Meniere’s Disease: A Craniocervical Solution

Meniere’s Disease (MD) is a debilitating illness with a lot of unknowns about it’s true nature. This misunderstanding has led to a lot of MD patients getting ineffective or excessively damaging treatments on patients that are desperate for relief. It’s also an illness that tends to be misdiagnosed by a lot of clinicians unless you have substantial experience working with dizzy patients.

So how do you know if you have a true Meniere’s Disease versus other vestibular disorders, and what are your options once you do know that you have Meniere’s?

Meniere’s Disease vs Other Vestibular Disorders

Meniere’s Disease is part of a spectrum of disorders called vestibular disorders. Vestibular disorders consist of any illness that affects the inner ear system that controls your sense of balance and equilibrium.

Examples of vestibular disorders include:

  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Vestibular neuritis
  • Vestibular migraine
  • Mal de Debarquement
  • Central vestibulopathy (stroke or brain injury)

Diagnosing vestibular disorders can be challenging because there’re so many things that can cause dizziness.

Meniere’s Disease is defined by vertigo that comes out of nowhere (episodic), hearing loss, ringing in the ears (tinnitus), and a clogged feeling in the ears (aural fullness).

When we compare Meniere’s to other disorders, the closest diagnosis has to be vestibular migraine because of it’s episodic levels of vertigo. It’s also challenging because there is a large overlap in patients with Meniere’s having a history of migraine headaches [Source]

The defining characteristic with Meniere’s Disease when you compare it to other vestibular disorders is hearing loss and auditory symptoms, specifically the feelings of fullness in the ears.

If you have vertigo and dizziness, but you don’t have hearing loss with auditory symptoms, then you do not have Meniere’s Disease.

Difficulty Treating Meniere’s Disease

Another key component with Meneire’s Disease is the fact that it is notoriously difficult to treat. While other vestibular disorders like BPPV and vestibular neuritis can be treated successfully with Epley Maneuvers and vestibular rehabilitation, these procedures are not beneficial for patients with Meniere’s.

A big reason is that Meniere’s Disease can come in the form of flare ups. So while patients with Meniere’s can get some benefit from doing vestibular and balance training between flare ups, they will often regress hard when a flare up occurs again.

The timing and frequency of flare ups is unique to each patient. Some may experience flare ups on a weekly basis while others can go months between episodes. Each flare up does tend to worsen auditory symptoms which is even more distressing.

Medications like Beta Histadine may provide some benefit between flare ups but generally doesn’t affect hearing. Recommendations for a low sodium diet appear to provide some relief in reducing episodes, but compliance to the diet is poor.

Furthermore, there aren’t any good therapies that affect the auditory symptoms. The constant feeling of fullness in the ear and the roaring tinnitus persist and get worse. Currently, only steroid or gentamyicn injections have been used for some patients, but outcomes are hit or miss.

Patients who are at their wits end may get surgical decompression of the vestibular organ, or choose to cut nerve in the ear in hopes to get relief. This comes with the price of hearing and vestibular loss for the affected ear.

Craniocervical Care

Anecdotal evidence from chiropractors focusing on the upper neck have given many with Meniere’s hope for some improvement. Dozens of case reports show that adjustments to the upper cervical spine have given patients relief in both the vestibular and auditory symptoms related to Meniere’s Disease.

Dr. Michael Burcon out of Michigan began a clinic specifically for treating patients with Meniere’s Disease and published outcomes on 300 patients with the disorder. [Source]

Over the course of 6 years, he reported a large improvement across 300 patients with most improvements occurring by 6 weeks. He also noted that many MD patients could identify a whiplash trauma to the neck about 15 years before symptom onset suggesting the cervical injury may play a role in people with a genetic disposition to Meniere’s.

How the neck influences Meniere’s is currently unknown. There’s suspicion that the upper cervical shift may distort function of the autonomic nervous system causing dysfunctional flow of blood and cerebrospinal fluid. The strong contributions of the upper cervical spine to the vestibular system is also a mechanism for how the neck can influence the dizziness and vertigo symptoms.

While these cases are anecdotal, the improvements that Meniere’s patients have with cervical focused chiropractors is compelling enough and safe enough for patients with MD to explore given the fact that other options are less safe and provide marginal benefit.

