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Dysautonomia and PCS

Dysautonomia – A possible cause of post-concussion syndrome

Dysautonomia and PCS

With concussion being a dominant topic in sports medicine, we have seen a large spike in research dollars being spent to study the effects of brain injury. Despite our increased knowledge, when someone has concussion symptoms for longer than 30 days, there still isn’t great consensus as to why these people develop persistent symptoms and what is causing it to happen.

The symptoms of post-concussion syndrome (PCS) are what make the illness difficult to understand. The primary symptoms of PCS include:

  • Persistent headache
  • Dizziness
  • Loss of balance
  • Difficulty with concentration/brain fog
  • Nausea
  • Impaired or slow cognitive activity

The symptoms are vague and non-specific. In medicine, there’s a tendency and a desire to have a condition be linked to one very specific piece of anatomy. That way you can treat the diseased organ and cure the illness.

The reality is that a head injury is likely disrupting multiple body parts simultaneously. The higher centers of the brain aren’t the only things that get scrambled during a concussion. A concussion is likely damaging multiple areas in the brain along with the inner ear organs, the neck, the jaw, and the eyes.

Since every head injury is unique in terms of velocity, direction, and magnitude, it means that each person’s head injury is likely to impact their anatomy in individual ways. This is where you can have a lot of variation in how someone with post-concussion syndrome looks symptomatically.

Another struggle is that different body parts can create similar symptoms. An injury to the neck can cause a feeling of vertigo just like an injury to an inner ear organ. An injury to the neck can also cause headaches symptoms just like the eyes or the vessels in the brain.

Some doctors are looking at another potential cause of persistent concussive symptoms called dysautonomia.

Dysautonomia – A Fight Between 2 Super Systems

Dysautonomia is a condition where the brain loses normal control of the internal organ systems of your body. Dysautonomia can show up in organs like the digestive system, bladder, glands, and pupils. Classically, these disorders show up in the cardiovascular system by affecting your heart rate and blood pressure.

Autonomic Nerveous System Chart

The autonomic nervous system is compromised in patients with dysautonomia

The most common disorders linked to dysautonomia are:

  • Multiple sclerosis
  • Fibromyalgia
  • Postural Orthostatic Tachycardia Syndrome (POTS) – an illness characterized by rapid heart beat to 150-200 bpm at rest
  • Neurocardiogenic syncope – a disorder characterized by unpredictable fainting attacks.

When people have these disorders then the broken function of the nervous system causes people to feel dizzy, in a fog, extremely fatigued, light headed, and anxious. When you read those symptoms on paper (or screen) it doesn’t sound like much, but the way those symptoms persist can drive someone mad.

People don’t just have a brain fog, they are scared and frustrated that their brain won’t allow them to focus and accomplish a task.

People don’t just have fatigue, they have an inability to socialize and be effective at work and at home because of exhaustion.

People don’t just have dizziness, they are worried about driving and being in open spaces because their body is betraying them.

People don’t just have a rapid heart beat, they have fear and anxiety that this next attack could put them in the emergency room.

Having dysautonomia whether it’s an illness on it’s own like POTS, or part of another illness like MS can make life much harder and depressing, because treatment for the illness is really limited.

Post-Concussion Syndrome and Dysautonomia

Going back to post-concussion syndrome, we discussed how the illness can be extremely frustrating because doctors and scientists have had a hard time coming to a consensus as to where the symptoms are coming from.

Some doctors and scientists are presenting an interesting theory that cases of post-concussion syndrome may be a manifestation of dysautonomia.

One of the first studies to look at this phenomenon was done in 2016 on young patients with persistent concussion symptoms. The study involved a test called the head-upright table tilt test. You can check out the full study here:

Orthostatic intolerance and autonomic dysfunction in youth with persistent postconcussive symptoms: a head-upright table tilt study

Image credit to Stickman Communications

Image credit to Stickman Communications

This test is used to diagnose feinting conditions but is also a hallmark test for POTS. The study showed that 24 out of 34 PCS patients had findings on the test indicating a form of dysautonomia. 10 Patients had syncope while 14 patients had POTS.

Even more interesting was that when the patients with POTS stopped having PCS symptoms, they also stopped having a reaction to the table tilt test when re-examined.

Another 2016 study showed that patients who have a history of concussion show a decreased ability to modulate their heart rate and blood pressure at rest indicating a loss of autonomic control. This was happening in patients without any overt signs or symptoms of dysautonomia.

