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The Beautiful Brainstem

The Beautiful Brainstem

 

The brainstem is arguably the most important area of the brain in terms of keeping us all alive. Most medically educated people know that the Brainstem is tied heavily towards our ability to breathe and maintain heart rate.⁣

But the Brainstem does so much more! It’s a bottleneck point for neural transmission the entire body, so lesions of the Brainstem can impact any other part of the body.⁣

When we look at the function of the Brainstem, we usually separate the anatomy into 3 regions.⁣

• Midbrain⁣
• Pons⁣
• Medulla⁣



By knowing the function of each region, we can examine a patient and get a sense for any possible dysfunction, especially when we evaluate a patient’s cranial nerves.⁣

A patient with impaired ability to move their eyes up and down may have midbrain dysfunction. A patient with issues with their face/jaw may have a problem at the Pons. A patient with nausea signs and balance problems likely has issues in the medulla.⁣

By understanding these issues, it can help us see if a patient has a serious , life threatening issue that needs special tests or referrals. It can also help us design rehab for patients if these issues aren’t pathological.⁣

Either way, looking at the anatomy and physiology of the Brainstem can create a sense of awe, as you understand that this small chunk of brain is responsible for so much of what makes us alive.⁣

Chronic Pain Structurally Changes our Brain

Chronic Pain Structurally Changes our Brain

Our brains are made up of gray matter and white matter. ⁣

Gray matter is made up of pools of neurons that are responsible for specific tasks.⁣

White matter is made up of axons which carry the information from our neurons to another region of the brain or body.⁣



When we look at how chronic pain changes our brains, multiple MRI studies have shown that size of gray matter in our brains decrease. This is observed in parts of the brain that are associated with the painful body region, but it also affects other areas of the brain that affect us emotionally and cognitively.⁣

We don’t necessarily know the exact implications of this, but it’s been suggested that decreased gray matter may be associated with decreased functionality of those brain regions. This is mostly driven by aging research where decreased gray matter is associated with declining cognition.⁣

This may be a mechanism for how chronic pain can have downstream affects on cognition, autonomic function, and depression.⁣

The good news is that these changes in gray matter are actually reversible!⁣



Studies have shown that when pain is reduced or eliminated, some of these brain changes actually start to increase again.⁣

We know that pain has a functional purpose in the acute phase, but chronic pain can be quite detrimental.⁣

While we can’t always rid someone of pain, having the ability to reduce pain and the consequences of pain is really important. It’s also really important to develop emotional and cognitive strategies to best manage painful syndromes as well.⁣

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.

Plasticity: How It Can Ruin or Restore Your Health

 Plasticity

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

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

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

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

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

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

The Popularity of Plasticity and The Perils of Hype

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

The Brain that Changes Itself – Norman Doidge

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

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

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

How neuroplasticity can help or hurt your recovery

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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