Tag Archive for: chronic pain

Can Your Brain Program an Immune Response?

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Late last year, a study was published that really brought surprising findings about how your brain can store and program an immune response.⁣
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For decades, it was thought that the Brain and the immune system operated independently from each other, but research in the past 20 years have put that idea to rest.⁣
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How the brain can regulate immune function has been largely unknown. Does it happen as a by product of neuro-endocrine regulation, or can higher neural centers in the cerebral cortex play a role?⁣
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Koren et al did a really interesting study published last year that showed an area of the brain called the insular cortex may actually store and trigger very specific immune responses. ⁣
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Their team took mice and gave them either a lab induced form of colitis or peritonitis. Both conditions will cause abdominal pain and inflammation, but in very different ways. Colitis will cause inflammation within the digestive organs while peritonitis will cause inflammation outside of the organs.⁣


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The researchers showed that colitis and peritonitis produced unique signatures of activation on the area of the insular cortex in mice.⁣
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Using some advanced techniques, they were able to specifically turn on the same neurons that were activated during the colitis or peritonitis flares.⁣
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They found that turning on those pattern of neurons in the brain reproduced a similar immune response in the guts of the colitis or peritonitis model 🤯⁣
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This is remarkable because it suggests that the brain may keep a map of different immune patterns like it keeps a map of your body parts and the space around us.⁣


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The implications are interesting because what it opens the possibility that some inflammatory pain issues have a brain-based cause.⁣
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Something may start as an immune disorder like rheumatoid arthritis or spondyloarthritis, but plasticity may encode these responses in a way that it gets turned on without a trigger.⁣
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Could this be a bridge for how autoimmune disorders and plasticity become entangled creating chronic pain issues?⁣

Chronic Pain Structurally Changes our Brain

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Chronic Pain Structurally Changes our Brain

Our brains are made up of gray matter and white matter. ⁣
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Gray matter is made up of pools of neurons that are responsible for specific tasks.⁣
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White matter is made up of axons which carry the information from our neurons to another region of the brain or body.⁣


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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.⁣
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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.⁣
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This may be a mechanism for how chronic pain can have downstream affects on cognition, autonomic function, and depression.⁣
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The good news is that these changes in gray matter are actually reversible!⁣


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Studies have shown that when pain is reduced or eliminated, some of these brain changes actually start to increase again.⁣
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We know that pain has a functional purpose in the acute phase, but chronic pain can be quite detrimental.⁣
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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.⁣
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Healing isn’t linear.

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A lot of people have gotten into the stock market in the past year. In many ways, investing and trading can be similar to the healing process.⁣
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We all wish that our healing and recovery would just go up in a straight line, but unfortunately it doesn’t work like that most of the time.⁣

We all wish healing moved like a straight line. Always getting better without any setbacks

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When you are recovering from an injury or a chronic condition, even if you are doing everything right, you will have up days and down days.⁣ On up days, it’s easy to convince yourself that you are fixed or cured. On down days, it makes you think that your condition is hopeless and you’ll never get better.⁣

In reality, healing has ups and downs. Sometimes we feel bad even though our bodies are moving forward

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Sometimes we have to zoom out to see where we have come from in order to know if we are going in the right direction.⁣ In our office, we like to look at the trend of someone’s progress. We like to see if a person is having more good days than bad, and if their ability to cope with bad days gets better.⁣
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Flare ups can happen, especially with chronic #dizziness #fibromyalgia #rheumatoid and #postconcussionsyndrome.⁣

 

 

Some days it feels like we are spiraling downward and that what we are doing isn’t working…..

On those red days, it’s important to zoom out and see which direction your health is trending.

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It’s hard to keep the energy to focus on progress when you don’t feel well, but it’s really important to develop that resilience so you don’t give up on your recovery too soon.⁣
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Remember, that it is important to know that you are making the right investment into your health. Don’t treat your body like a meme stock that will shoot up 1000% overnight but has a high chance of crashing.⁣
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Keep investing into the things that have proven benefits over time, and your health portfolio will continue to grow.

