upper neck, vagus nerve and whole body inflammation

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9258775/

It has become a bit of a popular thing to talk about the vagus nerve, (I blogged about it a year ago), but there are good reasons to bring it up again and again.

To be correct, we really should not be talking about the vagus nerve alone. The vagus nerve is the single largest autonomic nerve in the body, connecting the brainstem to a variety of internal organs in the thoracic and abdominal cavity, so we really need to talk about the entire system of feedback loops between the brain and the internal organs. The right and the left vagus nerve have slightly different target organs especially in the abdomen.

1 of the most fascinating aspects of vagal nerve function is the fact that it really is a 2 way system, with the brainstem directing organ function as well as organ function affecting the brain through a retrograde feedback pathway, especially from the digestive tract. This probably gives more scientific backbone to how much G.I. function, and especially G.I. dysfunction can affect mood modulation and cognition. One the area of fascinating recent research in the retrograde function of the vagal nerve is how much it can help modulate the way our body controls systemic inflammation. The article below talks about that in the context of how systemic body inflammation is affected by severe neurological damage to the vagal system, (spinal cord injuries in this case), however there is pretty good evidence in other articles that lesser forms of trauma or compromise of the vagus nerve probably results in the same effect. The vagal nerve is an extremely long nerve paths that can span as much as 3 feet in an adult body from the brainstem to the lower G.I., with the potential for multiple areas of vagal nerve insults along the way. Historically chiropractic has always recognized the special anatomical relationship of the vagus nerve in the upper cervical area, which was an almost exclusive focus of some of the earliest generation of chiropractors also known as upper cervical practitioners. I've certainly seen quite a bit of that in my practice over 29 years, although more recently I've come to realize that the lower cervical spine can also be an area of pretty profound vagal impact. This could explain how sometimes intervention in the cervical spine in patient presenting with rather chronic significant neck pain and headaches for example, can lead to the resolution of other systemic complaints of Vedic chronic persistent body information that has been refractory to other forms of intervention.

Other areas of vagal treatment have focused on cold laser (technically various forms of pulsed light therapy) in the thoracic and abdominal pathways of the vagus nerve, especially in people with direct trauma to those areas as well as severe concussions. The research on using electrical stimulation of the vagal nerve has, in my mind, been much less conclusive because of safety concerns of using electrical signaling on extremely delicately controlled nerve pathways.

CHIROPRACTIC AND SLEEP APNEA

As life goes, it's usually a series of similar discussions and encounters at the office that prompt me to write a blog and this week is no exception. I was looking at a series of labs, fitness trackers readings, and the topic of sleep apnea kept coming back.

Sleep apnea is a condition whereby you do not get enough oxygen into your body, and especially your brain, while you are asleep. It's actually a pretty broad umbrella of a variety of causes and conditions themselves. Most people are familiar with obstructive sleep apnea (OSA), a type of apnea caused by a narrowing of the upper airways and often associated with loud snoring and choking. There is another type of apnea that I seem to encounter increasingly called central sleep apnea, which is caused by a decrease breathing reflex while a person is asleep and is completely different from OSA.

Sleep apnea is really quite serious. Unfortunately a lot of patient suffering from it are very lackadaisical about it. Since snoring is often associated with OSA, patient suffering from OSA who are not themselves waking up from their snoring think of it as an inconvenience to others without considering the serious health ramifications for themselves (and to the people suffering from sleep deprivation as a result of their snoring).

Patients who are aware of the health implications of sleep apnea tend to understand the implication for cardiovascular health and stroke risk. Both of which are obviously very important. In my practice however, the detrimental affect of sleep apnea tends to manifest in different systems: chronic oxygen deprivation leads to very poor soft tissue recovery and healing, meaning that patient have slow recovery from the treatment, easy aggravations and re-injuries. For patients seeking general health and nutrition recommendations, the oxygen deprivation of sleep apnea is often associated with vague symptoms that are difficult to manage: fatigue, especially morning fatigue, mood disorders, cognitive decline.

