Why is Cranio-facial pain worse than everything else?

Read time: 7-8 minutes

Outline:

  • Pain is weird
  • Chronic head and face pain and suicidality
  • Why head and face pain feels worse
  • The neuroscience of suffering

Pain is complicated. It’s even more complicated as a doctor because the expectation from years and years of conditioning is that when you have pain, then something about that painful body part must be damaged to cause it. When people are in pain, doctors are typically trained to identify things like a ruptured disc, broken bone, or torn muscle to validate a patients’ sense of suffering.

In this model, the more damage that is present = more pain. Less damage = less pain.

However, the experience of pain can be way more complex than finding damaged tissue. The experience of pain is an emotional response to ‘painful’ sensory receptors called nociceptors. Tissue damage can cause a lot of pain receptorsto fire, and trigger increased pain, but it is far from the only factor in the pain equation. We have to take pain into the context of cultural, social, cognitive, and experiential factors.

Which takes us to an important point.

The amount of pain you experience can also depend on what body part is injured. As we’ll see today, there are hardwired circuits in your brain that can make the experience of pain in the head/face a different and perhaps worse experience then pain from the body as a whole.

Chronic Facial Pain and Suicidality

Chronic pain is a known risk for suicidal ideation, and has been documented in numerous studies [source]. These thoughts have a higher chance of turning into behavior when you have chronic pain and a co-morbid mental health disorder [source].

This effect seems most pronounced when the source of the pain is coming from the head or face. Two disorders in particular are highly associated with suicidal thoughts and behavior; trigeminal neuralgia and cluster headaches. Trigeminal neuralgia has a high enough association that it was historically dubbed the ‘suicide disease’, while cluster headache has been known to be called the ‘suicide headache’.

Both of these illnesses are associated with some of the most intense pain that human beings can experience. The severity of the pain combined with the chronicity of the pain lead to a sense of despair because these disorders can be difficult to treat, so there is always a fear of the next attack.

Scientists have recently uncovered some neurological pathways that might explain why conditions like trigeminal neuralgia and cluster headaches can cause such disproportionate suffering compared to other body pains.

The Trigeminal Complex and the Limbic System

It’s been known that pain experienced in the head and face activate the emotional centers of the brain more than pain felt in the periphery of the body [source]. From an evolutionary standpoint, a higher state of pain in the head and neck region may have served a  purpose so that there would be extra vigilance in protecting this region of the body from injury. What was unknown was weather this heightened sense of protection was derived from a psycho-social factors, or if it was something that was hard wired into our nervous system.

Duke University scientists may have some answers. A 2017 study in Nature Neuroscience showed that neurons in the head and face have a direct pathway to the emotional circuits in the brain.

Scientists identified a direct connection between sensory fibers of the trigeminal nerve into a part of the brainstem called the parabrachial nucleus. The parabrachial nucleus has direct connections into the emotional hub of the brain in the amygdala, which is highly tied to fear and avoidance behavior.

Why is this important? Because direct, aka, monosynaptic connections are way more powerful sensory stimuli than indirect pathways.

Think of it this way:

Let’s say you were mailing a time-sensitive package that needed to get to it’s destination as soon as possible. Would you choose to overnight it by plane, or would you choose regular first-class mail?

Cranio-facial pain uses direct and indirect pathways that tap into the brain’s emotional responses to pain.

You probably chose to overnight it right? Why? Because it’s going to get there faster, and because the person receiving it is going to perceive that package as more important because it was sent with all of this overnight labeling implying it’s importance.

These direct pathways are like your overnight deliveries, where the indirect pathways are like ground shipping.

Our brains place a higher priority on signals coming from these monosynaptic pathways.

While other body regions only use an indirect path to the parabrachial nucleus, the trigeminal distribution uses both indirect AND direct pathways to stimulate this emotional hub.

That means that firing from nociceptive pain fibers in the trigeminal distribution, or even pathways that share trigeminal distribution will have a higher chance of driving an emotional response than pain fibers from the shoulder, back, hip, etc.