#neuroplasticity #neuroscience #rehab #stonks #crypto

Hidden Drivers of Chronic Pain – We Have Been Thinking About Pain All Wrong

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What if what we always knew about chronic pain was wrong? 🤔

We are conditioned to think about pain as a direct product of injury. Because of this, we have strong, but incorrect assumption that the severity of pain correlates with the severity of injury.

These beliefs may be true for acute pain or injury, but they have poor carry over to chronic pain conditions. In fact, taking these beliefs into a chronic pain condition likely promotes nocebo and likely worsens outcomes in painful conditions.

As patients and health providers, we put most of our collective energy into the biological factors in pain.

  • structural issues
  • Inflammation

But we have a strong tendency to discount the psychological and social factors that contribute to pain.
– Fear and avoidance of movement
– False beliefs about the nature of pain
– The role of depression and anxiety in magnifying pain conditions
– How our friends and family deal with pain (walk it off vs rest till it’s better)


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While addressing the biological factors is important, the psychological and social factors behind pain might be most important in having enduring results.

Without addressing the psycho and social aspects of pain, patients are often in a roller coaster of temporary relief going from doctor to doctor or treatment to treatment never satisfied.

This starts in our office with a change in belief. A belief that your body is strong and anti-fragile. A belief that the body is self-healing and is always striving to maintain homeostasis.

 

In a perfect world, we hope that our patients start feeling better before we even put our hands on them because they are starting to embrace a stronger, brain-centric view of life and health.

Working on Your Curves: Long Term Outcomes From Fixing Military Neck

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I’ll admit that I’ve gone back and forth on the importance of cervical curves in my career. When I was in chiropractic school I was adamant about the importance of cervical curves and how the loss of a curve could affect the progression of spinal arthritis.

Then once I was in practice for a few years, I saw that most neck curves wouldn’t really change very much. Despite the fact that it didn’t change, I’d see really great changes and improvements of many of my patients, so I assumed that it is a nice feature, but probably not necessary to resolving a complaint. You can read some of my previous thoughts on cervical curves here:

I Have Military Neck: Now What?

So What Has Changed my Mind?

I still stand by my previous writings and say that having a proper neck curvature is a really good and positive thing, but you can still get really great results with most secondary conditions even if the neck curve doesn’t come back.

However, I have started to come around on the importance of having a proper neck curvature for the health of the human brain and nervous system. So what changed my mind?

Here are three pretty recent studies looking at the impact that cervical curve changes have on dizziness and cerebral blood flow.

Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis

The first paper is a study that looked at consecutive patients getting imaging of the arteries going into the brain. Magnetic resonance angiography (MRA) measured the intensity of blood flow with the neck in patients with a straight or military neck pattern. The patients were then placed on a foam orthotic to produce a curve in the neck and a new MRA was taken with the neck in a curved position.

Before and after changes in blood flow to the brain using a device to improve cervical curve.

The patients’ MRA scans showed significant improvements in blood flow in the brain when they were lying on the orthotic with an improved cervical curve! The interesting thing is that it’s been known for years that a loss of cervical curve was associated with decreased blood flow in the brain, but there was no evidence showing that improving the curve would change blood flow. Now there is.

The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study.

While the previous paper is interesting, it’s limited by the small sample size and lack of controls. It was also a proof of concept study, and not one where an intervention was performed and tested to see if it made a difference long term. However, it may help explain why patients can get significant improvement in pain and dizziness.

This next paper features a randomized clinical trial of cervical curve correction along with cervical manual therapies compared to manual therapy alone for cervical dizziness.

The study looked at the results for patients with neck pain and dizziness for short term improvement at 10 weeks, and to see if they sustained improvement at a 1 year follow-up. The results are below.

Differences in patients with cervical dizziness at 10 weeks and 1 year. Changes after 10 weeks were similar to regular physical therapy, but the changes were hugely different at 1 year when there was an improved curve in the neck

The chart shows that the patients who were in the cervical curve correction group had significant improvements in head posture and curvature at 10 weeks, but the scores in pain and dizziness were pretty similar for both groups. Both groups got better, but they had similar improvements.