Understanding and Treating Persistent Motion Sickness

Patients with persistent motion sickness represent a subset of patients commonly associated with dizziness and imbalance. While many patients with motion sickness have it in relationship with a condition like migraine, vestibular migraine, or BPPV, there are many patients who just struggle with it on it’s own without a complaint of dizziness.

Motion sickness isn’t an illness where you feel a false sense of motion like vertigo. Motion sickness is a problem that different types of motion or perception of motion will cause you to feel nauseated and sick. The difference between these concepts makes a big difference in how you will need to be treated.

Historically it has been a challenge to diagnose and treat these patients because traditional tests of dizziness and imbalance are going to be negative. Without a strong understanding of motion sickness, it becomes difficult to provide treatments or therapies that have enduring effectiveness, and all you are left with are anti-nausea medications.

Patients with motion sickness can feel ill along a wide variety and intensities of motion. The most common form of motion sickness occurs in people who have difficulty riding in boats or cars. A large portion of the population has experienced motion sickness when riding in a rocking boat or attempting to read in a car.

In it’s more severe forms, patients can feel sick with small amounts of head movement, or when exposed to a busy visual background. The feeling of sickness can cause progressive nausea that can eventually lead to vomiting.

What Drive Motion Sickness

As you can tell, being so sensitive to motion that small head movements or visual stimuli can induce vomiting can feel quite limiting and debilitating for a patient. I personally hate the feeling of nausea more than I hate pain, and it’s common for these patients to avoid social events and gatherings so they can feel safe in the comfort of home.

What happens in the body to generate this terrible feeling?

Most of our understanding of motion sickness stems from our knowledge of nausea and vomiting. Nausea can be driven directly by sensation from the vestibular organ or the gut. Neurological signals from the inner ear and the gut travel to the lower brainstem called the medulla where there are specific neurons dedicated to vomiting.

Diagram showing the inputs to the medulla that activate vomiting.

When these neurons are activated, they activate pathways that increase the production of saliva, take deeper breaths, and initiate contractions of the esophagus and diaphragm. That feeling is also triggering the sympathetic nervous system causing blood flow changes that can lead your hands to get cold and you start to sweat.

Remember that this is a pathway for vomiting. Many patients aren’t going to go through this entire process, but the brain regions associated with this process probably contribute to the levels of nausea people have with motion sensitivity.

Nausea and motion sickness can be driven by different sensory stimuli, but all inputs are likely driving sickness through the medulla.


Based on this knowledge, we have sense that patients with persistent motion sickness and nausea may have problems in these regions which serve as targets for treatment or rehabilitation:

  • Vestibular dysfunction – especially the otolithic organs
  • Gut dysregulation
  • Brain driven sensory sensitivity

Sensory Mismatch and Motion Sickness

The exact mechanisms for how motion sickness triggers the above neurological pathways is currently unknown. The most common theory that I’ve found to have practical treatment implications is called the Sensory Mismatch or Sensory Conflict theory.

The theory suggests that you have 3 systems in your body that help you detect if you are in motion. These are the:

  • Visual System
  • Vestibular System
  • Proprioceptive System

Under most circumstances, your brain takes information from these senses and compares it to the brain’s expectation for motion.

Let’s say that you’re going for a run. Your eyes detect movement of the background while you’re running, your muscles detect motion of your joints, your ears detect the bobbing motion of your head, and your brain knows what it is supposed to feel like to go for a run. When these senses all agree and your brain recognizes how this is supposed to feel , then your brain doesn’t have to resolve any conflict and motion feels perfectly fine.

In patients with motion sickness, the information coming from these senses might be weighted different by the brain. What does that mean? It means that your brain may be more sensitive and prioritize the information that comes from your eyes more than the information that comes from your vestibular system or vice versa.

Now your brain has a problem. Your visual system might be saying that you’re moving a lot while your vestibular and proprioceptive systems aren’t perceiving any motion (Kind of like driving in a car right?). Your senses are conflicting, so your brain has to make the final call.

If your brain doesn’t have good information for how this is supposed to feel, then the sensory mismatch isn’t resolved and the conflict leads to you activating the pathways that drive nausea. The most common expression of this is called vestibular-visual mismatch, and is likely the driving force in nausea and motion sickness in vestibular migraine.

When 2 of your sensory systems are in conflict, it’s up to the brain to reconcile the difference. If it fails, you get dizzy. If it succeeds, you are able to adapt.