Valsalva maneuver unveils central baroreflex dysfunction with altered blood pressure control in persons with a history of mild traumatic brain injury

Then you also have a wide range of studies looking at how concussion can impact your heart rate variability which is an increasingly utilized biomarker for autonomic nervous system activity.

HRV Studies

A dysautonomic theory of post-concussion syndrome can also help explain some of the unusual symptoms that may arise after a head injury. While it’s easy to understand how a PCS patient can have persistent headache and dizziness, there are a lot of people who will have a concussion or whiplash and start developing persistent gut issues and sensitivities to foods. Dysautonomia as a culprit helps to make better sense of this phenomenon.

What Does This Mean for Treatment?

Dysautonomia is a condition that is not well recognized by many physicians and there aren’t many choices for effective treatment options. In dysautonomia, the brain is having a terribly hard time making sense of its environment.

There’s some interesting work going on utilizing balance and vestibular exercises and graded cardiovascular exercise to help the brain recover from injury, but I’ll cover that on another day. Today I want to talk about the veins in your neck.

Dr. Michael Arata is an interventional radiology specialist in Southern California. I heard him speak at a conference in 2015 where he talked about the effect that the veins in your neck could have on your autonomic nervous system. It’s been an interesting and controversial theory that has been tied to illnesses like multiple sclerosis where dysautonomia is a hallmark of the illness. When the large veins in the neck become narrowed or occluded, it can cause abnormal fluid movement in the brain leading to venous reflux, congestion, and neuroinflammation in the brain.

Dr. Arata even published 2 studies that demonstrating that a procedure that uses a balloon to open these veins was able to create changes in the autonomic function of patients with multiple sclerosis including heart rate variability and blood pressure control.

Transvascular autonomic modulation: a modified balloon angioplasty technique for the treatment of autonomic dysfunction in multiple sclerosis patients.

Blood pressure normalization post-jugular venous balloon angioplasty

But that wasn’t the most interesting part of his presentation. During his talk, he talked about the concept of the atlas vertebra creating compression on these vascular structures. He even used an imaging technique called a venogram to show this happening in his patients:

Dr. Arata shows images of a venagram to show how atlas rotation can disrupt the internal jugular vein

Dr. Arata shows images of a venagram to show how atlas rotation can disrupt the internal jugular vein

It’s because of this phenomenon that Dr. Arata actually refers some of his patients for upper cervical correction so that they can influence this part of the autonomic nervous system.

If dysautonomia is a primary symptom generator in PCS patients, then the impact from a potential neurovascular insult like an craniocervical displacement should be considered especially considering the mechanism of injury includes a blunt force to the head.

An Personalized Approach to Post-Concussion Syndrome

Patients with post-concussion syndrome with signs of dysautonomia likely have multiple systems that must be addressed to regain normal functionality. In addition to dysfunction in multiple systems is the idea that each person will have a varying tolerance to different therapies.

In truth, no single therapy is likely to fix someone with persistent post-concussive symptoms and dysautonomia. These patients need to improve their tolerance to exercise with gradual increased load (especially if they’re an athlete). They also need vestibular rehabilitation so that their brain can move the head and eyes normally again. There’s no disputing the necessity and usefulness of those treatment strategies.

However, if we are concerned about the chronic effects of head injury and the ability to improve fluid movement through the brain, then we have to consider the impact that trauma has on the structural alignment of the neck and the neuroinflammatory consequences that these injuries can leave behind.

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Migraines and Concussions

Why Concussions Hit Migraine Patients Harder

Migraines and Concussions

 

The vast majority of people who suffer concussive injuries will recover without any chronic symptoms. However, about 15% of people who suffer concussions will go on to have post-concussion syndrome, where they will experience headaches, dizziness, and cognitive problems beyond 30 days after an injury. These symptoms can be debilitating, and some people can experience the effects of these head injuries for years later.

A lot of research has been done to identify people who are at higher risk of developing post-concussion syndrome. The most significant risk factor for this is having multiple concussions, but that’s a rather obvious one. The more concussions you’re exposed to, the greater the opportunity to have chronic symptoms. However, research has pointed to one specific risk factor that seems to contribute heavily to post-concussion syndrome in the athletic population. That risk factor? A history of migraine headaches.

Migraines and Concussion: a terrible duet

Post-traumatic headache is one of the hallmark symptoms of post-concussion syndrome. These headaches look a lot like migraines because of the wide range of neurological symptoms that concussions can cause.