However, the changes at 1 year were impressive, and highlighted in red. While the control group had some regression into neck pain and dizziness, the cervical curve group maintained their symptomatic improvement much better. The mean improvements for both groups all crushed statistical significance, and the mean difference of the Dizziness Handicap Inventory (DHI) was by almost a whopping 30 points. That’s massive!

Does improvement towards a normal cervical sagittal configuration aid in the management of cervical myofascial pain syndrome: a 1- year randomized controlled trial.

A similar study was published on patients with persistent neck pain where physical manual therapy was compared to manual therapy and curve correction.

Just like the study involving dizziness, this paper on neck pain showed that both groups had similar improvements in scores on the Neck Pain Disability Index (NDI).

Changes in neck pain with manual thearpy and exercise alone vs manual therapy, exercise, and cervical curve restoration. Cervical curve patients were a little btter at 10 weeks, but were much better at 1 year follow up!

Again, like in the previous study, the 1-year follow-up is where things got interesting. The group that had treatment to improve their cervical curve had a much stronger ability to maintain their improvements in neck pain, while the control group started to return to their original pain scores. This was also largely statistically significant.

Long-Term Improvements Matter

So the big thing that changed my mind is that there is a growing body of work that supports the idea that creating structural changes in your cervical curve seem to help improve long term outcomes.

So while I still believe you can get significant improvement with or without a curve in your neck, your chances of maintaining your results over time seem to increase a LOT when you rehabilitate that curve.

Then you have the possible added benefit of improved blood flow to your brain, and that provides a potential bonus of better brain health.

What Happens in Vagus: Chronic Pain and Dysautonomia

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

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

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

Fibromyalgia, Chronic Fatigue, and Dysautonomia

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

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

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

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

What Happens in Vagus….

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

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

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

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

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

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

Why?

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

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

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

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

Weak Vagus and Chronic Stress

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

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

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

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

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

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

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

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

Bringing Vagus Back

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

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

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

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

 

Ask Dr. Chung a Question

Plasticity: How It Can Ruin or Restore Your Health

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 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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A Gentle Approach to Chronic Pain

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A Gen

Breaking the Chronic Pain Cycle of Fibromyalgia

                  Chronic pain takes many shapes and forms, but we know that it has a huge social and economic burden. The Institute of Medicine reports that roughly 116 million, or 30% of the population suffer from pain lasting a year or longer. Although chronic pain isn’t a life threatening issue, it’s certainly a problem that has a dramatic effect on the quality of someone’s life. After taking care of hundreds of people with conditions like fibromyalgia, I know that these people experience quite a toll both physically and emotionally.

NUCCA requires a specific angle to achieve a desired correction angle.

NUCCA requires a specific angle to achieve a desired correction angle.

                  Perhaps the worst part about fibromyalgia is that there is no known cause or cure. It’s basically invisible to any blood tests or MRI studies, and most of the drugs available are for pain control. People with fibromyalgia may often be depressed, have anxiety, and have a sense of isolation because they don’t feel that their friends and family understand their struggle. This often compounded by the fact that their doctors have told them that the pain is psychosomatic, or just in their minds because no tests can reveal an underlying disease process.

                  In recent years, fibromyalgia has become one of the most published topics in medical journals. As a result, we are starting to develop an understanding of the disease on a deeper level to know that it’s certainly NOT just in the patient’s mind. Research is pointing to problems within the central nervous system and tiny blood vessels in the skin as likely causes of the deep body-wide pain. But what does this mean in terms of treatment?

                  For most people, drugs that target the nervous system like Lyrica or Gabapentin are the first line of treatment and many have had success. However, some patients can be sensitive to drug reactions, or their bodies may develop a high tolerance for the dosages. In cases like these, many patients start to seek out alternative therapies like acupuncture, reiki, and homeopathy.

                  Traditional chiropractic has also been a source of relief for many people seeking help with chronic pain. However, many people with the chronic pain of fibromyalgia can feel apprehensive about seeing a Doctor of Chiropractic because manipulations can seem too rough for someone who can barely stand to be touched.