How does this help us treat patients with motion sickness?

By understanding the influence that these sensory systems play in motion sickness, we can use a careful examination of these systems to determine where and how to provide different therapies.

In my office, we test eye movements, ocular misalignment, balance, and optokinetic responses to assess the way the brain responds to different sensory conditions.

Once we have an idea of how a patient’s senses might be betraying them, then we can move into a treatment strategy to fix it. First we would try to re-weight their sensory system, then we slowly expose the patient to the offending stimuli.

What does this look like as an example?

The majority of patients we have seen with motion sickness have a high level of visual dependency meaning that they rely too strongly on visual information to maintain balance.

If you have high visual dependency then your brain places too much emphasis on detecting visual motion. If this is the case, you can be watching a movie with a busy action sequence and your brain is going to think that you are moving despite the fact that your vestibular and proprioceptive systems say that you are sitting still.

So if we know that the patient is way too visually dependent, then we would have the patients perform exercises to increase their ability to rely on vestibular and proprioceptive senses. That means we might do a lot of their exercises or therapies with their eyes closed initially and gradually progress them to doing exercises with eyes open. As they can tolerate these motions better, then we might slowly start to expose them to the busy visual environments that would normally induce dizziness.

It can be complicated and nerve racking to confront motion sickness because patients with this problem have spent so much time designing their life to avoid these nauseating activities.

But at the end of the day if we are really going to give people their lives back, then we need to have the courage to confront the things that have kept us in the prison of our perceived broken bodies.

Stress, Heart Rate Variability, and the Immune Response to Infection

On our last post, we got familiar with a lot of the players of the immune system. If you missed that post and want to catch up with some of the main cells involved with immunity, you can check it out here:

A Brief Tour of Your Immune System

At the end of the article, I talked about the connection point between the nervous system and the immune system. While it seems like the nervous system and the immune system are mostly separated because of minimal direct nerve connections to immune organs, the brain actually exerts a large influence on immune function.

This is a critical piece to consider because the immune system left to its own devices can simply obliterate an infection with an uncontrolled immune response. This isn’t useful to the organism if an uncontrolled immune response ends up creating widespread tissue damage or killing its host in the process. It would be like setting your house on fire because you saw a roach in your garage.

One easy example is seen with control of a fever. During an infection, your immune system releases a variety of chemicals that will increase your body temperature to slow down the growth of bacteria. The hypothalamus of your brain keeps your body temperature between 98-99 degrees Fahrenheit under normal circumstances. But when an infection occurs, these immune chemicals will raise your body temperature, but the hypothalamus is monitoring your body systems to make sure it doesn’t get too high.

Fever is an example where communication between the immune system and the brain help fight infection while limiting damage to the body.

If your body is getting overwhelmed then your body temperature may continue to rise above 103 degrees and cause harm to your own body systems. This is generally a nuclear option that the brain tries to avoid, so there has to be a delicate balance in allowing your body temperature to rise a little bit while neural feedback will trigger inflammation reduction when temperature rises too high.

This is all mediated through a branch of the nervous system known as the autonomic nervous system.

Stress and the Immune System Relationship Status: It’s Complicated

Your autonomic nervous system mediates your response to stress. Your fight or flight system is activated by the sympathetic nervous system, which is countered by the rest and digest function of the parasympathetic system.

I used to be under the simple belief that stress from a fight or flight response suppressed your immune system because it caused your adrenal glands to release cortisol, and cortisol generally reduces white blood cell count and we end up catching more colds. [Source]

Just like everything else, it seems to be more complex than that.

It’s true that people who are chronically stressed out tend to get sick more often and have lower white blood cell counts. It’s also true that patients under with chronic stress are more prone to autoimmunity and hypersensitivity reactions like rheumatoid arthritis and asthma.

So how do we reconcile the fact that stress can reduce your immunity leaving your more susceptible to infection AND leave you prone to illnesses of a hyper-aggressive immune response?

A super insightful paper published in the Journal Neuroimmunomodulation brought this concept to light. The answer might be in the timing and context of the stress response.

It appears that if you are lightly stressed from exercise or acutely stressed during something that gives you an adrenaline rush, your immune system actually gets a surge of immune cells into the blood. From an evolutionary perspective this makes sense right?