It’s no secret that concussions can cause terrible headaches in people, but many people don’t know that having a history of migraine headache is a risk factor for worse outcomes in post-concussion syndrome. ¹ ² ³

This is important for a couple of reasons:

  1. If you know someone with migraines is at a higher risk for post-concussion symptoms we can be better prepared to see appropriate specialists in the event of a concussion.
  2. We have a better understanding for why sports like girls’ soccer are more susceptible to concussive injuries and can be more prone to chronic post-concussion syndrome.
  3. Because understanding the common physiology in migraines and concussion can help us identify effective treatments for one of its most debilitating symptoms.

Migraines, Post-Concussion Syndrome, and the Neck

Treatment for headache symptoms in migraine and post-concussion syndrome are pretty similar. Amitriptyline, propanolol, and topirimate. These medications target receptors in the brain that can become overactive and underactive during a migraine attack.

Most research is focused on finding effective drugs to treat headaches, but this treatment philosophy ignores the fact that the headaches from a migraine or concussion can often stem from dysfunction of the cervical spine.

When the neck is compromised the muscles and nerves that surround the upper neck can become areas of concern for the headache patient. The muscles at the top of the neck transmit information to the brain about where the head is in space.  Studies have shown that these muscles can be tied to chronic headache symptoms. ¹ Some studies have even shown that cutting these muscles can lead to headache relief.¹

You can read more about these troublesome little muscles on a previous article I wrote here:

Is This Small Neck Muscle Driving You Mad?

 

The muscles in the deep part of the neck have been implicated in headache disorderrs

The muscles in the deep part of the neck have been implicated in headache disorderrs

 

Additionally, the nerves in the top of the neck are important transmitters of pain. The C1, C2, and C3 nerve roots in the neck are linked to the trigeminal cervical nucleus which is an important relay center for pain in the head. Branches off the C1 nerve like the suboccipital nerve have been targets for nerve blocks in migraine patients with good success.¹

 

The nerves in the upper neck play a major role in headache physiology

The nerves in the upper neck play a major role in headache physiology

 

These mechanisms are important because research has shown that whiplash and concussions can have a significant impact on these anatomical structures. ¹ ² ³

Concussions Worsen Cervical Spine Problems

So here’s the main issue. Many (but not all) migraine issues can be tied to the neck. More than 80% of the migraine patients that come into our office get a tremendous improvement in the frequency of their migraine attacks just by fixing biomechanical issues in the neck, and there is some research that supports it. ¹

When someone has a biomechanical issue in their neck, then a major blow to the head like a concussion can make these neck problems worse. Several studies are starting to show that there are some interesting similarities with what happens in a whiplash and what happens in a concussion. The fact is that the amount of force that it takes to cause a concussion FAR exceeds the amount of force it takes to create a mild whiplash injury.

Whiplash and Concussion

The force required to sustain a concussion far exceeds the forces necessary to cause a whiplash

Obviously not every force over 5 g’s causes a whiplash and not every force over 100 g’s causes a concussion. Otherwise we’d all be walking around with with severe neck injuries every time we got off a roller coaster. There are factors involved like neck strength, timing of muscle bracing, and previous injuries that affect our susceptibility to these forces.

My point is that if you have sustained a concussion, then the probability of you also suffering an injury to the neck is really really high.

If you were a migraine patient before the concussion and the migraine was stemming from your neck, then the odds of that neck injury becoming worse and making the healing process after a concussion is much higher for you than most others.

If you had a small biomechanical issue in your neck that was contributing to your migraine headache symptoms, then the force of a concussion is going to injure the ligaments and muscles that were already compromised! This is addition to the way that concussions knock out your vestibular and ocular systems which are also known contributors to headache physiology.

Addressing the Neck

So what does this mean for you?

  1. If you are an athlete and have a migraine headache problem, you should get your neck checked and rule out any biomechanical problems in the upper cervical spine. Fixing these issues will likely address your migraines, and may provide some protection from head contact.This is even more true for female athletes than male athletes. Women suffer from migraine headache issues at a much higher rate than men, and this can be a contributing factor to the increased rates of concussion we see in girls’ soccer.
  2. If you play contact sports, getting your neck stronger may provide protection from concussive injury. Again, this applies even more so to female athletes because women will tend to have smaller neck muscles than men. Weight training and specific neck exercises is a safe and easy way to possibly mitigate this risk.
  3. If you have a history of neck injury from whiplash and concussion, make sure you’re seeing someone with expertise in addressing the cervical spine. People with traumatic neck injuries may not respond well with vigorous treatment methods and may regress with too much force applied to injured tissue.