The Emotional Brain’s Influence On Pain

How big of an influence does emotion make in the experience of pain? In this study, the researchers stimulated pain receptors in the paw or in the face of mice using a chemical called formalin. Using a technique called optogenetics, researchers can selectively activate brain activity in a mouse model using different light frequencies.

When light activated the direct pathway, the mice showed more intense avoidance behavior to the formalin on the face. When light was used to knock out this pathway, the mice didn’t react as strongly.

So you have the same amount of pain stimulus, the same mouse, and it experiences pain differently because the path to the parabrachial nucleus was turned off.

It suggests that our emotional brain’s connection to a painful stimulus plays a substantial role in the experience of pain.

Biology vs Psychology

There’s always a debate about nature vs nurture when confronted with the struggles of human existence. In recent years, it has evolved into a debate between biomechanical/orthopedic search to treat identifiable lesions vs a biopsychosocial approach which generally tends to lean heavily on the psycho and social components of the pain experience.

Here is some evidence that suggests that the two are inseparably linked together.

The experience of pain is intimately tied to our thoughts, memories, expectations, and current mental state. If the experience of pain is tied to some of these neural circuits, then changing our mind activating our different neural circuits in the brain can change our experience of pain.

It also means that fear/avoidance behavior, and repetitive responses to painful stimuli may reinforce the neural circuits that generate the same pain over and over again.

Changing thoughts and behavior can have a significant impact on the perception of pain and the feelings of suffering for a persistent pain patient.

That doesn’t mean that we are just telling people in the midst of a terrible trigeminal neuralgia or cluster headache attack that they have to suck it up and think differently about their pain.

It means that when people have persistent pain disorders, in the process of treating patients with various interventions, we have to help and guide a patient through the process of re-framing their pain and illness.

This is really hard for patients with persistent pain. It means that sometimes we are walking a line where a patient may feel like we are telling them that the pain is just in their head. Sometimes it means that the patient is going to ask the same question, or tell you the same symptom over and over again because they’re looking for you to just understand that what they are feeling and that know that they’re being heard.

Trying to help a patient disassociate themselves from their chronic pain emotionally is challenging. After all, most of us didn’t become doctors and therapists to be a patient’s psychologist. However, empowering a patient with a stronger belief in the resilience of their body can be extremely fulfilling, and in my opinion puts people on the path to recovery while they’re in the process of receiving quality care.

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Why Does Balance Break With Parkinson’s?

Balance and postural control are some of the most challenging areas to deal with in Parkinson’s Disease. Dopaminergic treatments that are typically given for PD have not shown much benefit for the stooped posture and unsteady feeling that PD patients commonly experience. This suggests that other parts of the brain may be causing these balance problems, and that other forms of therapy may be required to improve balance and posture in PD patients.

The good news is that basic exercise programs that simply get the body moving have been shown to have lasting improvements in patients with PD. This includes things like Tai Chi, resistance training, and even boxing training have been shown to have positive lasting effects in people with early to moderate symptoms.

How does something as simple as exercise improve the symptoms of a brain disease like PD? How can we use some of these concepts to help patients with PD overcome plateaus in their improvement? That’s what I’ll try to answer today.

Proprioception: The Underdog of the Senses

It’s hard to appreciate just how complicated balance is until you start to lose it. The maintenance of posture and balance is so important and complex in the human body that some of the largest and fastest tracts in your spinal cord are dedicated to the use of your back muscles.

In order for balance to work properly, it requires the use of 3 super important sensory systems. This includes your vision from your eyes, the vestibular system from your inner ears, and your proprioceptive system from your skin and joints. Most of use can understand how important your vision and vesibular system are to your sense of balance so I won’t get into that much, but many people have no idea what proprioception is.

The 3 super systems that maintain your balance

Proprioception is a sense dictated by movement detected by your skin, muscles, and joints. If you were to close your eyes and raise your hand over your head, you can reach up with your other hand and touch that body part without looking at it. How does your body know? Because there are sensors in your skin and joints telling your brain where it is in space all of the time.

When it comes to balance, these same sensors that exist in your spine and in your ankles play an enormous role in keeping you upright, and it is the breakdown in this system that commonly leads to balance and posture problems in people with PD.

