting our bones from breaking, but they can’t really stop the transmission of forces that travel into the brain and shear some of those delicate axons.⁣

Some have even made the case that because helmets protect our skulls so well, that new helmets have been increasingly weaponized in tackling forms that may increase concussive injury. For better or worse, rules against targeting have started to reduce this problem.⁣

So what can protect us from concussion in sports?⁣

So far the best evidence is to avoid head and neck contact, especially in earlier age groups.⁣

There are studies going on looking at therapeutic tools like vision training, neck muscle training, specialized mouth guards, and specialized neck collars.⁣

The truth is that the evidence for these things are still early and flawed, so we can’t say anything with confidence yet.⁣

In the meantime, the best things we can do is to make ourselves maximally prepared in strength, awareness, and reaction time so we can avoid the hits that may cause our brains harm.⁣

The Trigeminal Cervical Nucleus – Headache, Neck Pain, Facial Pain, and More

This region of the brainstem and upper spinal cord is really important for our perception of our head, neck, and face. This is especially true in terms of pain.⁣

Pain experienced in the head/neck/face have strong and fast connections to areas of the brain associated with autonomic and limbic consequences. That means that pain in these areas have a greater probability to have effects on emotions and organ function, which may explain why nausea and heightened distress and suffering are tied to chronic pain in these regions.⁣

The reasoning is that these areas can have strong direct connections to pain modulating areas of the brain. They also have been shown to have strong effects on blood flow patterns in the arteries of the brain in animal models.⁣

For practical purposes, we have to consider that pain in one part of the head/neck/face may be coming from another area with similar neurological origins. We should also consider that if someone has pain in one region, that we can treat another region to modulate the pain response as the actual source of injury may be too sensitized and makes the patient feel worse.⁣

The important takeaway is that we don’t necessarily need to treat the exact site of pain in order to get a good outcome⁣

Pain is tricky and can fool us, but an understanding of neurology can sometimes help us work around it.⁣

Healing isn’t linear.


A lot of people have gotten into the stock market in the past year. In many ways, investing and trading can be similar to the healing process.⁣

We all wish that our healing and recovery would just go up in a straight line, but unfortunately it doesn’t work like that most of the time.⁣

We all wish healing moved like a straight line. Always getting better without any setbacks

When you are recovering from an injury or a chronic condition, even if you are doing everything right, you will have up days and down days.⁣ On up days, it’s easy to convince yourself that you are fixed or cured. On down days, it makes you think that your condition is hopeless and you’ll never get better.⁣

In reality, healing has ups and downs. Sometimes we feel bad even though our bodies are moving forward

Sometimes we have to zoom out to see where we have come from in order to know if we are going in the right direction.⁣ In our office, we like to look at the trend of someone’s progress. We like to see if a person is having more good days than bad, and if their ability to cope with bad days gets better.⁣

Flare ups can happen, especially with chronic #dizziness #fibromyalgia #rheumatoid and #postconcussionsyndrome.⁣



Some days it feels like we are spiraling downward and that what we are doing isn’t working…..

On those red days, it’s important to zoom out and see which direction your health is trending.

It’s hard to keep the energy to focus on progress when you don’t feel well, but it’s really important to develop that resilience so you don’t give up on your recovery too soon.⁣

Remember, that it is important to know that you are making the right investment into your health. Don’t treat your body like a meme stock that will shoot up 1000% overnight but has a high chance of crashing.⁣

Keep investing into the things that have proven benefits over time, and your health portfolio will continue to grow.

#neuroplasticity #neuroscience #rehab #stonks #crypto

Otolith Dysfunction: A Forgotten Cause of Dizziness

This month we have had a couple of dizzy patients who have been getting vestibular rehabilitation for a few months, but have continued to struggle with a sense of imbalance and dysequilibrium.⁣

They initially had a pretty bad vertigo attack from a likely viral infection, but they haven’t felt vertigo since their initial attack. Although they don’t spin anymore, they can’t shake the sense of feeling like they’re tilting or being pulled off balance.😵‍💫🤢⁣

Vestibular and balance rehabilitation is fantastic at addressing most of these cases, but some cases seem resistant to head shaking and balance training exercises.⁣

What gives???? 🤷🏻‍♂️🤷🏻‍♂️🤷🏻‍♂️⁣

Many patients will have caloric and #BPPV testing done when they see an ENT which tests function of the 𝘀𝗲𝗺𝗶𝗰𝗶𝗿𝗰𝘂𝗹𝗮𝗿 𝗰𝗮𝗻𝗮𝗹𝘀 and 𝘃𝗲𝘀𝘁𝗶𝗯𝘂𝗹𝗮𝗿 𝗻𝗲𝗿𝘃𝗲, but many people don’t get the otolithic organs tested.⁣

Otolith dysfunction can be tested using electrical myographic tests called VEMPs, but are not done commonly.⁣

Another simple way to test it is measuring subjective visual vertical testing.⁣

This test allows us to see if you are perceiving then world on a tilt.⁣

When your otoliths don’t work, your brain doesn’t perceive gravity well, and your eyes may roll the wrong way and cause an abnormal head tilt.⁣


You may not realize the world is crooked because your brain is really good at using context clues to make your world straight. I.e- your brain knows that the horizon is level, so it will reorient your view to make that level.⁣

We can test it by blocking out most of your vision except for a line, and ask you to make it

⁣If we know the otolith is malfunctioning, we can do different therapies using tilt, specific ear vibration frequencies, or even e-stim to activate the otolith and straighten out your visual vertical.⁣



#dizzy #vertigo #neuroplasticity #neuroscience

Hidden Drivers of Chronic Pain – We Have Been Thinking About Pain All Wrong


What if what we always knew about chronic pain was wrong? 🤔

We are conditioned to think about pain as a direct product of injury. Because of this, we have strong, but incorrect assumption that the severity of pain correlates with the severity of injury.

These beliefs may be true for acute pain or injury, but they have poor carry over to chronic pain conditions. In fact, taking these beliefs into a chronic pain condition likely promotes nocebo and likely worsens outcomes in painful conditions.

As patients and health providers, we put most of our collective energy into the biological factors in pain.

  • structural issues
  • Inflammation

But we have a strong tendency to discount the psychological and social factors that contribute to pain.
– Fear and avoidance of movement
– False beliefs about the nature of pain
– The role of depression and anxiety in magnifying pain conditions
– How our friends and family deal with pain (walk it off vs rest till it’s better)

While addressing the biological factors is important, the psychological and social factors behind pain might be most important in having enduring results.

Without addressing the psycho and social aspects of pain, patients are often in a roller coaster of temporary relief going from doctor to doctor or treatment to treatment never satisfied.

This starts in our office with a change in belief. A belief that your body is strong and anti-fragile. A belief that the body is self-healing and is always striving to maintain homeostasis.


In a perfect world, we hope that our patients start feeling better before we even put our hands on them because they are starting to embrace a stronger, brain-centric view of life and health.

Keystone Brain Bytes Episode 4 – The Vestibular System in Memory and Cognition

Keystone Brain Bytes Episode 4 – The Vestibular System in Memory and Cognition


On this episode of Keystone Brain Bytes, Dr. Chung talks about the impact that the vestibular system has on memory and cognition.

  • Did you know?
    • Scientists used to destroy the vestibular nerve in rats, and rats struggled to get through mazes. They also had difficulty finding their home and places where food was left
    • Patients with vestibular loss have problems with spatial intelligence and spatial memory
    • Vestibular loss is associated with specific forms of Alzheimer’s disease

Learn more by checking out our latest episode. Make sure you like and subscribe to the channel if you like the content