 

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equestrians-and-concussion

Are Equestrians More Resilient to Concussive Injury Than Everyone Else?

equestrians-and-concussion

 

Concussions, Balance, and the Equestrian Advantage

Concussions are a hot topic in professional football, but it’s something that horse lovers have been familiar with for years. A 2014 paper in published in the Sports Health medical journal showed that almost 50% of competitive riders will have experienced a concussion during their life while riding. Surveys have also shown that helmet usage amongst equestrians is extremely low with estimates ranging from 9%-25% of riders opting to ride without head protection.

The sudden deaths of high profile professional football players have made the complications of head trauma a hot button topic in sports and medicine. Concussions are considered a mild traumatic brain injury, but the truth is that a brain injury of any sort is anything BUT mild.

While most people will recover from the effects of a concussion within 7-10 days, approximately 15% of patients will experience symptoms beyond 30 days. When these concussive symptoms persist,  the patient will likely receive a diagnosis of post-concussion syndrome or PCS. The symptoms of PCS include:

  • Headache and migraine
  • Vertigo or loss of balance
  • Brain fog/difficulty with concentration
  • Memory dysfunction
  • Dysautonomia and fatigue

Pro-Riding and Pro-Brains. Not Mutually Exclusive

There are risks to all sports, and as an athlete you have come to accept those risks as part of the game. Additionally, if you have been involved with riding for a while, it’s easy to accept head injuries as an inevitable part of the sport, and the truth is that most people will recover in a week or two.
It’s a common thread with sports doctors to say that sports like riding are too risky for the developing brain. The truth is that concussions shouldn’t be something that scares you from playing your sport. Getting into sports like riding are the most effective ways for people to stay active and fit throughout your life.

I try to teach my riders 2 important concepts:

  1. If you get an injury, make it an injury of performance. Take the right steps to prevent injuries of negligence or careless behavior like not wearing a helmet.
  2. Know what to do after a head injury so that you can ensure maximum brain health and recovery.

 

Taking Care of the Concussed Brain – Performance Over Pathology

When talking about the long-term health consequences of head injury, it’s best NOT to get your stance from places like Will Smith’s recent film, Concussion. The brain illnesses discussed in that movie are pretty rare, and apply to very specific types of athletes.

However, that doesn’t mean that concussion is free of long-term consequences. Studies of athletes with a history of concussion have shown slightly slower cognition and reaction time 30 years later, even if there are no symptoms of head injury. Studies of previous football players have shown that athletes with a history of concussion are more likely to have back and leg injuries after retirement because of the way concussions affect control of your own joints.

Here’s where getting the right treatment after concussion can make all the difference in the world for an equestrian athlete. While most athletes aren’t overly concerned about something abstract like brain health, athletes are VERY interested in anything that can affect their performance on the field or rink.

The Equestrian Advantage

While equestrians are at a higher risk of head injury than most sports, the unique features of equestrian sports may help confer protection from some of the chronic problems associated with concussion.

From a neuroscience perspective, horseback riding requires a tremendous amount of work from the parts of your brain that control balance. Your sense of balance is made up of a delicate interplay between your inner ear (vestibular system), eyes (ocular), and joints (proprioception). Your brain takes information from these 3 systems and paints the image in your mind of where you are in space.

The 3 super systems that maintain your balance

The 3 super systems that maintain your balance

When you ride a horse, your body is constantly bobbing in a way that far exceeds the normal force of walking. Your brain has a magnificent system in place to help keep your vision in focus even though your head is moving all over the place. If this system gets corrupted, then really simple movement makes us feel off balance or dizzy. In other cases, this system also affects our emotional control and cause headaches.

The brain, like any other part of the body gets stronger and adapts the more that you use it and challenge it. Between simple riding, jumping, and dressage, equestrian athletes have to challenge their vestibular system more than almost all people, including many athletes. That means that many equestrians are likely to have a stronger sense of balance than most people, and research is actually starting to demonstrate that1. The effects that horseback riding has on balance or so strong that they are even being suggested for the treatment of balance problems in the elderly2 and in stroke patients3.

No Symptoms No Problems In Concussion Patients

So why is that important for a concussion? Most people associate concussion with your ability to think, but concussions actually have the strongest and most immediate impact on this balance system. When people suffer with concussions, you’ll often see that their ability to stand still and walk is affected even if they don’t have any cognitive symptoms at all. The brain hates when the balance system is broken. Overtime, as balance issues fail to get fixed, it spills over into problems leading to vision disturbances, headaches, and brain fog.

One of the things that I notice in my experience with equestrian patients is that many won’t show signs of head injury in their normal daily activities, due to their strong sense of balance. When your body feels like it has a good sense of balance, some of the cognitive and pain symptoms from a concussion don’t impact you quite as badly. This is a great thing in that a head injury won’t cause an obvious deficiency in your quality of life.

