A Brief Tour of Your Immune System

For the past 10 years, I’ve spent my free time and creative energy learning and teaching about neuroscience and the human nervous system. It’s why our office has evolved to integrate neuroplasticity in our clinical practice.

However, there was a time where I was a major in Microbiology/Molecular Biology, and I was enamored with the study of the immune system.

With all of the time we have social distancing because of the spread of COVID-19, I wanted to see if there was interest in people learning about the immune system and the brief intro on Instagram really took off, so today we’re going to take a brief tour of your immune system and how it protects us from bacteria and viruses.

Innate vs Adaptive Immunity

Your immune system has 2 major divisions: innate immunity and adaptive immunity. They’re made up of different cells and attack germs in different ways. Both are equally important, and both rely on each other for a comprehensive response to potential infection.

Innate Immunity – The first line of defense

The innate immunity is considered your first line of defense. It includes physical barriers like your skin and nose hairs which provide a wall to prevent entry from foreign invaders. It also includes things like mucous and stomach secretions which can entrap or inactivate proteins that may cause us harm.

From a cellular stand point, we have groups of white blood cells that are the first to show up whenever a bacteria, virus, or organism that breaks through the physical barriers. Your innate immune response acts immediately, and is usually responsible for the initial inflammation and swelling you see after you have a cut on your skin.

You can see the main players in the image below:

The different cellular components of your innate immune system

These cells form a general response to anything thing that isn’t part of your own body. Some cells like macrophages and neutrophils can literally eat bacteria on the spot.

A neutrophil engulfing a rogue bacteria.

Other cells like basophils, mast cells, and natural killer cells have granules that acts as chemical weapons that can contain or slow down an infection, or act as a controlled demolition if a cell gets infected.

All of these cells work together in harmony to contain or eliminate an infection before the big guns of the adaptive immune system get involved. They also act as the scouting report or reconnaissance team of the immune system because they teach your other immune cells what the germs look like, and the potential weaknesses of the germ.

In a perfect world, the innate immune response eliminates the threat and doesn’t allow germs to spread. The innate immune system encounters germs all the time and we don’t get sick, because the infection is small enough to keep to keep from spreading.

Adaptive Immunity – The Big Guns

If a virus or bacteria gets through the first line of defense, then adaptive immunity has to kick into gear which involves an extensive process of finding a germ’s weakness and creating an army of cells to dominate it.

A simplified breakdown of the adaptive immune response.

The adaptive immune response uses a different type of white blood cell called lymphocytes. Lymphocytes are like the equivalent of a military special forces team. Each cell is trained to recognize just one type of threat and to neutralize or eliminate it with brutal efficiency.

These lymphocytes can be divided into two types: T-cells and B-Cells. While these cells are very potent, they take days or weeks to develop an effective response to eliminate a new infection.

T-Cells:

T-Helper cells are specialized T-cells which act like generals for the immune system. They patrol your body looking for any signs of the infectious organism, and they emit chemicals called cytokines to recruit the other immune cells to go in and attack infected cells or the organism itself. These are the cells that are destroyed by HIV, so when you lose these helper cells, it is extremely detrimental to the immune system as a whole.

Cytotoxic T-Cells are the immune systems demolition team. When the cells of your body get infected by a virus, it’s critical to prevent the spread of the virus that occurs when a virus overwhelms a cell. Fortunately, your cells have a self-destruct button that allows a cytotoxic T-Cell to come in and turn on the self-destruct switch which takes the viruses down with it.

How a Cytotoxic T-cell limits the spread of viruses.

B-Cells

B-cells are the immune cells that have the important job of making antibodies to fight infection. Antibodies are the immune systems primary weapon for overwhelming or inactivating a virus or bacteria.

While it’s not full proof, one of the ways a lab can tell if you are immune or have been exposed to a virus is by testing you for antibodies against the virus. For most cases, if you can produce antibodies against an infection, you are much less likely to get sick from that infection (HIV being one of the important exceptions to this rule)

When your immune system knows what type of infection to attack, it turns your B-cells into plasma cells which are basically antibody factories. Your plasma cells go on to flood your blood stream with these special weapons designed to target a specific virus, bacteria, or toxin to get an infection under control.

The evolution of a B-cell to a plasma cell for antibody defense.

Memory Cells

Probably the coolest part about about your adaptive immune system is that it can retain a memory of previous infections through memory cells. If you have successfully fought off a virus, you are unlikely to get sick from the same strain of the virus again. All of the activated Plasma cells and B-cells that fought off the germ will start to die off because you don’t want your immune system in staying in war mode all of the time or else you will be more prone to autoimmune illness.

Your B-cells and T-cells will just form memory cells that are not actively fighting, but just hanging out in your tissues. If your innate immune system or your memory cells encounter the same strain that made you sick before, the memory cells will quickly form activated plasma cells and T-cells

Instead of taking days or weeks to form a response, your immune system uses these memory cells to form a response within hours.