When Proprioception Breaks Down

Research has shown that patients with Parkinson’s Disease typically have a balance system that is overly reliant on vision and has mostly normal inner ear function. This implies that it is the proprioceptive system that breaks down leading to a heavier reliance on vision to compensate.

Why does this break down? Because the basal ganglia (the area of the brain affected by Parkinson’s) plays a really important role in your body’s joint position awareness. The basal ganglia is a really important relay station for proprioceptive information to get to the higher parts of the brain in the cortex. When the brain can’t integrate this proprioception, then it can’t provide feedback to the muscular system to make appropriate adjustments.

This can be problematic because in people without balance problems need proprioception to stay upright and balanced with stability. If you can’t make adjustments to your muscular system, especially in the dark, then your likelihood for falling increases dramatically with a little push from an unexpected source.

Teaching an Old Brain New Tricks

Proprioception is a big fancy word that sounds like it requires tools and advanced therapies, but in reality it is generated by simple movement. Every time your muscles contract or a joint moves, you are increasing proprioception into the brain!

That’s why exercise of all shapes and sizes tends to help patients with Parkinson’s Disease. 

In addition to standard exercise programs, patients with PD may benefit from therapies that help their brain better integrate sensory stimuli. This can include different types of proprioceptive therapies that include visual feedback training, eye movement training, and vestibular rehabilitation from a functional neurology perspective.

Plus the impact that a specifically targeted chiropractic adjustment has on the the proprioceptive system of the brain is becoming more well documented as a reason it can help people maintain better balance.

The right combination of therapies may help patients with PD improve posture, gait, and general difficulties with movement. While we can’t fix the area of the brain that is damaged, because the brain has the ability to change itself, we can teach different parts of the brain new tricks to help the brain better adapt to the environment.

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What Happens in Vagus: Chronic Pain and Dysautonomia

I’ve been doing a lot of reading lately about the vagus nerve and the autonomic nervous system. We’ve been super fortunate to work with a handful of patients with POTS in the past 6 months with some really great and surprising results from taking a cervical and vestibular approach to care, and it’s driven me to learn more about this unconscious super system in the body.

While dysautonomia is considered a rare problem, there are actually certain types of patients that have a higher risk of having dysautonomia as a co-morbid condition. This includes neurodegenerative disorders like multiple sclerosis and Parkinson’s Disease, but the ground I want to cover is something that affects people as an invisible illness.

Today we’re going to breakdown the relationship between chronic pain and the vagus nerve.

Fibromyalgia, Chronic Fatigue, and Dysautonomia

Fibromyalgia and chronic fatigue syndrome (aka myalgic encephalomyelitis) are 2 conditions that are frequently associated with each other. Estimates as high as 75% of of fibromyalgia patients report fatigue as a major symptom and 20% of chronic fatigue patients also report having widespread body pain [source].

What’s unique about these disorders is that they both show an unusually high amount of dysautonomia compared to the general population. A review in the Journal of Clinical Rheumatology showed that patients with fibromyalgia frequently show scores reflecting autonomic dysfunction along with non-pain symptoms like light-headedness on standing (orthostatic intolerance), digestive complaints, excess sweating, and fatigue.

It’s also been reported in the Journal of Internal Medicine that patients with chronic fatigue syndrome frequently have postural orthostatic tachycardia syndrome (POTS) enough to classify the POTS patients as a distinct subgroup of chronic fatigue.

So why is chronic pain associated with this breakdown of the autonomic nervous system?

What Happens in Vagus….

The nervous system is classified into different branches. For ease of understanding, you have one branch that controls all of your muscles like your biceps, triceps, and quads called the somatic nervous system. You also have another branch that controls your organ systems called the autonomic nervous system.

The autonomic nervous system is further divided into the sympathetic nervous system and the parasympathetic nervous system. The sympathetic system is the one that causes the things you feel when you get stressed out. Rapid heart beat, sweating, high blood pressure, along with increased blood flow to your muscles. It helps you prepare to fight or escape danger. The sympathetic system is primarily driven by a bundle of nerves called the sympathetic chain.