However, many times this is due to a compensation strategy by the brain. When you suffer a concussion, the parts of the brain that control the eyes, cognition, balance, and movement become compromised. When the brain suffers damage to one area, then other areas of the brain will start to work harder to perform the duties of the damaged region. This is driven by a concept called neuroplasticity. This is what allows blind people to have a heightened sense of hearing, or deaf people to have a more focused visual sense.

As a rider, a concussion may damage the regions of the brain that control neck and eye movements, which can be detrimental to your balance. However, your balance system from the inner ear is so strong that it can take over the task of keeping you upright without much of a hitch. Even though you feel good and your balance seems strong, there’s only so long that the brain can manage these compensation strategies before it starts to fail.

Compensated Performance = Suboptimal Performance

 So now we’re going to bring it all back together.

When you suffer a concussion and parts of this comprehensive balance system breaks, many equestrians are fortunate enough to bounce back without prolonged symptomatic consequences because of a well-trained balance system in the brain.

The problem is that our brain is designed to work with contributions from all of our sensory systems. If we partially lose a system like proprioception from the joints and the inner ear system works overtime, then we will gradually lose more and more function from the joint position system. It won’t affect us immediately, but it may start to show up as back pain and knee injuries later on in life. If we lose some of our visual sense, then things like double vision or blurry vision can become long-term consequences.

You can even perform simple tests to see if some of your balance systems are not working well. Something as simple as standing with your eyes closed vs standing with your eyes open helps to see if your inner ear and joint position sense are working. If you start having difficulty concentrating while reading, your ocular system may be compromised.

The good news is that the same plasticity that helps us compensate is what allows us to develop strategies to rehabilitate the brain when we know which system is compromised. A thorough structura and neurological exam can help ensure that your brain does not just survive after a concussion, but to get it back to thriving again.

  1. Kim SH, Lee C, Lee I. Comparison between the effects of horseback riding exercise and trunk stability exercise on the balance of normal adults. Journal of Physical Therapy Science. 2014 Sep; 26(9): 1325-1327
  2. Kang K. Effects of mechanical horseback riding on the balance ability of the elderly. Journal of Physical Therapy Science. 2015 Aug; 27(8): 2499-2500
  3. Kang K. Effects of horseback riding simulator exercise on postural balance of chronic stroke patients. Journal of Phhysical Therapy Science. 2013 Sep; 25(9): 1169-1172.

 

Young Brains and Football

One Season of Football and the Developing Brain

Young Brains and Football

 

Read Time: [5-6 minutes]

 

2016 continues to be a troublesome year for football as science reveals more information about the effects of repetitive head contact on the brain. It’s pretty well established that concussions can create lasting changes in the structure of the brain, in recent years scientists have sought to study if contact sports can change the brain even without concussion.

Two studies presented this year sought to answer that question, and it looks like football without concussions can still affect a young and developing brain. Here are some links to studies below:

Brain Changes seen in youth football players without concussion

Head impact lead to brain changes in high school football players

Both of these studies had a similar design, but they were performed on different age groups. One was performed on players between the ages of 8-13, the other was performed on high school players. Players were given special helmets to quantify how much head impact they were receiving in practices and in games. The players were also scanned with a special form of MRI called diffusion tensor imaging (DTI) before the season and after the season to see if there were any changes in the structure of the brain after the season.

About DTI

DTI helps to measure structural damage to the brain by helping doctors look at a part of a neuron called an axon. Axons are like power lines of a nerve cell. Whenever a neuron fires, it transmits an electrical signal down these wires so that it can pass the message along to the next neuron in the chain. DTI measures the continuous movement of water through these “wires”.

The resulting image is actually something quite beautiful and remarkable to see. Almost like something you can hang in an art exhibition as you can see below:

 

Image Credit: Google Creative Commons

DTI Image of the axons in the brain. Image Credit: Google Creative Commons

 

One of the things that has been well established is that concussions can damage a lot of the axons in the brain through a process called axonal shearing. It’s basically like a hurricane coming in and knocking down your town’s power lines.

 

Image credit to Artery Studios via Pineterest Arterystudios.com

Image credit to Artery Studios via Pineterest
Arterystudios.com

 

When these axons get damaged, that beautiful DTI image that you saw before hand will start to show some gaps like you see below:

DTI Normal vs Abnormal

Back to Football and Young Brains

So we know that concussions definitely cause axonal injury, but what about all those hits to the head that happen without a concussion? Could they also damage these axons?