That’s why if you get sick from a strain of the seasonal flu, the same strain of the flu won’t make you sick again that season because these cells are ready to go.

Final Thoughts

This is just a very basic run down of the big players in your immune system. The levels of complexity that go into how this system operates are far beyond the confines of this article.

At the end of the day, here’s what matters:

  • Your body is constantly fighting off viruses and developing immunity and most of us have the tools to do this effectively.
  • Persistent stress is known to be immunosuppressive. Getting stress under control and avoiding panic is a critical part of having a robust immune response.
  • Besides Vitamin C and Vitamin D, we don’t really know what “Boosts” the immune system. Protect yourself from charlatans who are trying to boost your immune system when we really have no idea because of the insane complexity of this system.
  • The same things that you would do to maintain a healthy body are the same things that help your immune system stay healthy. Don’t simply try to do things to boost your immune system. Maintain a healthy body, don’t be an insane germaphobe so your immune system can have routine exposure, and maintain a reasonable amount of hygiene so your immune system doesn’t get overwhelmed.

The Nocebo Effect: When Our Words and Beliefs Make Us Sick

Most everyone knows about or has heard of the placebo effect; the seemingly magical ability for our bodies to feel better or overcome illness from a belief in a treatment that has no effect.

It’s one of the things in medicine that we are always wary of, especially when selecting treatments associated with alternative medicine. After all, no one wants to waste time, energy, or money on something that isn’t supposed to work. It feels like you’re getting scammed, even if the end result is positive.

However, there is a lesser known effect that I believe is more harmful phenomenon that isn’t being discussed enough. It’s more pervasive in the entirety of healthcare, and it’s societal ramifications can have massive implications on outcomes related to your own health.

We’re talking about the Nocebo Effect

Nocebo, No Bueno

Where positive beliefs about a treatment lead to positive health outcomes in placebo, nocebos occur when negative beliefs about a treatment or condition lead to negative health outcomes.

We don’t really think about nocebos because in the context of healthcare, we are not really encountering clinicians or practitioners who are intentionally trying to to make us feel worse. It’s just a poor business model.

Nocebos affect us in much more subtle ways. They happen when patients have false or exaggerated beliefs about a treatment, condition, or situation, and these beliefs can often come from well-intentioned providers or social media influencers.

Here are some of the examples of known nocebic responses in society:

  • People who think they are sensitive to MSG and feel sick after eating Chinese food with suspected MSG, but feel perfectly fine eating MSG-rich snack foods. David Chang tackles this in his series Ugly Delicious on Netflix. You can watch the clip here (Warning: uses the F-word a few times). I’m not saying that people can’t be sensitive to MSG (probably really uncommon), but if you are sensitive to MSG in Chinese food, but not Doritos, then you’re not sensitive to MSG, you’re likely expressing a nocebo.
  • Patients who take a placebo pill in a drug trial and hear a list of potential side effects are much more likely to experience those side effects compared to patients without hearing the side effects. [Source]
  • In 1998, a teacher in a Tennessee school reported a “gas-like” smell inside of a school. The school was evacuated, and the ensuing panic from a suspected gas-leak led to over 100 students/staff going to the emergency room with 38 of them being hospitalized over-night. It turns out that it was a false-alarm and no leaks or chemicals were detected so the illness was attributed to a mass psychogenic illness. [Source]

But remember this because it’s super important:

People experiencing nocebos are NOT faking their illness. Their symptoms and experiences are very real, but the cause of their pain or illness is not what they think it is.


Our minds exert extraordinary influence on our bodies, but our minds are easily fooled for the better with a placebo, or for the worse with a nocebo.

Are Doctors Creating Nocebos?

One example we see often in chiropractic are beliefs about X-ray or MRI findings. Many patients after getting X-rays and MRI show signs of disc degeneration or disc herniation. Disc herniations in particular are known to cause radiating arm and leg pain, especially in the acute phase of injury.

Doctors frequently talk about disc herniations and tell people that they can’t play sports anymore or lift heavy things because they have disc herniations.

But the evidence is overwhelming in showing disc herniations don’t necessarily cause chronic back pain. In fact, most disc herniations are completely asymptomatic!

By the time we are 50, we will all have disc degeneration, and most of us will have bulging discs and we will walk, run, and exercise fine without any pain!

A large study using MRI on patients without pain showed that common MRI findings associated with pain are present in PAIN-FREE people as we age.

But if we have taken the patient with a disc herniation and convinced them that their back is weak from herniation and to avoid exercise, we are predisposing this patient to nocebo to one of the best things for the chronic back pain patient….EXERCISE.

As clinicians and healthcare providers, we have to be extremely judicious with our words when interacting with patients. We are responsible for knowing when something has life altering consequences and making the appropriate recommendation for care. On the flip side, we have to be informed and know when a diagnosis is probably self-limiting and allow the patient to feel empowered that they’re going to get better; with or without our help.