If you are fighting or escaping danger, there is a high likelihood that you will have some sort of injury that will expose your blood to wounds and pathogens. You want more immune cells in your blood to get ready to fight. Your adrenaline-based stress hormones (epinephrine and norepinephrine) tell your immune organs to release more white blood cells into circulation. This also causes a drop in monocytes and lymphocytes, and an increase in neutrophils which would seem that you are evolutionarily preparing your innate immune system. [Source]

At the tail end of a stress response, you want to turn the immune cells down, so as your body releases cortisol, this causes a decrease in immune cell production to reduce the opportunity for autoimmunity. You also get a boost of activity from your vagus nerve which turns on an anti-inflammatory reflex to calm the body back down and reduce inflammation by your immune system. [Source]

However, cortisol also triggers a redistribution of the cells in your blood to go into your tissues to wait for any germ challenges that show up in the skin, lungs, or digestive tract. While this can keep the immune cells armed at the sources of common infection, a cycle of chronic stress that continues to dump immune cells into these battleground locations has the potential to prime these locations for autoimmune disease [Source].

Dhabhar described this as the Barracks to Boulevard to Battleground mechanism for how stress mobilizes the immune system. [Source]

The Barracks to Boulevard to Battleground analogy proposed by Dhabhar https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3412918/

Adrenaline in acute stress tells your spleen, thymus, and bone marrow to “mobilize the troops” from their barracks and get on the road to the battle. This means there are loads of white blood cells on the boulevards (blood stream) ready to go to wherever the battle is going to be. At the end of the stress response, cortisol and other corticosteroids maneuver the white blood cells into battle ground tissues like the skin, lungs, and digestive tract that are likely to engage with potential invaders.

We end up in a situation where just a little bit of stress increases immune responsiveness and increases resistance to infection and cancer which is great!

But chronic stress induces hormone signaling that can reduce white blood cells in the blood stream and into tissues. If you are chronically stressed and dumping more soldiers into your tissues, there can be a risk for autoimmune reactions. At the same time, chronic activation of the stress response is reducing troops in the blood which leaves you prone to other infections.

How acute vs chronic stress can change the way the immune system functions. Acute stress may increase immune protection but can increase hypersensitivity reactions. Chronic stress can suppress the immune system or shift neuroendocrine function to dysregulation

What this likely means is that you don’t have widespread immune suppression from a stress response. In fact, a little bit of stress from things like exercise or being involved in something exciting may actually increase immune protection.

Even chronic stress isn’t necessarily immune suppressive. What chronic stress likely does is redistribute your immune cells to other bodily tissues. Chronic stress is also likely to drive hormone dysregulation which can trigger immune dysregulation leading to the double whammy of increased infections and increased autoimmunity.

Can Heart Rate Variability Tell Us About Our Immune Response?

Now we know that stress can modify our immune response via our autonomic nervous system, can measuring stress tell us about our immune response?

Maybe.

A measurement called Heart Rate Variability (HRV) is a tool we can use to measure your your body’s baseline stress response. I’ve written a lot of thoughts about HRV here.

Long story short, a high HRV score generally tells us that we are have more parasympathetic physiology (less stressed), while a low HRV score generally tells us that we are more Sympathetic physiology (more stressed).

Heart Rate Variability and Stress

If we are under chronic stress, you are generally going to have lower HRV and a stronger likelihood for stress related illness. It’s shown a strong ability to predict outcomes in cancer and stroke, but it also can tell us if a healthy person is more likely to get injured during exercise.

Heart rate variability is generally tied to the function of the Vagus nerve and the parasympathetic nervous system. An extensive amount of work has been done studying something called the cholinergic anti-inflammatory pathway which is driven by the Vagus nerve.

We know that the vagus nerve plays a role in driving inflammation down, and it’s probably a key piece in what helps us get back to normal after the immune system has fought a war with an infection. This anti-inflammatory pathway is how the vagus nerve tells the immune system to calm down and it has been studied extensively in terms of autoimmune, cariovascular, and metabolic disease associated with inflammation. [Source]

We need vagus/parasympathetic physiology to help us balance out the effects of chronic stress, and HRV seems to be a good and cheap way to let us know if it’s working.

But……

Can a stress reading from HRV tell us anything about our ability to fight infection?