According to these 2 recent studies, a year of youth or high school football can make observable changes in the structure of the brain.

The studies also showed that the players who had impacts that were more frequent or more forceful correlated with greater signs of damage.

In high school athletes, the researchers also measured functional changes in the brain and showed that players with greater or more frequent impact showed decreased delta wave activity which is a characteristic sign of brain injury.

So far, not so good.

Imaging Is Not A Death Sentence

So before we draw any conclusions, let’s talk about 2 things.

While we know that these DTI findings are related to concussion and head impact diagnosis, we have no idea if this means anything for the health and quality of life of the patient in the future.

Findings on DTI are NOT predictive of how impaired a patient is, nor does it predict if a patient will have future brain damage or post concussion syndrome. In fact, findings on DTI don’t predict all that much at this point in time.

Obviously we prefer that brains don’t suffer any damage at all, but we do know this:

Most people who suffer head impact and concussions will go on to live normal healthy lives.

Now it’s up to science to figure out how much can someone’s brain take, and how do we take care of these people who are at risk for future brain disease.

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Dr. Chung Joins ESPN West Palm to Talk Youth Football, Neck Surgery, Stroke, and Heat

ESPN1063

This week Dr. Chung joined Jeremy Marks-Peltz on ESPN West Palm Tonight. The interview is available below. This week Dr. Chung addresses:

  • The new study showing changes in the brains of youth football players
  • Dolphins Linebacker Koa Misi will be getting fusion surgery for herniated disc in his neck
  • The tragic Katie May stroke incident and chiropractic
  • Heat basketball
Post-Concussion Syndrome

Case Study: 6 months of Post-Concussion Syndrome

Post-Concussion Syndrome

 

Read Time: [3 minutes]

Post-concussion syndrome has become a big deal with more athletes showing concern about the risks of chronic brain injury. Recovery from a concussion usually takes about 7-10 days for most people but many will have symptoms that last 30 days or more.

Our most recent case had post-concussion syndrome that lasted 6 months prior to visiting our office.

Background

A young woman was a passenger in a car that was struck from the side. The shock of the accident caused her head to whip from side to side and she lost consciousness immediately.

Although many concussions are a result of a direct blow to the head, a concussion can occur through rapid acceleration and deceleration of the head causing the brain to move and collide with the inside of the skull.

Following the concussion, the patient began having daily episodes of migraine headaches. During the migraine attacks, she would also have vertigo that led to a persistent feeling of nausea.

After being discharged from the hospital the patient was seen by an orthopedist and chiropractor. While chiropractic adjustments were helpful, she felt her symptoms come back repeatedly within hours of her treatment. The patient had an appointment with her orthopedist to receive neck injections, but was referred to our office before that to see if correcting her atlas would help.

Assessing the Neck in Concussion

The patient was put through a full examination to evaluate the  neck. In many cases of post-concussion syndrome, the neck has numerous pain-generating tissue that can be responsible for these neurological symptoms. This includes precise x-rays of the top of the neck, evaluation of neck muscle tone, structural positioning, and evaluation of head and neck control.

You can see some images of our head control laser testing below.

img_4266

Laser head positioning system

Testing head control using a maze

Testing head control using a maze

When people suffer a concussion or whiplash injury, it can cause damage to the muscles and allow us to control our head and neck movement. These injuries can lead to headaches, but they also cause problems with our sense of balance.

Once we have some baseline information on their current abilities, we can monitor how they respond and heal from the damage to their neck.

Results:

After her 2nd visit, the patient said that her headaches and nausea were almost completely non-existent.

Imagine that. Going from daily migraines, to no headaches for an entire week. All from a getting the head and neck into a better structural position.

Now that isn’t to say that life is perfect after that. There were certainly some ups and downs along the way. Overall, the patient’s headaches have improved about 80% in frequency and intensity. She has elected to skip getting injections, and is working hard everyday to get stronger.

Here’s the most important element and really the part that matters:

After the head injury, the patient was unable to do the things that made her life fun. She had trouble working out and getting motivated to exercise. Staying focused at work meant having to rely on pain killers. Taking care of a young daughter meant gritting her teeth through pain and nausea instead of being present in the moment.

That’s what all of this is about. It’s not about the pain reduction, it’s about the restoration of normal life!

For more information, you can read this patient’s testimonial below:

I’m a very active mommy that carries around the weight of a 6 year old and owning a salon full time. Work and mommy duties call for my body to be at all times ready and with it. There isn’t time for rest, much less any fatigue or achy-ness. Between playing sports when I was young, actively working out and having the burden of standing on my feet the majority of my work days, my simple adjustments just got me through. I didn’t realize that there could be a cure for my migraines, constant neck stiffness and what seemed to be a much older body that I was trapped in.