Combating Nocebos

None of us are immune to the effects placebo or nocebo because of the powerful influence that beliefs have on human physiology. Our brains love to create patterns out of noise in order to make sense of the world, and the easiest way to make sense of the world is when our perception matches our beliefs.

It is important that we have strategies that reduce the impact of nocebo because nocebos can decrease your ability to recover from chronic pain and illness.

I’ve seen so many patients come into the office that have become so scared of normal human behavior that they may as well wrap themselves in bubble wrap.

This isn’t a way for a human being to live.

So how do we counter the effects of nocebo? Here are some major factors I’ve seen in practice:

  • Never Make Your Diagnosis Your Identity: You would never willingly allow someone to steal your credit card and social security card, but you should be even more protective about what you allow to identify as yourself. When people make their diagnosis their identity, they become resigned to accept all of the possible negative consequences of their diagnosis as an inevitable part of their life.
  • Embrace the Idea That Your Body Is Resilient: One of the first things we teach patients in our office is that their body is capable of healing itself. Having a belief system that your body is capable of facing challenge and enduring allows people to have a condition or illness and not allow the condition to hold them back.
  • Don’t Trust Health Providers That Scare You Into Treatment: It’s one of my biggest pet peeves in the world when I hear other providers using a patient’s condition to scare and coerce people into procedures. I having patients coming in each week that have doctors telling them that a small herniation is a risk for paralysis if they get into another accident and that the only solution is surgery. I’ve also had patients whose chiropractor told them that they had the worst spine they’ve ever seen because they had some signs of age related disc degeneration on their X-ray. This. Is. MADNESS

As healthcare providers, we have to ensure that our words don’t compromise the ability for a patient to get better. When we use fear and scare tactics to coerce people into taking treatment plans, we not only abusing patient trust for financial gain, you are also compromising the outcomes of patients who simply want to get better.

We have to do better and help all of our patients combat this insidious plague on our patients by empowering people to have faith and confidence in their ability to heal.

Creatine N=1: Muscle Gains and Brain Games

I’ve been into weight lifting for about 20 years now. I started when I was a teenager in high school mainly because my high school baseball coach and the school’s weight lifting coach were the same person. Getting fitter and stronger was a necessary part of just getting better.

I grew to really love working out. I legitimately just felt better on days that I exercised. It also helped to have the testosterone of a teenager and young adult where really minimal training led to bigger biceps almost overnight!

But despite two decades of strength training, I never really got into the cycle of using supplements to enhance my training efforts. I didn’t have any philosophical stance against supplementation, it just wasn’t something I wanted to do for the extra money that I would use to spend on it. My main goal for exercise more about feeling good than about aesthetics, so why bother?

Fast forward to 2017, and I’m going through my stack of interesting papers about traumatic brain injury and neurodegenerative diseases when this guy shows up:

Creatine and Its Potential Therapeutic Value for Targeting Cellular Energy Impairment in Neurodegenerative Diseases

It’s been well known that creatine provides performance enhancing benefits for sport and training by improving the ability for muscles to use energy. Thousands of studies generally support this effect on muscle [Source]. It is known.

It Is GIF - It Is Known GIFs

Apparently creatine through it’s action on cellular mitochondria has therapeutic potential to help the brain.

Image result for whoa meme

Therapeutic potential is cool and all, but lots of things have biological potential. Was there any supporting data that showed supplementing with creatine could affect the brain? If it could, then it’s possible that just taking a cheap supplement like creatine could help with age related muscle loss on top off addressing some of the cognitive decline we all experience as we get older.

So what’s out there?

Creatine appears to preserve cognition during periods of neurologic decline and neurolgic stress. A randomized trial of creatine vs placebo on healthy adults under laboratory controlled oxygen deprivation with some striking results. [Source] While the placebro group tanked across multiple cognitive tests with oxygen deprivation, the creatine group not only showed reduced decline, but actually showed slight improvement in 2 domans of cognition.

Cognitive scores under oxygen deprivation. Creatine in black compared to placebo in white.

Creatine supplementation has also shown an ability to mitigate some of the cognitive effects of sleep deprivation, bipolar depression, and possibly traumatic brain injury. While creatine has shown promise in animal models of Parkinson’s Disease, it has been largely ineffective in improving quality of life in patient’s with PD.

But what about healthy individuals? The results get a little more fuzzy here. Studies have shown improved cognitive performance in healthy vegetarians and healthy aging populations, but results in healthy young adults were unremarkable.

So it looks like creatine has good upside for helping the brain during metabolic distress or metabolic decline, but young healthy people has slight or no difference.

N=1 with Dr. Chung

So that brings us to our current experiment. Being creatine ignorant all my life, I wanted to see what kind of physical, mental, and cognitive effects we might have by just taking 8 grams per day.

Here are some baseline physical numbers:

  • Weight 185 lbs
  • Bench Press: 225 lbs
  • Back Squat: Recent 310 lbs, lifetime 315 lbs
  • Deadlift: Recent 365, lifetime 400 lbs

For cognitive testing, I used a platform that we test in our office called Cambridge Brain Sciences and an app called Brain EQ.