Not All Adjustments are Built the Same

                  In chiropractic, there are dozens of techniques and approaches to correcting the spine. Some are heavy handed and require a lot of force, but others are very gentle and rely more on precision. It’s not to say that one is better than the other, but some are just designed for specific patient populations in mind.

                  In my office, I attract many patients with fibromyalgia, trigeminal neuralgia, and TMJ problems that are Secondary to a Structrual problem in the neck called Atlas Displacement Complex. Most of these people are afraid to be touched, and gravitate to a lighter approach. This type of condition requires a precision type of adjustment called an Atlas Correction. This type of adjustment is so light, that most people often wonder if I even touched them, and then they start to feel their body change. Currently, only about 1000 doctors in the country are trained in this type of care.

                  This approach is effective because of the spine’s influence on the central nervous system. When the top of the neck shifts abnormally and moves improperly, the nerves firing into the brainstem become distorted. In this way, the brain is like a computer that relies on spinal positioning to operate normally. When there are garbage signals going into the brain, then garbage signals come out in the form of pain. This phenomenon in fibromyalgia patients creates a condition called central sensitization. This is the reason why people with fibromyalgia can feel excruciating pain from a light touch. It’s not that there’s a physical injury, but the nervous system is getting scrambled signals and is primed to experience pain.

Your nervous system can act like a computer. If poor information comes in, then poor information will come out.

Your nervous system can act like a computer. If poor information comes in, then poor information will come out.

                  This is NOT designed to cure you. The cure lies in the fact that the body is capable of healing itself. When you remove interference to the body’s self-healing ability, I find that people can return to a level where life is livable again. By breaking the pain cycle through the nervous system, you can impact the way stress affects the body and the immune system. By no means is this a cure all, but it can be a great catalyst to being steered back on the path towards a normal life. I’ve seen numerous patients who’ve been able to go from disability to working or resuming exercise again in a matter of months.

One of the greatest joys of doing this type of work is giving people a glimmer of hope. So many people are convinced that they have to live in pain, or have been told that the problem they’re having is all in their head. In my office, I’ve helped hundreds of people recover from chronic pain with this gentle procedure. However, it’s not for everyone. Only people with a problem in their Atlas can receive this type of care, and that requires a detailed Upper Cervical Chiropractic Examination to identify the problem. Sometimes a little bit of hope is all a person needs to start healing again.

Why Pain Can’t Tell You Where You Need Treatment: A TMJ Case Study

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TMJ and neck

Jaw pain/TMJD is a very frequent problem we see in the office. It’s so frequent that I spend one day each week inside of a dental office in West Palm Beach doing consultations with a great local area dentist that specializes in pain syndromes of the jaw.

Most of the patients that see us with jaw pain have already seen a variety of jaw specialists. They’ve had MRI’s done, mouth pieces made, and various therapies done on the area of pain.

The problem of course is that pain, especially chronic pain, does a poor job of telling us what is wrong with you. Chronic pain is complex. Chronic pain is misleading. Chronic pain is also a poor locator for pathology.

Identifying the Pain Source

One of the common questions asked during a case history is to highlight or point to the area where you feel pain. It can be useful sometimes when pain patterns are reflecting specific nerve roots, and it also gives a general vicinity for a doctor to examine more closely. For most cases of chronic pain, examining the area of injury often leads to dead ends. There’s no damaged tissue to treat or remove that’s likely to explain why someone hurts.

Patients with TMJ pain frequently seek the treatment of these specialized dentists, and most of them do really well when in the right hands. However, sometimes jaw pain isn’t truly a problem in the jaw. Sometimes it’s a pain problem somewhere else in the body.

I recently took care of a patients who were was referred by another chiropractor. The patient had been to 6 different jaw and mouth specialists but could not get any form of relief from treating the jaw.

When we examined the patient, we didn’t pay much attention to the jaw itself. The patient already had imaging and tests done to their mouth already, so I wanted to spend my time elsewhere.