The parasympathetic does the opposite. It forces you to breathe slowly, digest, breathe slowly, and think about reproducing. The parasympathetic system is mainly driven by your vagus nerve.

The Vagus Nerve has a direct connection to most of your body’s internal organ systems

These systems generally work in opposition to each other to set the tone for how your body is going to operate.

The vagus nerve is an special and unique nerve that travels from your brainstem into the bulk of your internal organ systems. It gives the brain a direct line of communication with your organ systems because your body generally wants to spend most of it’s time being parasympathetic. 

Why?

Because when your body is more parasympathetic it is able to breath easier, digest better, engage in sexual intercourse, sleep, and heal from injury.

The sympathetic system is designed to help you survive from an imminent threat, but your parasympathetic system is there to ensure that you can adequately heal and recover from that threat.

The more active the Vagus nerve is, the more likely your body is able to heal and recover. This isn’t just some pleasant billboard sticker either. Research has shown that increased parasympathetic activity is associated with higher survival heart disease and cancer. It’s also associated with improved recovery and decreased injury in athletes.

Most importantly for the patient in chronic pain, lower vagus nerve activity was associated with chronic pain compared to healthy controls. [Source] It’s also been shown that lower vagus activity can be associated with intensity of symptoms in patients with fibromyalgia. [Source]

Weak Vagus and Chronic Stress

Vagal activity is measured using something called heart rate variability (HRV). Many years ago, you could only measure heart rate variability from electrocardiograms (EKG) and measuring the distance between each heart beat. Today, there is no shortage of computer and even smart phone applications that have brought HRV to a wide audience.

In general terms, the higher your HRV is over time, the higher your vagal or parasympathetic activity. The lower your HRV is over time, the higher your stress or sympathetic activity.

If your body is in a chronically high state of stress, then it is going to:

  • Decrease blood flow to your organs
  • Increase exposure to your stress hormones (adrenaline and noradrenaline)
  • Decrease your stores of serotonin (feel good neurotransmitter)
  • Increase your blood sugar (diabetes)
  • Increase your blood pressure
  • Decrease your immune system
  • Decrease tissue healing

Why? Because if your brain thinks that it is in danger from attack, then it does not care about healing and immune function. It is strictly concerned about getting you out of danger.

When you have low HRV and high sympathetic activity, your body is at a distinct disadvantage when it comes to healing and resilience. While low HRV isn’t necessarily the cause of heart disease, cancer, fibromyalgia, or chronic fatigue, but if you have a low HRV then your body’s ability to adapt and overcome these conditions is compromised.

I’ll put that in bold text because that’s an important distinction:

When you have low HRV and high sympathetic activity, your body is at a distinct disadvantage when it comes to healing and resilience. While low HRV isn’t necessarily the cause of heart disease, cancer, fibromyalgia, or chronic fatigue, but if you have a low HRV then your body’s ability to adapt and overcome these conditions is compromised.

Bringing Vagus Back

There was an interesting study published in 2014 that used strength exercise as a treatment for patients with fibromyalgia. The study showed that patients with Fibromyalgia had significant improvements in pain and quality of life through a regiment of strength training, but no significant changes in HRV. The study was surprising, because exercise is one of the best, easiest, and cheapest ways you can improve your HRV, but the biggest surprise was in the conclusion. The study concluded that strength training was an effective therapy for patients with fibromyalgia, which is absolutely true, but also said that changing the autonomic nervous system is not a goal worth achieving in patients with fibromyalgia.

Knowing what you know now about the autonomic nervous system, it seems like a rational and reasonable goal for any patient because improving the autonomic nervous system improves the health and survival of patients regardless of what condition they have.

The best part is that vagal tone can be improved using non-invasive methods that include cardiovascular exercise, resistance exercise, breathing exercise, mindfulness training, non-invasive vagal nerve stimulation, and yes even upper cervical chiropractic.

By taking the focus away from just addressing the pain, and making the focus of care on the autonomic nervous system, it gives us the ability to affect the person as a whole, instead of just addressing a symptom. By taking people away from their condition, and returning them to their bodies.