Brain EQ:

Brain EQ App Pre-creatine scores and averages

Cambridge Brain Science Tests

Cambridge Brain Science Cognitive Test. Pretty average, but those years of teaching people Stroop makes me pretty good at Double Trouble

Mostly pretty average scores. Though taking these tests are humbling and make you feel like an idiot frequently.

In particular, I didn’t feel great about my spatial processing and my memory scores. No matter who you are, it never feels good to be on the bottom end of the bell curve, even if that curve is still average.

Ouch. I’m not as good at navigating space as I thought

So we had our baselines and now we did our creatine protocol.

I basically took 8 grams per day of Metagenics Creatine Monohydrate.

Kept my workouts and diet the same and I intentionally avoided any cognitive training to avoid a practice effect from baseline to followup. No other interventions done for roughly 4 weeks.

Results

Alright, so let’s see what happened.

Physical Numbers:

  • Weight: 192 lbs
  • Bench Press: 235 lbs (10 lb increase)
  • Back Squat: 325 lbs (10 lb increase)
  • Deadlift: 365 lbs (no change)
Image result for nod yes
So far so good

How about the cognitive scores?

BrainEQ: Mostly unchanged. My reaction time and speed on rapid scanning improved slightly, but I did worse on other scores.

Post Creatine: Brain EQ Scores some what worse except speed tests.

Cambridge Brain Sciences: Improved on 7 scores with 2 being a lot better. Did slightly worse on 5 scores.

7 Scores improved with 2 showing large improvement. 5 Scores worse.

The scores that improved the most naturally came from the tests I did worst on.

The Bad Scores that jumped up.

So What Does It All Mean?

Overall, most of the cognitive scores seemed to be the same. Many scores improved and some decreased but only one score appeared to show a statistically significant difference.

The scores that seemed to improve the most happened in the tests that I did poorer than expected so there was room for a regression to the mean.

My physical strength numbers were substantially better and I can only really attribute creating to the change. I’ve tried maxing out my back squat numerous times in the past 3 years, getting over 315 has always seemed like it was really out of reach.

Overall it looks like my short experience with creatine fits with what’s in the scientific literature so far

Being someone who is mostly cognitively normal, the literature seems to show that creatine doesn’t really change much in terms of cognitive scores.

However, in conditions of increased mental stress or potential nutrient deficiency, creatine seems to have the ability to buffer the cognitive decline in stressful brain states.

This might include:

  • Traumatic brain injury
  • Aging
  • Sleep deprivation
  • Post-exercise/exertion fatigue

Since creatine doesn’t appear to have much downside in patients with healthy kidneys, there seems to be a space where taking a daily dose of 5-8g/day can have some benefit in building the storage and availability of creatine for stressful events.

Final Thoughts

Some final thoughts. Overall I felt really strong and pretty good mentally during the experiment. However, it may be coincidental or not, I did have some digestive unrest and my bowel movements were noticeably decreased.

I’ll run the experiment again under similar conditions and again with high fiber plant heavy diet and see if this offsets some of those digestive effects.

Cervical Degeneration and Cervical Vertigo

Cervical vertigo is a controversial entity in the world of balance and vestibular disorders. It has generally been a diagnosis of exclusion when a patient is feeling dizzy but has no diagnosable pathology in the inner ear or brain.

The reality is that problems in the cervical spine are commonly linked to feelings of imbalance and disequilibrium. Cervical spine problems are rarely tied to the spinning rotational vertigo of someone having inner ear pathology. Most people with cervical “vertigo” really have which can include feelings of being really off balance, shaky, or a tilt like feeling of motion.

A 2018 study looked at how a degenerative problem in the neck can be associated with a diagnosis of cervical vertigo:

Mechanoreceptors in Diseased Cervical Intervertebral Disc and Vertigo

The study looked at patients with neck and arm pain related to cervical disc problems presenting for surgery. The patients were divided into patients with and without a complaint of vertigo. The patients with vertigo were examined to rule out other causes of vertigo like vestibular neuritis, benign positional vertigo, or stroke.

The research team examined the discs from patients with vertigo, without vertigo, and a control group of cadavers with no disc degeneration. The findings were really interesting.

In patients with vertigo, there are large increases in mechanical receptors in the degenerated discs compared to the patients without vertigo, and to the control group. These Ruffini Corpuscles help detect movement and position from your joints and muscles to help tell your brain what your joint is doing in space. Free nerve fibers are responsible for transmission of stimuli usually associated with pain. You can see the distribution below:

Patients with vertigo had significantly more Ruffini Corpuscles in their degenerated discs than the non-vertigo and control group. What does this mean for dizzy patients?
Patients with vertigo had significantly more Ruffini Corpuscles in their degenerated discs than the non-vertigo and control group. What does this mean for dizzy patients?
The data from the above chart in bar graph form showing increased receptors in the vertigo patients.