I was a back seat passenger in a car crash on New Years, where the car was deemed totaled. There were no major signs of trauma, besides the concussion and black eye I received, however, I knew something was wrong when my pain was continuing to get worse months after the accident. My routine visits to the chiropractor, became tedious weekly visits that just got me through; my pain kept coming back if I didn’t get adjusted that day. I refused to succumb to cortisone shots previously, but felt desperate. Instead of my Chiropractor sending me off the receive the possible relief from an invasive procedure, he referred me to his dear friend Dr. Chung that specializes in post concussion, migraines, fatigue and achy-ness.

Dr Chung was very thorough and did a series of X-rays and tests to see how my whole body was aligned and reviewed my MRI. He explained the symptoms and showed me what was happening to my brain and surrounding inflamed tissues. After one precise adjustment and many months of not being able to be active or myself, I felt 150%. I was scared and apprehensive as to when my pain would return. To my surprise, months later and just a few maintenance NUCCA adjustments, my pain has not returned and I was immediately able to carry on with my workouts, mommy life and my physically involved career. I was even able to hike, travel and do Cross-fit within weeks of being adjusted. My energy and range of motion has returned. I couldn’t be happier for the referral to such a dedicated, intelligent, passionate Doctor of Chiropractic. Thank you so much for your passion to treat your patients and wish you much success.
Jessica S.

ESPN1063

Dr. Chung talks about Tony Romo’s broken back and the Palm Beach Concussion Seminar

ESPN1063

 

Dr. Chung was featured on ESPN West Palm Tonight to talk about Tony Romo’s broken back and the Palm Beach Concussion Seminar. Check out the interview here. For the best coverage of the Palm Beach County sports scene, check out espnwestpalm.com.

 

Head tilt

Why Does My Head Always Tilt to the Side?

Head tilt

Read Time: [5-7 minutes]

How do I know if someone has an Atlas problem? Can a regular person see it?

Head tilting posture is something we’re used to seeing with curious puppies, but it may be a sign of a problem in the central nervous system. This can be one of the most important signs of poor neurological activity even in the absence of pain or symptoms.

Head tilt

Image from paper in the journal Laterality. Source: http://www3.canisius.edu/~noonan/research/researchreports/human_head_tilt.htm

Poor Head Position = Poor Interpretation of Gravity

Poor head positioning is one of the most important postural findings I look for in a Structural Chiropractic Examination. From a clinical perspective, it’s a lot more important than something like slouching. For the most part, people have the ability to recognize and correct a slouching posture when they want to. When it comes to a persistent head tilt, most people have no idea when it’s happening. It’s also a posture that is related to things like head injury, whiplash, or a balance problem.

When you have a persistent head tilt, you typically don’t know that your head is tilting because in your mind, it’s perfectly straight. This is an underlying indicator that your brain is working inefficienctly.

When you really think about it, posture is primarily your brain’s response to gravity. Whatever your body experesses as a straight posture is how your brain thinks it needs to exist in a gravitational environment. That means that a crooked head position means that the brain is getting bad input, which is leading to poor output.

Garbage in, garbage out

What does garbage out look like to the body? Garbage out expresses itself as Secondary Conditions like:

  • Headaches
  • Facial pain
  • TMJ
  • Vertigo
  • Balance Problems
  • Syncope (Dysautonomia)

All common problems experienced after a concussion or whiplash injury.

Why Head Tilt?

So what does head tilt have to do with concussion, whiplash, and all of these Secondary Conditions?

When your head and neck is exposed to a force, it can affect one of 3 systems in the body that control and regulate your balance and posture.

  1. Visual and Ocular system
  2. Inner ear/vestibular system
  3. Neck/Spine Proprioceptive system

Together these 3 systems integrate into your brain so that your brain knows how to regulate your body in space.

Your vision and movement of your eyes make sure that your head stays level. Your ears tell your brain if your head is moving. Your joints provide information on if your limbs or your spine are moving.

This system works best when all 3 give the same information. If your eyes and muscles say one thing, but your ears say another, then it creates a problem for the brain to process.

The 3 systems that form the Balance Triad

The 3 systems that form the Balance Triad

When you take a blow to the head or neck, then these structures can become damaged and start to malfunction.  We can see this malfunction manifest as a persistent head tilt to the side.