Surprisingly not that much research has been published in this space, but here’s some of what has been studied:

  • Low HRV is a predictor for death from sepsis across several studies [Source] It’s unknown whether lower HRV was caused by sepsis, or if lower autonomic capacity allowed for worse disease progression
  • Low HRV scores predicted the progression of disease in patients with hand,foot, and mouth disease from enterovirus infection. Lower HRV scores corresponded with higher organ system involvement [Source]
  • HRV scores in healthy adults showed correlations with increased inflammatory bio markers and lower white blood cell counts in those with lower HRV. [Source]
  • Low HRV after predicted patients who would suffer infection after stroke [Source]
  • Loss of sympathetic modulation identified on HRV was associated with worse outcomes in community-acquired pneumonia patients [Source]
  • Lower HRV in healthy adults shows a slight shift in immune cells towards neutrophils while higher HRV is associated with more lymphocytes [Source]

Taken altogether, it appears that people with better outcomes from a disease process when they have a higher HRV score. However, we don’t really know if HRV is the chicken or the egg. Did the people with poorer outcomes have a better baseline autonomic function or did someone with a worse infection just wipe out that patient’s autonomic nervous system resulting in poor outcome.

We don’t have answers to that quite yet, at least not from clinical research on infectious disease, but maybe something else can give us a clue.

HRV and Cancer

Besides infectious disease, the immune system is heavily involved in eliminating and controlling the spread of cancer cells. Your body is constantly producing mutated cells during the process of normal cell reproduction, but the vast majority of these mutated cells are eliminated by a healthy immune system.

The relationship between stress, heart rate variability, and cancer has been studied really extensively. So much so that there are multiple systematic reviews suggesting that heart rate variability is a strong measurement to assess a cancer patient’s progress in fighting the disease. [Source] One study even suggested that HRV was more reliable in predicting the prognosis of prostate and colorectal cancer than knowing what stage of cancer the patient had. They also found that the more advanced stage you had, the more important vagal activity was in survival, which is a finding consistent in metastatic cancer cases. [Source] You can read more My thoughts about that particular paper below.

Research: Active Vagus Nerve Predicts Cancer Survival Regardless of Stage

Just stop and think about that for a second. The thought that you can crunch the data from a patient’s heart rate and you can tell who is going to have a better outcome in 6 months with all other factors kept equal. It gives us hope that having a better stress response and higher HRV is a driving factor in protection from cancer and not just the product of cancer’s affect on the autonomic nervous system.

Me reading these papers about HRV and cancer

Decouck et al in a 2018 review in the Journal of Oncology explored the concept of vagus nerve activity in cancer even further. Instead of just looking at the studies that measured heart rate variability, they included studies that observed the effect removing the vagus nerve had on cancer progression.

In most animal models, an experimental vagotomy showed higher rates in cancer and worse rates of metastasis implying that a loss of vagus nerve function was causative in developing cancer in mice. We can’t really do these experiments in humans, but we can follow patients who have had their vagus nerve cut in the case of a disease like ulcers. Patients who had a partial vagus nerve removal had higher odds of developing cancer in the organs that lost their vagus nerve connection.

Patients who had a partial vagus nerve removal had higher odds of developing cancer in organs that became disconnected from the nerve.


Do we know if the vagus nerve removal means that there’s less immune surveillance in defending against tumor cells?

Not really.

The effects of the vagus nerve on human physiology are wide spread, so we don’t have any experiments that inform us on this.

But, but but….There are theories.

My favorite looked at the effect that stress and depression had on immune function the progression of cancer.

Stress and depression-induced immune dysfunction: Implications for the development and progression of cancer

Stress and depression’s role on the HPA axis results bias the immune system to an immune response that decreases activation of natural killer cells and cytotoxic T-cells which are responsible for controlling the spread of tumors. Maria E. Et al. International Review of Psychiatry 2005.

Chronic stress and major depression disorder are associated with reduced cellular immunity which is the branch of your immune system that can destroy infected or mutated cells. This response is mediated by Natural Killer Cells in your innate immune system, and T-Cells in your adaptive immune system. These cells patrol your body looking for tissue that has been infected by a virus or has mutated leading to cancer.

They work by binding to the infected or mutated cell and provide a chemical signal for that cell to self-destruct so it can’t spread.

A review of how Cytotoxic T-cells eliminate infected viral threats. Similar mechanisms occur for Natural Killer Cells of the Innate Immune System.

These cells have been found to be reduced or less active in patients who with untreated depression as well as patients and caregivers with prolonged mental health symptoms related to traumatic events.