As expected, the patients with neck pain only, and neck pain with vertigo have a similar increases of free nerve fibers compared to controls. That’s probably why their neck is hurting.

However, a big reason why this study is interesting is because many people in the world of rehab and manual medicine would usually associate dizziness with a decrease in mechanical receptors in their spine, not an increase.

So what gives?

We don’t know exactly what this means, but it’s possible that increased density of these receptors may be transmitting excessive or erroneous information to the brain about the joint position.

The same group did a follow up study after they had performed disc surgeries on these patients. You can see the link to the study below:

Cervical Intervertebral Disc Degeneration Contributes to Dizziness: A Clinical and Immunohistochemical Study

During the study, they performed surgery on 50+ patients and 25 patients refused the surgery and received basic physical therapy and cervical collar recommendations. You can see the results below:

Comparison of patients with cervical dizziness and neck pain getting surgery vs routine physical therapy and neck bracing.

You can see that the patients who had the neck surgery showed clear and long lasting improvements in both neck pain and dizziness compared to the conservative group which implied that the degenerated disc was the probable source of bad sensory information to the brain.

So Is Surgery the Right Answer for Cervical Dizziness?

Maybe for some cases. If you have radiating arm pain with weakness tied to a badly herniated disc, then surgery might be able to help resolve both complaints, but there’s still a lot of research that needs to be done. Surgery is a BIG deal, and generally reserve that for really bad herniation cases with clear signs of neurological deficit like weakness, loss of reflexes, and atrophy of muscle.

The good news is there are a lot of ways to address cervical dizziness beyond routine physical therapy, and they have really great outcomes. One method is by improving the curve in the neck. A randomized trial of curve based rehab compared to routine physical therapy showed significant improvements in neck pain and dizziness at 1 year.

You can read some more about cervical curves and dizziness at this link:

Working on your curves: Long term outcomes from fixing military necks

A randomized clinical trial of cervical curve rehab on cervical dizziness

There’s also numerous cases of cervical dizziness that have no signs of degeneration in their spine. This is especially prevalent in patients with dizziness after whiplash and head injury in young athletes. These patients seem to do well when we focus on the upper neck where the injury is likely to affect the ligaments of the craniocervical junction.

Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial.

Long story short, degeneration of the cervical spine doesn’t have to be a sentencing for dizziness. It’s a risk factor, but it can be modified with the application of effective conservative interventions for the neck.

What’s the Cost of a Blockbuster Headache Drug?

Migraine headaches remain the most common neurological disorder in the world. While there are a number of drugs that can target a stop a migraine attack in its tracks, there are many patients who have been resistant to current medications and have to endure several migraine days or more each month.

In the last 2 years, a new drug has hit the market that is targeting a promising chemical pathway that is known to affect migraine patients. The drug is called Aimovig. It is an inject-able antibody that hits a compound called calcitonin gene-related peptide or CGRP. It’s the first drug of it’s kind targeting this pathway as migraine medications have historically targeted blood vessels as a source of migraine related pain.

Image result for cgrp and migraine
Image Source: Russo AF.
Calcitonin gene-related peptide (CGRP): a new target for migraine.
Annu Rev Pharmacol Toxicol. 2015
Link:
https://www.ncbi.nlm.nih.gov/pubmed/25340934

Scientists and clinicians have been excited about this drug for a little while as clinical trials have shown it to be well-tolerated with few side-effects. It’s also promising in the fact that it seems to help reduce migraine frequency so it might serve a preventative purpose.

Cost Benefit Analysis

In terms of results, clinical trials on patients suffering from 8 headache days per month had a reduction of 3.7 headache days per month compared to 1.8 days on placebo. It also showed that 50% of the patients taking the drug were able to cut their headache days in half compared to 26% on placebo. [Source]

The price for Aimovig comes out to $575/month with an annual bill of $6900 which you may need to take throughout your life.

It might seem like a lot, but for many patients with treatment resistant migraines, the cost is worth it to experience less days wasted by the suffering of a migraine.

The Value of Upper Cervical Care

We know that a subset of migraine patients do extremely well with upper cervical chiropractic care. If you talk to many doctors, they will often report that many of their patients will have greater than 50% reduction in their headache days, with some having an almost complete resolution.

This is because a large number of patients who have several migraines per month also have an upper cervical spine problems which are a known driver of migraines. A small study looking at the effects of NUCCA on migraine cases showed a significant reduction in migraine days and large improvements in migraine disability.

You can read the full paper here: Effect of Atlas Vertebrae Realignment in Subjects with Migraine: An Observational Pilot Study

Migraine patients under NUCCA care with headache days and quality of life improvements at 4 weeks and 8 weeks.
Migraine disability scores significantly improved in NUCCA patients from baseline to 12 weeks

This was a small study with no control group, so we can’t tell exactly how effective this is on a large scale. However, the experience seen by the patients in this study is a close reflection to what we see in clinical practice everyday.

Probably the most significant aspect of upper cervical care is the fact that it’s capable of producing these outcomes at significantly less expense. For many chronic migraine patients, getting them to the point where a reduction in their migraine days are stable can happen within 8-12 weeks.