Head tilt may not be the cause of these problems, but it is a clear and obvious sign of a breakdown in this system.

It’s easy to see how a blow to the head can affect the neck because the two structures are connected via the top bone in your neck called the Atlas. In our Wellington office, we handle this problem by re-centering the head on top of the neck again utilizing the NUCCA procedure.

When the head is centered, then it’s almost like a re-boot to the system to make the brain work normally again.

Not All Head Tilts Cause Pain

Notice that not all head tilts cause pain, but head tilt is almost always a sign of a problem in the brain. Lots of people can go through a bad car wreck and not feel any pain immediately. However, the structure of their spine and the function of the brain has changed. This means that a problem can develop over time due to chronic malfunction of the nervous system.

That’s why everyone should get checked for a Atlas Displacement after an injury even if there’s no pain or symptoms present.

Not All Head Tilts Are a Neck Problem

Not every head tilt is related to a problem in the neck, though there is almost always at least some contribution from the neck. As we discussed earlier, there are 3 main systems that dictate your sense of balance.

There are times when I have done my best effort in correcting someone’s neck that a head tilt persists. That’s why it’s important to work with a team of professionals that are capable of addressing this problem.

  • Optometrists/Vision Therapy/Neuro-opthamology – These professionals are trained in addressing the ocular system. It’s a rapidly growing field thanks to our growing knowledge of concussion and how it affects the eyes.
  • Vestibular Therapist / Functional Neurologist – Special types of chiropractors and physical therapists are trained at rehabilitating problems in the inner ear. They use special assessments and exercises to restore normal function of the inner ear.

Remember: No one therapy cures all. An interdisciplinary approach is often the best way to solve many of these complex cases.

 

 

Case Study

Case Study – What Happens When A Current Patient Has a Head Injury – Chiropractor in Wellington

Case Study

 

Last week I had a really unique situation that I wanted to share. It really helps to clarify what my approach to patient care is when a case is not going the way that I expect.

Case Presentation:

A year ago, a woman came into the office to see me for daily headaches. The headaches had been a problem for over 40 years. They had been using over the counter medications and meditation techniques to keep the headaches under control. The worst times for the patient were the days that it rained. On rainy days, their dull headache would start to become more of a pounding type pain. In West Palm Beach where it rains most days in the summer, it’s a pretty miserable way to live.

After 2 weeks of gentle Atlas Corrections, the patient’s headache frequency dropped to 1x/week and the rain no longer had an impact on their headaches.

Within 2 months, almost all headache symptoms had resolved completely.

Enter the Concussion

The case above is a pretty standard and regular occurance in the office. Headache cases are probably the fastest responding and most successful Secondary Conditions that resolve when the Atlas is corrected. What made this case interesting is what happened about a year after she first saw me.

The patient ended up having a concussion, and as a result started showing new symptoms. There was neck pain that was never present, a new headache pattern, and a persistent abnormal tingling that wouldn’t go away.

The patient came in about a week after the concussion happened. After evaluating the patient to make sure it was safe to take care of them, I attempted to use a similar adjustment that had worked on her in the past.

While some of the post-concussion symptoms got better, the headache and the abnormal sensations didn’t budge. The patient was concerned that they might have to seek out more aggressive medical options to address the new symptoms.

Many times, an Atlas Correction is like a key to a unique lock. It rarely changes over time, but a head trauma can force that lock to break, which means you need a new key. A new and different correction becomes necessary.

I decided that I needed to re-evaluate the situation based on the NUCCA protocol for Structural Correction.

Some people think it’s uncalled for, and others think it’s excessive, but I decided to take a new set of X-rays on the patient. The radiation dosage on craniocervical X-rays are about the same as a cross-country flight, and the patient thought it was worth it.

I never want to irradiate a patient more than they need and I look to avoid X-rays if I don’t need them. I decided that the chance to help this patient recover from their post-concussion symptoms warrented a new series.

Concussion Created a New Lock, NUCCA Provides a New Key

As it turns out, the new imaging revealed a completely different angle that I needed to use for the correction. The head injury disrupted the structure of the neck so much, that it rendered the previous correction useless.

Within minutes of using the information from the new X-ray, the patient’s headache and abnormal head sensations vanished.

It’s one of the reasons I embrace the NUCCA procedure because it provides a very elegant way of troubleshooting a difficult case, especially one that had achieved such success in the past.

Some people go through and have an extremely successful run with chiropractic care, but out of nowhere it stops working.

In these moments, I encourage people not to dismiss chiropractic as a whole, but to reevaluate the APPLICATION of chiropractic to find what went wrong.