These cells are so potent in addressing tumor activity in laboratory models that Immunotherapy for cancer is looking at how to harness T-cells and NK cells in treating active cancer patients. [Source]

So Here’s What we know:

  • We know that chronic stress and depression affect heart rate variability negatively.
  • We know that chronic stress and depression are associated with worse or dysregulated immune responses.
  • We know that chronic stress can increase cancer rates via persistent activation of the HPA axis.
  • We know that cancer patients generally have worse HRV and vagal nerve activity than healthy controls.
  • We know that cancer patients with higher HRV have better prognosis and survivability than cancer patients with low HRV.
  • We know that autonomic activity is related to vagal nerve activity which has immune consequences.

We discussed how we couldn’t be sure if having better autonomic function was the cause or the effect of better outcomes with infectious disease, so we couldn’t be certain that having a better autonomic nervous system in a healthy person could protect us from infectious disease.

But we know that cancer survivability is a product of better autonomic function, then it’s my personal contention that building up your autonomic nervous system is a causative factor in having better immune function against infectious illness.

Can We Improve our HRV and Does It Matter?

This article has gone on way longer than I anticipated, but before I close let’s discuss if therapies to improve autonomic function to stress have any potential value.

So the last question we have to ask ourselves is this. Can we change the output of our autonomic nervous system and vagus nerve and does it really matter?

It’s nice to know that having a high HRV gives you greater resilience and survival to disease, but it’s not helpful if some people are just born and raised to have better autonomic control than others. But if HRV can be improved, and that improvement leads to better outcomes, then it gives us tools to improve our lives across multiple dimensions.

Here’s the good news. At least in short term studies, we have tremendous power over our autonomic nervous system. Many of which are free with various mind-body therapies, and others that utilize practitioners of drug-less healing.

Here are some things that have some evidence for improving heart rate variability that also have carry over into improving general quality of life. I’ve highlighted as to whether they can be done free at home, or whether they require outside help or purchase:

  • Free: Systematic review of yoga shows promise for improving Heart Rate Variability [Source]
  • Free: Tai-Chi and Tai Chi/yoga for stress reduction [Source]
  • Paid Apps/Therapists: HRV Biofeedback Training reduces markers of inflammation in asthma, heart disease, and depression [Source]
  • Clinically guided or purchased device: Noninvasive Auricular vagus nerve stimulation reduced depression [Source]
  • Free: Employee based Mindfulness training and meditation improves HRV along with overall life and job satisfaction [Source]
  • Free: Medium intensity exercise improves HRV and patient outcomes across a wide spectrum of chronic illness [Source]
  • Clinically delivered: Upper cervical spine manual techniques [1, 2, 3]

Closing Thoughts

As you look through those sources, you’ll notice that none of those studies really talk about immune function. All this tells us is that improving HRV is possible, and it seems to help us live a better life when we do it.

We can’t measure whether we have optimized our immune system because we have no clue what markers tell us if our immune system is optimized. We know when our immune system is broken, and we know when it is deficient. That’s it.

But we can measure and improve on the function of our autonomic nervous system, and we can do it on the cheap.

Healthy immune function isn’t the goal of improving our autonomic function. It is a potential product of a healthy autonomic nervous system.

We are improving our autonomic function because it is a necessary part of being a healthy human being. Healthy immune function is a product of doing things that we know we should be doing already.

It’ about taking care of yourself mentally.

It’s about building a physical body that is prepared to take on stress.

It’s about ensuring that the function of our nervous systems are not obstructed.

We can’t stop the world from being infected at this point, but we can build a resiliency that will allow ourselves a better chance to fight off disease so we can move on to protect others.

In times of stress, we often forget that we have power and we have control over our lives. During this pandemic, not only do we feel powerless, but we are more afraid than ever. Not just of this invisible virus, but of our fellow human beings.

This fear, this anxiety, this depression that we feel collectively is taking away one of our body’s best weapons to endure our invisible enemy.

In one sense, it’s our immune system, but in another sense it’s something deeper. It is the power human beings discovered when we realized that we are way better fighting together as a village, than as an individual alone in the wild.

While it’s up to experts smarter than I am to give us the best chance to avoid illness, it’s up to us as people to confront this threat without the panic and fear that will not only make us sick physiologically, but will make us a sick species by stripping us of our collective humanity.

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.