Once they’re there, then patients are usually ready for periodic visits to maintain their atlas alignment. While costs vary, the average migraine patient in our clinic might spend $1500-1800 in their first year with us, and a few hundred dollars in subsequent years.

A large difference from $6900 a year on going.

The Pyramid of Plasticity: Organizing and Prioritizing Brain Functionality

How do we organize such a diverse array of functions for the brain? When someone has a #concussion, it’s rarely just one part of the brain that gets injured. The interconnectedness of the brain means that damage to one part means multiple functions will deteriorate.

So when someone comes in and they are feeling dizzy, their cognition is foggy, they have headaches, their heart is racing, how do we decide how to prioritize their care?

A concept developed by Dr. Matt Antonucci of Plasticity Brain Centers (@brainguru) helps to prioritize different levels of brain function. The good thing is that the areas of function seem to correlate with the anatomical organization of the brain.

The functional organization of the brain closely mirrors the anatomic organization of the brain. The bottom areas are primal and necessary for survival, and higher areas allow for stronger adaptability.

In many cases the areas of the brain that responsible for survival are lower in the brainstem, where as the areas concerned with higher level thought processes are high in the cortex.

If your brain can’t control blood flow very well for survival, it is certainly not going to care if you can do complex mathematics.

So when we assess a patient, we have to prioritize the systems that will restore function at the bottom of the pyramid, because many of the systems on the top depend on the bottom portions working.

What does this look like practically?

If a patient had a concussion and their chief complaint is brain fog, many people will want to target their cognitive areas of the brain. But what if they have brain fog because they have undiagnosed #dysautonomia causing an erratic heart rate?

We don’t fully have the answers without a good exam, and every patient’s experience is unique, but this can give people a strong starting point to organize their recovery after a brain injury.

Concussion and Eye Movement Series Part 2: Smooth Pursuits

Smooth pursuit eye movements are the ones we use to follow a moving object without moving our heads.

We take it for granted how simple this is, but this eye movement requires the coordination of several brain regions including the parietal lobe, temporal lobe, cerebellum, and multiple brain stem nuclei.

Image result for smooth pursuits neural substrates

Here’s a ridiculously complex graphic about the brain regions involved in smooth pursuits. It’s insane what goes on in the brain to accomplish such a seemingly simple task. A concussion can disrupt any part of this pathway, or multiple parts depending on the nature of the injury.

It requires us to:

  • Predict an object’s velocity – Correct for quick changes in direction
  • Maintain focus and attention
  • Ignore new and interesting background stimuli

After we hit our heads, any one of these areas can be affected which means different elements of smooth pursuit can become compromised.

Brain injuries can cause our pursuits to become slow, get pulled off target, delay reaction time, or even ignore parts of your visual field.

This can cause problems for athletes who need elite visual tracking abilities like baseball players, wide receivers, and hockey players. But some important notes:

  • Smooth pursuit deficits can be completely asymptomtic
  • Having poor pursuits isn’t useful diagnostically because many problems including aging can cause bad pursuits
  • Smooth pursuit testing needs to be taken on the context of other exam findings to localize the problem in the brain and determine the best method of rehabilitation

While it doesn’t tell us much diagnostically, it can be used as a metric to see how well your brain is responding to #neurorehabilitation.

Concussion and Eye Movement Series Part 1: Anti-Saccades

Eye movements have become an important diagnostic for patients with neurological disease and dysfunction. It’s one of the reasons we have invested into using extremely sophisticated eye tracking technology so that we can asses and manage patients effectively with traumatic brain injuries.

This will be the first in a series of posts about eye movements that are commonly affected with concussion. The first eye movement we’ll discuss is called anti-saccades.

What’s A Saccade?

In order to know what an anti-saccade is, we have to know what a regular saccade is. A saccade is a fast eye movement that takes your eyes from one target to another. Saccades are the eye movements we use to explore the world around us. They are also eye movements that react very quickly to new things in our environment. These can be a movement in the background, a flashing light, a loud noise, or a touch on our skin.

When we perceive there’s something in our environment that needs our attention, we use saccades almost like a reflex to direct our brain’s attention toward that new stimulus.

What’s an Anti-Saccade

An anti-saccade is a concept developed to see if someone can consciously inhibit a desire to look at something new. During an anti-saccade, we would have you fixate on a central target, and when a new target comes up, we ask you to move your eyes in a spot opposite to where the new target appeared.

The anti-saccade test


Antisaccades require our brain 🧠 to ignore a new stimulus and to create a plan to move the eyes 👀 to a mirror location.

This task requires higher level brain activity because our brains are wired to look at new stimuli. Specifically it requires a functioning prefrontal cortex (PFC).

In patients with concussion, their ability to perform Anti-saccades is compromised where they make frequent eye movements towards the new target, or they take a long time to move their eyes in the opposite direction. This indicates problems with a function called response inhibition. It’s the ability for our brain to stop doing something we don’t want it to do.