We found that the patient had poor motion in their shoulder and neck area on the right side. They were also showing a large amount of forward head posture characteristic of anterior head syndrome. Surprisingly, the patient’s jaw seemed to move pretty well. There wasn’t the clunky abnormal opening and closing of the jaw that you would usually see in a TMJ where the jaw displays a large side to side movement. From my view, the patient’s jaw movement looked really great, but the patient’s neck was moving poorly.

Correct the Neck and Pain Self-Resolves

We did our normal protocols with this patient. We did a gentle NUCCA correction to the patient’s neck. We post-x-rayed the neck to verify a neck improvement, and then we waited. You can see the x-ray results below.

Pre and Post X-ray shows a small shift, but an almost perfect correction.

Pre and Post X-ray shows a small shift, but an almost perfect correction.

3 days after her first appointment, we had our first follow-up appointment scheduled. The patient had gone 3 consecutive days without any jaw pain at all for the first time in 2 years!

Pretty good, but would it last?

3 months later, we re-examined the patient. The patient was now going 1 month between appointments because it would be important to see if the patient could go that long a distance between appointments without pain. The jaw was still moving normally, but now their head and neck could move in all ranges of motion smoothly. The patient also stopped showing a persistent right tilt of their head.

Most importantly, the patient could now talk with no restrictions, and had no more food limitations on what she could eat. For all intents and purposes, she became a normal teenager again.

Final Thoughts

Now if we had kept on trying to treat the jaw and identify pathology in the jaw, would she still have gotten better?

It’s hard to say, but after 2 years of doing every jaw therapy under the sun, it just seemed to make sense to look at other pieces of anatomy.

The complexity of chronic pain often means that we can’t look at things linearly. We have to know that someone has pain in one region, but we also have to think about all the different anatomy that shares a connection with the part of the body that hurts. This doesn’t mean that every person with chronic jaw pain will get better from a neck adjustment, because that’s not true either.

It means that we have to take care of people and see them for what they are globally instead of treating them as an object with a specific piece of meat that hurts today.

 

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Why Does Fibromyalgia Occur in Rheamatoid Arthritis – a Neurological Perspective

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Rheumatoid Arthritis and Fibromyalgia

When working with a large number of patients with chronic pain and illness, you begin to notice patterns in relationship to certain illnesses. One of the more common trends I see today is the association between having an inflammatory illness like rheumatoid arthritis along with widespread body pain like fibromyalgia.

Rhumatoid arthritis and fibromyalgia share some commonalities in that they disproportionately affect women more than men, are associated with flare ups of increased pain intensity, and are chronic illnesses with no cure. Although they are separate and distinct health issues, it seems that if you have an inflammatory illness like rhematoid arthritis, 10-15% of these patients are likely to report the widespread body pain of fibromyalgia. Let’s see if we can break this phenomenon down.

Rheumatoid Arthritis and Inflammatory Illnesses

Rheumatoid arthritis falls into a class of inflammatory disorders where flare ups of inflammation can create damage to joints throughout the body. The pain from these flare ups can be debilitating, and the damage done to the joints can be quite severe when left untreated.

CanStock Photo

Notice the deformity of the thumb and index finger on the right hand. CanStock Photo

The damage to these joints is caused by an autoimmune reaction. Autoimmune disease is a condition where the body’s own defenses inadvertently create harm to the body itself. In the case of rheumatoid arthritis antibodies can build up in the joint spaces and cause other immune cells to create an inflammatory reaction in the area. This is where people can feel the heat, swelling, and pain that is known to occur in flare ups.

Patients with rheumatoid arthritis tend to have arthritic flare ups affect joints like the hands, toes, and neck. However, they are also more prone to wide spread pain in other regions not associated with arthritic breakdown. Why would pain exist in an area that is not associated with inflammation and destruction of the joint?

Chronic Pain: Central  Mechanisms

Pain is an extremely complex phenomenon. We generally think of pain having a direct relationship to tissue damage. When we get a cut, sprain an ankle, or break a bone we expect that pain will occur because of the injury. Therefore it’s not surprising that the pain and destruction from a rheumatoid arthritis attack to be very painful.

