Keystone Brain Bytes Episode 3 – Our Approach to Dysautonomia

Keystone Brain Bytes Episode 3 – Our Approach to Dysautonomia

Dysautonomia is becoming a more common complaint in our office and one that we have had a good amount of success in treating. It will likely become a more prevalent issue in the coming years. In this episode of Brain Bytes, Dr. Chung explains our approach to dysautonomia and the neurological reasons why we use the cervical spine and vestibular system as our window into the autonomic nervous system.




Gait Testing Can Predict Future Post Concussion Syndrome

A recent study in the journal Gait and Posture looked at various biomarkers in posture and walking in athletes who suffered a #concussion.⁣

⁣Prognosis for Persistent Post Concussion Symptoms using a Multifaceted Objective Gait and Balance Assessment Approach

They wanted to see if any specific findings on balance or gait testing could predict which patients would have a worse recovery.⁣

The study found that out of all of the balance and walking parameters, 2 metrics were associated with the development of persistent symptoms or #postconcussionsyndrome

𝗗𝘂𝗮𝗹 𝗧𝗮𝘀𝗸 𝗮𝗻𝗱 𝗚𝗮𝗶𝘁⁣
The study found that when concussion patients had to perform a cognitive task while walking, there were changes in their walk that predicted future symptoms.⁣

Patients that were more likely to have future symptoms showed 𝙞𝙣𝙘𝙧𝙚𝙖𝙨𝙚𝙙 𝙢𝙤𝙫𝙚𝙢𝙚𝙣𝙩 𝙤𝙛 𝙩𝙝𝙚𝙞𝙧 𝙡𝙤𝙬𝙚𝙧 𝙗𝙖𝙘𝙠 when walking, and also 𝘀𝗵𝗼𝘄𝗲𝗱 𝗺𝗼𝗿𝗲 𝗿𝗮𝗻𝗱𝗼𝗺 𝗳𝗼𝗼𝘁 𝗽𝗹𝗮𝗰𝗲𝗺𝗲𝗻𝘁 when landing when they were engaged in a cognitive task.⁣

This might not seem like a big deal, but this may be a subtle sign that the brain is struggling to compartmentalize basic movement patterns, so it is using important resources from the frontal lobe to do something as simple as walking straight.⁣

This is why we have all of our patients perform a walking test with and without a cognitive challenge.⁣

The dual task paradigm gives us insight into brain function, and it also lets us know if we can use dual task exercises like the Fitlight to enhance our rehab.⁣


Occipital Neuralgia – Migraine-like Pain without the Migraine

A sharp and sometimes electric nerve pain coming from the back of the head that can radiate over the top of the skull or into the eyes.⁣

The pain from occipital neuralgia can be severe, and is often misdiagnosed as a #migraine.⁣

While occipital neuralgia is common after a head injury like #concussion, it can come out of nowhere from tight neck muscles or inflammation to a nerve called the greater occipital nerve.⁣

These types of headaches can be resistant to most medications, but can be alleviated by addressing mechanical factors in the neck, especially in the #atlas of the upper cervical spine.⁣
While there is no definitive test to diagnose occipital neuralgia, we can often find a tender point in the back of the head/neck that can reproduce the pain. That along with a detailed health history can help us identify the source of the head pain so it can be treated properly.⁣

The Dangers of Stroke

This post hits close to home, but it’s so important that lay people understand the signs and risk factors for stroke.

As a chiropractor trained heavily in neurology, I’ve spent years understanding and training to recognize when someone may be having a stroke. Despite my training, my wife suffered multiple strokes over the course of 3-4 days, and I was only able to catch the largest and most recent one.

Survival and recovery from stroke heavily depend on early recognition and treatment, and depending on the location of the stroke, a matter of minutes can mean the difference between life and death.

Signs of Stroke
The most common signs involve looking for facial dropping, arm weakness, and speech issues.

However, other serious signs include alterations in consciousness/awareness, nystagmus, and unsteadiness in walking and balance.

What makes stroke unique from other problems is that these signs will present suddenly and out of nowhere.

You can also combine the signs and symptoms with a patient history of risk factors.

Big risk factors are any history of high blood pressure, artery disease, and heart disease.

Important risk factors for stroke

Also be aware if someone is taking medications like blood thinners or birth control which can contribute to stroke risk.

Lastly, a recent history of infection or a recent autoimmune flare up can increase risk of stroke.

Strokes can be scary, and it can be terrifying to see a loved one show these signs. However, it is survivable and can be treated when recognized and treated early.