This requires a part of our brain called the pre-frontal cortex. Specifically, the dorsolateral prefrontal cortex. We’ll just call it the PFC for short. The PFC is what allows us to inhibit a desire to do something that may be inappropriate.

We need our PFC to stop ourselves from making inappropriate reactions. It’s one of the main differences between an adult brain and a child’s brain is that our PFC keeps us from having meltdowns when something goes wrong.

Parents of toddlers, you guys know what I’m talking about.


So when we take a hit to the head and our PFC goes down, we can have responses that aren’t appropriate. This might mean an emotional outburst, or problems controlling wreckless behavior like uncontrolled gambling. A viable PFC is critical for that and for keeping our bodies from over reacting to stress.

This provides us a meaningful way to assess PFC activity and gives us an way to improve PFC activity using eye movement therapies.

Not only can anti-saccades be used to assess the functionality of someone’s PFC. It can play a role in helping someone rehabilitate their PFC or other aspects of the brain connected to it.

Working on Your Curves: Long Term Outcomes From Fixing Military Neck

I’ll admit that I’ve gone back and forth on the importance of cervical curves in my career. When I was in chiropractic school I was adamant about the importance of cervical curves and how the loss of a curve could affect the progression of spinal arthritis.

Then once I was in practice for a few years, I saw that most neck curves wouldn’t really change very much. Despite the fact that it didn’t change, I’d see really great changes and improvements of many of my patients, so I assumed that it is a nice feature, but probably not necessary to resolving a complaint. You can read some of my previous thoughts on cervical curves here:

I Have Military Neck: Now What?

So What Has Changed my Mind?

I still stand by my previous writings and say that having a proper neck curvature is a really good and positive thing, but you can still get really great results with most secondary conditions even if the neck curve doesn’t come back.

However, I have started to come around on the importance of having a proper neck curvature for the health of the human brain and nervous system. So what changed my mind?

Here are three pretty recent studies looking at the impact that cervical curve changes have on dizziness and cerebral blood flow.

Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis

The first paper is a study that looked at consecutive patients getting imaging of the arteries going into the brain. Magnetic resonance angiography (MRA) measured the intensity of blood flow with the neck in patients with a straight or military neck pattern. The patients were then placed on a foam orthotic to produce a curve in the neck and a new MRA was taken with the neck in a curved position.

Before and after changes in blood flow to the brain using a device to improve cervical curve.

The patients’ MRA scans showed significant improvements in blood flow in the brain when they were lying on the orthotic with an improved cervical curve! The interesting thing is that it’s been known for years that a loss of cervical curve was associated with decreased blood flow in the brain, but there was no evidence showing that improving the curve would change blood flow. Now there is.

The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study.

While the previous paper is interesting, it’s limited by the small sample size and lack of controls. It was also a proof of concept study, and not one where an intervention was performed and tested to see if it made a difference long term. However, it may help explain why patients can get significant improvement in pain and dizziness.

This next paper features a randomized clinical trial of cervical curve correction along with cervical manual therapies compared to manual therapy alone for cervical dizziness.

The study looked at the results for patients with neck pain and dizziness for short term improvement at 10 weeks, and to see if they sustained improvement at a 1 year follow-up. The results are below.

Differences in patients with cervical dizziness at 10 weeks and 1 year. Changes after 10 weeks were similar to regular physical therapy, but the changes were hugely different at 1 year when there was an improved curve in the neck

The chart shows that the patients who were in the cervical curve correction group had significant improvements in head posture and curvature at 10 weeks, but the scores in pain and dizziness were pretty similar for both groups. Both groups got better, but they had similar improvements.

However, the changes at 1 year were impressive, and highlighted in red. While the control group had some regression into neck pain and dizziness, the cervical curve group maintained their symptomatic improvement much better. The mean improvements for both groups all crushed statistical significance, and the mean difference of the Dizziness Handicap Inventory (DHI) was by almost a whopping 30 points. That’s massive!

Does improvement towards a normal cervical sagittal configuration aid in the management of cervical myofascial pain syndrome: a 1- year randomized controlled trial.

A similar study was published on patients with persistent neck pain where physical manual therapy was compared to manual therapy and curve correction.

Just like the study involving dizziness, this paper on neck pain showed that both groups had similar improvements in scores on the Neck Pain Disability Index (NDI).

Changes in neck pain with manual thearpy and exercise alone vs manual therapy, exercise, and cervical curve restoration. Cervical curve patients were a little btter at 10 weeks, but were much better at 1 year follow up!

Again, like in the previous study, the 1-year follow-up is where things got interesting. The group that had treatment to improve their cervical curve had a much stronger ability to maintain their improvements in neck pain, while the control group started to return to their original pain scores. This was also largely statistically significant.

Long-Term Improvements Matter

So the big thing that changed my mind is that there is a growing body of work that supports the idea that creating structural changes in your cervical curve seem to help improve long term outcomes.