Obstructive sleep apnea is often associated with environmental factors that can be modified such as abdominal obesity, chronic use of alcohol or other central nervous system suppressants. Most people are already aware of that. However there are other risk factors commonly encountered in a chiropractic practice that can increase the risk of obstructive sleep apnea. Namely significant anterior cervical curve dysfunction (causing some crowding of the upper airway), soft tissue adhesions from previous anterior cervical muscular injuries such as whiplash, mildly depressed brainstem function from even mild TBI's. I often see that some patients reported decrease in their snoring and choking at night when those are treated. However, as a starting point patients should always get a firm diagnosis of obstructive sleep apnea and monitor the effectiveness of any therapy rather than operating under the assumption that it is being resolved. There is too much at stake, especially for long-term brain health and cardiac health, to be wrong on that.

The diagnosis of sleep apnea is made through a sleep test that measures various vitals while the patient is asleep (respiration, oxygen saturation, heart rate etc.). A traditional sleeping test is done in an outpatient hospital lab. They are still the medical gold standard, however due to the associated costs in the thousands of dollars, and the fact that patients often sleep very differently when in a foreign environment much less hooked up to electrodes and knowing that they are being watched, so at home take screening tests are becoming more popular and prescribed by primary care physicians. That is my preferred route, however I do recognize that there are some barriers that will prevent people from pursuing that route (not having a PCP, fear of medical encounters, uninsured/underinsured). In those cases, for under $200 you can obtain an over-the-counter FDA approved version to do it yourself at home, such as the one in the example below (I do not endorse any brand or product, this is just an example you can find by doing a brief Google search)

https://lofta.com/products/sleep-apnea-test?currency=USD

treating sleep apnea is a topic that will not fit in this blog, and may be worthy of a follow-up. Traditional CPAP machines, oral appliances, throat exercises, weight loss, brainstem vagal exercises all can play a part in improving someone's sleep apnea. The bottom line is that you have to monitor the effectiveness of the treatment with some objective follow-up sleep data in order to ensure that you not continuing to sleep with your head on the water for 8 hours every night.

Epidural lipomatosis: the connection between high BMI and central lumbar stenosis

For some reason I've been going through a lot of lumbar MRIs recently. Some that I ordered and some that came with patients on their 1st appointments. Central stenosis seems to be the common recurrent theme in all of these patients. Central stenosis describes an anatomical situation where the canal that hosts the spinal cord and the nerves that go to the lower extremity and lower abdominal organs is narrow and potentially causing neurological compression.

The compression can come from a variety of sources including disc herniation's crowding the front of the canal, posterior disc margin bony spurs, congenital narrow canal, degenerative changes that narrowed the vertical dimension, thickening of the posterior canal lining ligaments causing crowding into the posterior canal, chronic posterior slippage of a vertebra (retrolisthesis). The last one on the list is a problem that we are seeing at an increasing frequency on MRI reports called epidural lipomatosis. It describes a phenomenon whereby the normal fat pads on the outside of the spinal cord lining become enlarged and crowd the nerve bundles.

I recently had a very enlightening conversation with 2 seasoned spine radiologist about this phenomenon. For a while this was thought to be an idiopathic finding meaning we did not know what was causing it, however there is very strong new research suggesting that epidural lipomatosis is part of metabolic syndrome associated with high BMI, abnormal carbohydrate and lipid metabolism. The type of fat that makes up the fat pad is very similar to visceral fat, and responds to the same signaling to grow or recede. My long-standing radiologist stated that he has seen a few cases of patient going on very stringent weight loss diets with subsequent follow-up MRIs showing almost complete resolution of the epidural lipomatosis and significant resolution of the central stenosis.

This blog is not meant to beat up on people who already struggling with high BMI and metabolic syndrome. But it can be an encouragement for some people who are wondering if dropping their weight in improving the body composition will have any impact on some of their chronic referred spinal pain. The answer is that it will. Let that be an encouragement to stay the course or to take on the process in the 1st place.

auricular and occipital neuralgia

There is often a lot of confusion about pain in the back of the head. Is it referred pain? Is it a headache? And to some extent in depends on who you ask, but really should look again a little more closely at the anatomy of the Innovation of the back of the head to better distinguish where the problem is, in order to have a chance at resolving the problem.