After the acute threat of stroke is over, a plan for comprehensive neurological rehabilitation can drastically improve a survivor’s life.

Is Your Neck Muscle Connected to Your Heart Muscle?

Is Your Neck Muscle Connected to Your Heart Muscle?

A 2015 study suggests that it might be the case. At least in rats.

Neck muscle afferents influence oromotor and cardiorespiratory brainstem neural circuits

The authors of the study were evaluating the anatomic mechanisms for how whiplash disorders and dystonia could cause problems with facial, oral, and cardiorespiratory issues.

To do that, they applied electrical stimulation to the upper neck muscles of rats and used molecular tracing techniques to identify what areas of the brain were stimulated.

They found that stimulating the upper neck muscles had unique pathways into an area in the brainstem called the nucleus intermedius, which had a direct impact on breathing and heart rate in the mice.

Even more interesting was that stimulating the neck muscles had as strong an effect as stimulating that area of the brain stem directly!

This effect was also specific to neck muscle stimulation, as pure sensory fibers didn’t produce the same effect. The effect was also not reproduced when stimulating nerves from the lower neck.

Obviously we don’t know for sure if this happens in humans because this was a rat study after all.

But studies like these might help explain why doing an adjustment to the upper neck seems to elevate vagus nerve function as measured by heart rate variability. It might also explain why many of our patients with #potssyndrome and other forms of #dysautonomia have had success with NUCCA.

The science on this is still very young, but it’s exciting to see the anatomical connections that make the upper neck such an important area to work on.

Inflammation: Friend or Foe

Last week I gave a talk to a group about the role of your immune system in pain and inflammation.

It’s easy to forget that the immune system that is responsible for fighting germs and illness is the same immune system that produces the inflammation that heals sprained joints or causes arthritic joint pain.

Acute inflammation vs chronic inflammation

It’s also easy to forget that inflammation in of itself is not good or bad. It’s a response from specific cells and systems in the body in response to a perceived threat.

While chronic inflammation can have negative effects on your heart, arteries, and brains, we need acute inflammation to help heal from injuries and to fight off infectious diseases.

A key lynchpin to an appropriate immune and inflammatory responses goes back to the brain and nervous system.

Acute inflammation acts like a reflex not much different than when a doctor taps on your knee to see if it kicks. If you have a cut or scrape, your immune system will kick into gear to wall that area off from germs and create heat and swelling and there’s nothing you can do about it. It’s embedded into our physiology.

These responses allow your body to clean up and repair damaged tissue while also containing germs trying to get in and invade the body during injury. Acute inflammation can be painful and uncomfortable, but it is a marvelous example of how we evolved to survive injury.

On the flip side, chronic inflammation is a maladaptive response where the body’s immune system isn’t shut down. It can occur in a variety of ways including:

  1. An underlying infectious process is never fully dealt with
  2. The presence of antibodies that attack the body’s own tissues (Lupus, Grave’s Disease, Rheumatoid Arthritis)
  3. A dysregulated stress response
  4. Inappropriately primed immune cells from brain injury or gut barrier problems

These processes can predispose people to a higher risk of heart disease, stroke, diabetes, and cancer, on top of just not feeling well on a day to day basis.

In order to beat the causes of chronic inflammation, we have to address the reasons that body creates inflammation.

It’s through this understanding that we have the ability to help address some of the chronic inflammation that leaves us susceptible to the chronic diseases of aging.

Vestibular Migraine – When the Brain Causes Dizziness

Vestibular migraine (VM) is a condition in which dizziness and vertigo can occur from central brain changes that occur similar to migraine headaches.

Although VM has #migraine in its name, it can happen with or without the feeling of a migraine headache. Some patients have just #vestibular symptoms like #vertigo. Others will have both #headache and vertigo along with other neurological manifestations.

VM is the most common cause of episodic vertigo, but it is frequently misdiagnosed for other inner ear disorders.

The hallmark signs of VM are a history of migraine headaches and increased visual dependency in balance.

Even when not in the midst of a vertigo attack, patients with VM can have debilitating imbalance and motion sickness between episodes and are persistent.

The good news is that many cases are treatable with migraine treatments like migraine meds, anti-CGRP antibody therapies, and vagus nerve stimulation seem to reduce attacks.

Between attacks, cervical and vestibular rehab can help decrease the burden of persistent imbalance and dizzy symptoms.

This is a place where functional neurology and upper cervical care really thrives.

Check out our most recent VM patient and you can see significant decreases in their disability scores and big improvements on their balance and sway.

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.