So while I still believe you can get significant improvement with or without a curve in your neck, your chances of maintaining your results over time seem to increase a LOT when you rehabilitate that curve.

Then you have the possible added benefit of improved blood flow to your brain, and that provides a potential bonus of better brain health.

Why Weak Muscles Are NOT the Reason Your Back Went Out

I’m a mega-proponent of strength training. It’s a major part of my life and it’s something I’ve always encouraged for my patients, family, and friends as a way to dramatically improve someone’s life.

That being said, strength training is an integral part of the treatment and prevention of musculoskeletal pain. There’s probably no condition in the world that has been widely attributed to a strength deficiency than lower back pain.

Got back pain? Must be those

  • Weak glutes
  • Weak transverse abdominus
  • Weak multifidi
  • Etc, etc

So now we have an entire world of fitness focused on preventing lower back pain by developing really intricate exercises to strengthen an unending list of muscles connected to the back.

Are Weak Back Muscles Really The Cause of So Much Back Pain?

I do believe that being sedentary, and the general weakness and de-conditioning associated with a lack of movement does put people at risk for low back issues. After all, being sedentary and de-conditioned is basically a risk for just about everything.

However, I do think that we need to re-evaluate why so many active and relatively strong people throw their backs out doing really slight movements.

What do I mean by that?

For many of the patients that have come to my office for chronic back pain, their stories don’t usually feature an attempt to lift something that was extraordinarily heavy. It’s generally things like:

  • I was reaching to grab my phone when I heard a pop
  • I was rolling out of bed when I felt something seize up
  • I was bending over to pick up a pillow when my back went out

Plus these people aren’t necessarily weak. These are people who can deadlift 400+ lbs or spend their day as construction workers lifting heavy things every day. I can promise you that these individuals did not have weak glutes.

So what might have happened?

The Principle of Coordination

All of the strength in the world is useless when the body is not prepared to make use of it.

Have you ever been to a bowling alley and picked up the wrong ball by accident? It’s a strange feeling. You may be accustomed to picking up a 9 lb ball, but the ball next to it was the same same color and shape but it weighed 14 lbs.

So you went to pick the ball up with the amount of force that you expected to easily lift the 9 lb ball, but your arm moves slower and you have to catch yourself for a second before reaching down and grabbing the correct ball.

Even though you are plenty strong enough to lift a 15 lb object without any problems, you were thrown off because your brain made a calculation wasn’t appropriate for the lift it was about to perform.

This takes a coordinated effort for your brain to tell your muscles to use the correct amount of force with the right timing in order to make lifting an object feel more effortless. It’s a really neat system when it works properly!

But if you didn’t know how much something weighed, and you went in without expectation, you would probably take a conscious effort to over-prepare your body to lift an object up so you wouldn’t be caught off guard. Your brain has plans and contingency plans for when it encouters an unknown situation.

So what does this have to do with your bad back? Your back is different from most of the other muscles in your body in that it is a muscle group that is almost always on. Your arm and shoulders don’t get used unless you need to perform a task. Your legs are always on when you’re standing, but they can be rested when you are sitting. Your spinal muscles only get a rest if you are laying down, which is a small chunk of the day for most.

Control of spinal movement is dictated by an intricate control system between the brain receiving feedback from the spinal muscles and joints, and commands to control it

This is an important concept because our spine has to move for just about everything. Even when you are lifting your arm or your leg, your brain is sending messages to your spinal muscles on how to move your spine to accurately perform an arm/leg movement.

When Coordination Fails

So we know that the spine is always on, and even when you are just trying to move any body part alone, your brain is still getting your spine prepared to brace or move in concert with other limb movements.

There is a lot of coordination that has to happen with this, and sometimes there are just moments in time where coordination will fail, and injury can occur in those small windows.

It wasn’t just an issue of being weak. It was an issue of timing that one part of your muscular system didn’t create a good enough response to protect the parts of your spine that may generate pain.

This doesn’t mean that you’re broken. It doesn’t mean that you need fixing. It means that when you’re active and putting your body under a steady dose of mechanical stress through exercise, sometimes things may get hurt.

It’s okay! Your body can heal, get better, and improve with time, especially when you have good alignment, flexibility, mobility, and appropriate rest.

Can Coordination Improve?

There are a number of things people can do to improve the coordination of your spine and nervous system. It involves making your spine more adaptable. So how can we improve our adaptability?

  • Respect your alignment and biomechanics. You don’t have to be obsessed about it, but dysfunctional spinal joints from structural shifting of the spine can decrease neurological coordination
  • Expose your body to different loading patterns. Perfect form in the gym is great, but your brain needs exposure to variation in movement so it knows how to deal with it in the future. Mix up your lifting and movement strategies
  • Train on different surfaces – You won’t always be on a nice flat gym surface when you have to lift something up. Perform movements and exercise on different surfaces to allow for your nervous system to adapt
  • Do reaction time training – reaction time training or rhythmic movements can train your body to work in different patterns and rhythms.