There are a total of four peripheral nerves that cover the back of the head from the midline to just above the ear: the third occipital nerve, very close to the midline, and not often a big player, the greater occipital nerve, slightly lateral to the center and often an intense source of referred head pain, the less occipital nerve, slightly more lateral, in the auricular nerve, just behind the ear and often feeling like it's deep in the bone.

All of the four nerves that cover the back of the head or originate from the upper cervical spine from C3 all the way to the occiput. What is less understood is the fact that they have to exit through a variety of myofascial paths, including fairly lateral behind the big SCM muscle. As a result, posterior head pain can be referred from the spinal articulations themselves as well as a variety of myofascial structures. Differential diagnosis of posterior head pain requires a careful examination of the structures from the spine all the way to the exit points at the nuchal line. Cervical misalignment, facet syndrome, facet degeneration, muscle spasm and muscle scoring from injuries all can be accounting for the chronic posterior head pain. It takes some detailed palpation to tease them apart. In particular I feel that a lot of the SCM muscular injuries from things like whiplash are often the source of posterior head pain but often get missed because the myofascial entrapment is likely more to decide than the referred posterior head pain.

Is chiropractic care safe for infants ?

https://pubmed.ncbi.nlm.nih.gov/25439034/

I am wrapping up the first day of our Homecoming continuing education classes and relishing our last segment of the day on pediatric chiropractic care. The office is full of new babies recently, reminding me of the privilege of serving that slice of that demographics.

When parents seek chiropractic care for their new baby for the first time, they often have questions and hesitations, especially regarding the safety of chiropractic treatments. ( sometime fueled by their medical provider, who may not be familiar with chiropractic care for infants). Prior to treating , we will spend a little time educating moms and dads about the different methods of treating an infant spine, which are quite different than those applied to adults.

Research data is also a good way to properly reassure a parent seeking care for their baby, and I have been directing them to this wonderful 2015 JMPT literature review article. The article reviews all reported pediatric adverse events to spinal manual therapies in the medical literature. The take home message is as follows:

• serious adverse events are very rare

• none of the 3 deaths reported in the last 30 years were the result of treatment by a Doctor of Chiropractic

• in all serious adverse events, there were silent serious predisposing problems ( neurological mainly)

• manual therapies consisting of high velocity manipulation combining rotation and extension of the upper neck were identified as potentially being a risk for adverse event. Chiropractors focusing on the young pediatric population use single axis adjustment with no extension and very minimal rotation.

It also important to point out to concerned parents that the risk factors of any intervention are relative to the risks factors of other interventions used to treat the same problem. In that regard, the medical alternatives to common conditions treated with chiropractic ( antibiotics for ear infections, PPI medications for reflux), carry a surprisingly high risk of serious side effects.

Are "gateway foods" as risky as "gateway drugs"?

https://www.sciencedaily.com/releases/2022/09/220907105453.htm?utm_campaign=Friday%20Favorites&utm_medium=email&_hsmi=230513745&_hsenc=p2ANqtz-__fiHLmVu7gUl3GUFjJE1MZy9ZdyOlFRCSgjUcTpuhUWYK-FzPO8JZfrZ0Dajj2tLT5KkoGxk5T4uXXP8Igq1YpDnQYw&utm_content=230513745&utm_source=hs_email

It's a delicate topic to broach because emotions often run high and the concern over the less-than-robust mental health of our teens in general often leads us to dodge important questions about habits, especially poor habits where change would be beneficial. Nutritional habits, however, have been under increasing scrutiny in light of the recent recommendation concerning the increased prevalence of severe childhood obesity, and the drastic recommendation to make even preteen children eligible for weight loss drugs and bariatric surgery.

Current stats indicate that 20% of US children are in the moderate to severe obesity category. That's a whopping one in five children. This does not include the remainder of children may be in the mild obesity, with the BMI between 23 and 30, which is still alarming in terms of health outcomes. The medical profession now is obviously raising the question of the metabolic consequences of these statistics, such as hypertension, kidney disease, etc. From a clinical perspective in my daily practice, I also see another side of this high BMI + malnutrition complex: children who have poor skeletal and soft tissue structures because of the lack of appropriate nutrients which have been displaced by empty calories; poor recovery from relatively minor injuries; chronic fatigue; and mood changes associated with nutritional deficiencies.

