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

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

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

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

We’re talking about the Nocebo Effect

Nocebo, No Bueno

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

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

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

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

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

But remember this because it’s super important:

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


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

Are Doctors Creating Nocebos?

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

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

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

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

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

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

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

Combating Nocebos

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

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

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

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

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

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

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

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

Cervical Degeneration and Cervical Vertigo

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

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

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

Mechanoreceptors in Diseased Cervical Intervertebral Disc and Vertigo

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

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

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

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

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

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

So what gives?

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

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

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

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

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

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

So Is Surgery the Right Answer for Cervical Dizziness?

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

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

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

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

A randomized clinical trial of cervical curve rehab on cervical dizziness

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

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

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

The Pyramid of Plasticity: Organizing and Prioritizing Brain Functionality

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

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

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

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

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

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

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

What does this look like practically?

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

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

Concussion and Eye Movement Series Part 1: Anti-Saccades

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

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

What’s A Saccade?

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

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

What’s an Anti-Saccade

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

The anti-saccade test


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

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

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

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

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

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


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

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

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

New Research Shows Concussion + Neck Injury = Longer Recovery

If you’re a reader of our blog, then you’re aware of our stance that an injury strong enough to concuss is strong enough to also injure the neck. You can read some of our thoughts on this subject here:

2 Reasons Why Your Concussion Symptoms Aren’t Going Away

Head Injury, Chronic Dizziness, Concentration Problems, and the Atlas – A Case Study

What a 10 mph car accident does to the neck

You can find a lot more by using the search tool on the website, but that should get you started.

 After years of research, we now know that injuries to the neck can mimic symptoms seen in concussion. This is a big reason why patients with chronic whiplash look really similar to patients with post-concussion syndrome when you’re just looking at symptoms alone [source]. However, many clinicians have suspected that when patients have both a neck injury and a brain injury, that it can take longer for the patient to recover and return to sport.

A study published in the Journal of Head Trauma Rehabilitation is helping to shed light on this concept. THe study looked at patients in a multidisciplinary pediatric concussion clinic with sports related concussion. A total of 246 patients were included and were assessed for neck pain, headache, dizziness, and abnormal cervical spine exam findings. Out of the 246 patients with concussion, 80 met the criteria for a neck injury.

When reviewing the data, the authors found that patients with a neck injury took an average of 28.5 days to make a clinical recovery compared to 17 days for the patients who only showed physiologic brain injury alone. Patients with neck injury were also almost 4 times more likely to experience delayed recovery (longer than 4 weeks) from their symptoms.

So just to summarize, if you have a neck injury + concussion:

  • It will take on average 10 days longer to make a clinical recovery than a concussion alone
  • You are 4 times more likely to have symptoms beyond 30 days than a concussion alone

So you might be saying….well…maybe some of these neck injuries were really serious ones. Like the ones you might see where people have to wear a neck brace and get carted off the field. Obviously people with severe neck and spinal cord injuries can drastically skew the number of days it takes for people to recover and some may not recover at all.

The authors actually accounted for these types of injuries. One patient had a compression fracture and 5 patients had spinal cord injury or cord neuropraxia. All of these patients were taken out of the data analysis. So that leaves us with patients with a neck injury, but an injury that compromises the spinal cord.

Protect the Neck

The role of the neck has become a growing area of research in the field of head trauma. One study looking at the relationship between neck strength and risk for concussion showed that for every pound of increase in neck strength, there was a 5% reduction in risk of concussion. Another study shows a rehabilitation program that includes treating the neck in patients with post-concussion symptoms can accelerate a patients return to normal activity.

The neck is a neurologically important and inherently mobile area that can be prone to injury. When it is injured, people with a combination of brain and neck injuries may have higher levels of sensitivity than patients with more routine neck pain. That means that people who suffer concussions and neck injuries may benefit from more precise and gentle care than approaches that take a more aggressive style of treatment.

 

What are the risk factors for poor outcomes after a concussion?

When patients suffer a concussion, the vast majority of patients will have symptoms for 10 days or less. About 10-15% of concussed patients will develop persistent symptoms and be diagnosed with post-concussion syndrome.

Thanks to an explosion in concussion research in the last 20 years, we know a lot more about these head injuries than we have in the past. While we don’t know the exact physical reasons why some people are more likely to suffer from post-concussion syndrome, we do know some specific risk factors for people developing persistent symptoms.

Here’s a short but important list of factors that may make a young athlete more susceptible to chronic concussion symptoms:

  1. Patients with a history of migraine headache
  2. Patients with a history bipolar or anxiety disorder
  3. Patients with a family history of bipolar or anxiety disorder
  4. Patients with a previous concussion

There’s a few interesting things to take away from this:

  • Having a history of migraine likely means that your nervous system will be more vulnerable to the headache and nausea experienced with concussion symptoms. It may also signal that you have a sensitivity in your neck to issues that may stimulate the headache process and can be worsened by head trauma.
  • The first is that mental health seems to be a major player in the future expression of post-concussive symptoms like headache and dizziness. It shows us the power that mental health can have on physical health problems.
  • There’s no association with the severity of the concussion or losing consciousness. While a more severe hit to the head or getting knocked out seem like they would predict worse recovery, the data suggests that it doesn’t play a significant role in the development of persistent symptoms.
  • A lot of people get their physical symptoms treated for post concussion symptoms by a variety of providers, but a lot of people ignore their psychological and cognitive treatments. Having someone that can help manage their anxiety appropriately and use cognitive behavioral interventions can help many patients benefit from their physical symptoms.

Don’t Forget: Health Is A 3 Legged Stool

It’s easy to think about health in terms of physical ailments, but your overall well being is dependent on physical, mental, and emotional health. There’s a reason why people with depression and anxiety have worse outcomes for every physical ailment that exists. If you have a poor mental and emotional outlook, your brain simply doesn’t mobilize it’s repairing and recuperative resources as effectively.

In the world of concussion we often talk about getting the right care for concussions linking it to cervical spine problems, vestibular problems, or brain problems. What we sometimes forget is that some of our susceptibility to illness is related to our belief in the fragility or resilience of our bodies. Let’s restore faith in the strength of our bodies and make ourselves more robust healing machines.

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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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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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.

 

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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