 

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The Link Between the Neck and the Jaw

Temporomandibular joint disorder (TMD) is a difficult condition to deal with. It is the most common non-dental cause of orofacial pain. It is characterized by a change to the joint of the jaw bone, which effects the chewing muscles involved and the person’s bite. TMD is a condition that causes a number of problems such as headache, neck pain, face ache, and ear ache. This condition affects more than 10 million people in the United States and is more common in women than men. Besides suffering from neck pain and jaw pain, people commonly report stiffness, popping, clicking, or locking of the jaw. This can make activities such as eating, singing, or talking difficult. [1]

The TMJ connects the jaw to the rest of your head. It’s purpose is to help guide the jaw, so that the bottom teeth are in alignment with the top teeth resulting in an even bite. When the misalignment of the TMJ occurs, the jaw muscles preform differently which causes the the muscles of the head and neck perform differently as well. If this happens, it will effect the person’s bite and possibly lead to an early break down of the joint.

How does the neck play into TMD?

The TMJ might not be the root cause for the disorder and research suggests that the structure of the head and neck plays a factor.  Evidence suggests that when there is an increase in cervical spine disorders it perpetuates factors for TMD. A cervical spine disorder being caused my repetitive motions and postural alterations of the head and neck. Another study showed that alterations in the TMJ can shift the vertebrae in the neck, especially the Atlas bone. This demonstrates their close relationship and when one of these structures shifts it can cause the others to shift as well. When this happens it puts abnormal stress on these structures where they’re connected effecting their proper function. That’s why it’s not too uncommon for a person to develop TMD after a traumatic event such as whiplash from a car accident.

The severity of TMD can vary from person to person. Some will find their TMD to be just an annoying click while others may feel a severe amount of pain and extremely limited ability to open or close their jaw. Patients who suffer with severe TMD are usually faced with the prospect of splints or surgery to fix their problem.

While some types of TMD may require surgery, many cases respond well to a structural approach to chiropractic using the NUCCA protocol. A gentle correction of the top vertebrae may be enough to decrease the jaw, neck, and headache pain as well as encourage some relaxation of the jaw muscles. When done in conjunction with a specialist in neuromuscular dentistry, many patients can experience a tremendous amount of relief.

If you are looking for conservative options to help address TMD, a Complimentary Consultation with our office can help you see if you a good candidate for this type of treatment.

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

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

Parkinson’s vs Parkinsonism Disorders: A Complete Clinical Picture

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

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

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

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

 

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

 

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

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

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

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

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

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

 

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

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

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

The Craniocervical Junction and PD

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

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

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

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

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

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

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

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

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

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

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

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

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

Closing Thoughts

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

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

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Ringing in the Ears is a Pain in the Neck

Tinnitus and Neck

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

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

How is My Hearing Related to My Neck?

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

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

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

 

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

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

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

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

Upper Cervical Chiropractic and Ear Problems

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

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

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

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Plasticity: How It Can Ruin or Restore Your Health

 Plasticity

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

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

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

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

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

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

The Popularity of Plasticity and The Perils of Hype

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

The Brain that Changes Itself – Norman Doidge

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

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

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

How neuroplasticity can help or hurt your recovery

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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Homocysteine and Migraines – What Does It Mean?

Homocysteine and Migraine

 

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

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

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

Homocysteines are a major player in chronic inflammation.

Homocysteines are a major player in chronic inflammation.

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

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

What is Special About Cerebrospinal Fluid

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

Why Is CSF Important to Us?

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

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

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What Happens To Your Brain When You Move Your Head?

brain with head movement

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

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

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

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

Brain Movement and Head Movement

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

Movement of the brain with a simple head turn.

Movement of the brain with a simple head turn.

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

Look at that jello jiggle

Look at that jello jiggle

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

Tagged MRI of rotation

Tagged MRI of flexion

Magnetic Resonance Elastography

 

A Cervical-Vestibular Approach to Dysautonomia: 2 Case Studies

Dysautonomia Case Studies

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

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

Case 1

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

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

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

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

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

You can see her in her own words below.

Case 2

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

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

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

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

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

 

How Does This Work for Dysautonomia Symptoms? 

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

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

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

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

Dysautonomia and Concussion

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

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