However, we also know that pain can occur long after an injury has healed, and even in the absence of injury whatsoever. This is what happens in patients with the widespread pain of fibromyalgia. People with fibromyalgia often have nothing to point to as a cause of their pain. It’s an enigma that makes chronic pain syndromes so frustrating because they have no test or image to prove why they feel so poorly.

Many suspect that this widespread body pain may be from dysfunction at the level of the central nervous system. In normal circumstances, the brain has a few ways of controlling how much pain it will feel.  This ensures that our bodies don’t overreact to normal everyday stimuli and interpret as painful.

One mechanism is by pain inhibition. Pain inhibition involves the brain using it’s own pharmacy of pain killing chemicals to stop a pain signal from going up the spinal cord.

Pain can be inhibited by chemical pathways inherent in the brain.

Studies on patients with rheumatoid arthritis have shown that the brain’s ability to inhibit pain becomes compromised leading to an increase in pain with normal stimulation. [Source]

Pain Inhibition broken

When your brain has difficulty inhibiting pain, then you begin to feel it in places where there’s no injury

Another way that the brain can modulate pain is through a concept known as the pain gate. The pain gate operates on the idea that pain has to hit a certain threshold for it to be consciously perceived in the brain. In this way, it allows the brain to ignore things that aren’t causing much damage or risk.

In a perfect system, you would only feel pain when you have actually created injury or are under imminent threat of injury. However, this appears to be another mechanism that gets disrupted in chronic pain patients. When people have chronic pain, it probably means that the gate that is meant to block most of your pain is letting everything in.

Pain Gate Theory

 Does Rheumatoid Arthritis Break This System Down?

The main treatment for inflammatory arthritis focuses on managing inflammation. Most patients with this type of arthritis will take a wide variety of anti-inflammatories that cover a wide spectrum. They include drugs that specifically target the inflammation associated with RA like Trexall, immune modifying biologics like Humira, and go all the way down to non-steroidal anti-inflammatories like ibuprofen.

In many of these cases, the inflammatory pain of arthritis is under control by these drugs, yet the widespread body pain persists. We don’t really know how or why these inflammatory disorders can lead to pain sensitization, but studying other acute pain conditions may give us some clues.

Studies done on patients with acute pain from a traumatic injury and post-surgery pain issues. When someone suffers from the pain of a major injury, the neurons associated with the pain response start to fire more frequently to guard against the area of injury. This is only supposed to be a short term response to significant injury, but in some cases these changes become persist through a phenomenon known as plasticity. When these spinal cord neurons stay hypersensitive, it means that a person’s nervous system will become hypersensitive to the pain response. [Source]

While inflammatory arthritis isn’t necessarily an injury in the classic terms, make no mistake that inflammation can create a significant amount of tissue damage when it goes unchecked.

Making Your Nervous System Less Sensitive

If the nervous system can be made more sensitive by persistent pain, can it work in the opposite direction? A lot of the research on pain has been focused on targeting these mechanisms which has lead to a higher usage of opioid medications. The obvious problem is that opioids are highly addictive and has become a major public health issue.

There is a growing need for non-pharmacologic interventions to address these chronic pain issues, and fortunately there are some that can be really effective. In cases of chronic pain, the best approach is one that addresses a person from a mental and physical standpoint rather than chasing after a holy grail treatment.

When you look at the pain gate theory image, you can see that the factors that impact your pain threshold include brain and spinal input which exercise and chiropractic adjustments can play a major role. Things like memories, emotions, expectations, and attention are all factors that can be changed with neuropsychological therapy. Out of that entire list, everything except your genes are modifiable factors.

Our approach to chiropractic is focused on the head and neck, which has been shown in at least one study to improve long term outcomes in patients with fibromyalgia syndrome when combined with exercise and cognitive based therapy. You can read more about that in a previous article below:

Fibromyalgia and the Atlas

Conclusion

At the end of the day, there is no cures for rheumatoid arthritis or fibromyalgia yet. There may not be cures for years to come. However, many people with these illnesses can see their quality of life improve by addressing some of the neurological consequences of the disease.

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