It's a very complicated topic to which no one can do justice in a blog entry. However I wanted to bring up this paper because it highlights an issue to which we have been desensitized. Kids, especially kids in the developing world and even more so in the US, eat a stunning amount of junk food. It has no nutrients, and it has been engineered by the food industry to be highly palatable with additives that trigger very targeted brain responses, causing children to be addicted to to these foods. There is currently a level of tolerance to junk food in our children that is not serving them well. The idea that kids should be able to splurge, have dessert, enjoy "treat foods", is out of control. What used to be a once-in-a-while event, a couple of times a year for special occasions like birthdays, is now creeping up in the kids’ daily diet. But it's time to recognize that those foods are not as innocuous as we think they are, and they may well be "gateway foods", the equivalent of gateway drugs: foods that create levels of dependence and addiction leading to a vicious cycle of increased craving and consumption.

I also recognize that this blog entry is not going to be a platform to outline a complete solution, especially for parents who struggle with the complex issues of children exposed to food influences outside the home that are hard to combat. But it is intended as an encouragement for those parents who are convinced that they should limit their kids’ access to junk food because you are doing the right thing and not overreacting. Leading scientists in the field are supporting your instinct to protect your children. I hope this article will give you some robust data to have discussions with your children, your family, and anybody else who is involved in your children's diet.

Customizable Pillow

https://luxome.com/products/layr-adjustable-pillow?variant=31902303125565

Just before COVID hit Dr. Alvarez and I were talking about live workshops we were hoping to offer (we had just finished the “pregnancy prep” and “infant basic craniosacral” classes and wanted to veer off a bit). High on the list was a workshop cheekily dubbed “pillow talk”, basically a class on selecting the right pillow for the condition and sleeping position, with an actual hands-on portion where patients could try a variety of options. Needless to say, bringing a large group of folks indoors (and sharing cheek space on the same piece of fabric) became scary overnight and we never got to complete the project

Years ago we had a working relationship with a local upholsterer who was able to custom-build pillows based on the measurements we took and would then send to her for individual patients. It was a fascinating and challenging process that involved coring out a base of frozen memory foam to make room for the head at right cervical length, then adding layers of batting and foam to the right thickness. The final product was simply amazing, but our source eventually retired and nobody wanted to take over that kind of craft. Ever since then I have been on the hunt for something similar. I have recently discovered that there are several new pillow brands on the market that offer the option of customizing the thickness and firmness of a pillow, by having the customer add and remove either internal batting layers or raw form material to adjust to their needs. Here would be one example of such a product. From what I have seen, those modifiable pillows do a decent job at allowing patients to modify the pillow for thickness, firmness, although they are lacking the ability to account for the length of the cervical spine and switch from side to back sleeping position. That being said, it may still be the best option I have yet found as a replacement for the fully custom pillows we used to order.

Metabolic Syndrome and Risk of Lumbar Discogenic Pain

https://chiro.org/Conditions/Metabolic_Syndrome_Components.shtml

The question that invariably comes up when we sit down with patients to review films demonstrating significant levels of disc degeneration, especially in the lumbar and thoracic spine, is “what causes that?” Patients seem to already understand the correlation between age and degenerative disk disease (later referred to as DDD), and of obesity. Fewer patients grasp the correlation with trauma, acute and repetitive. And fewer yet understand a more nuanced reason: the disc is at the mercy of poor body chemistry. Spinal discs are soft tissue structures that have a limited blood supply to bring in nutrients needed for routine maintenance and injury repair. If the body “soup” is of poor quality (inflammation, nutrient deficit, free radicals) the disc is not going to meet needs for self repair and will deteriorate at a faster rate than one would expect for one of that age and cumulative trauma load.

Of special interest is the impact of impaired glucose tolerance (a.k.a., diabetes or pre-diabetes) on disc degeneration, even independent of excess weight. This is sobering news in the context of US health stats predicting a rate of adult diabetes close to 30% by 2030 if we do not reverse course on some of our health habits. I have seen this time and time again in practice. Metabolically driven DDD is quite real, and quite profoundly complicates treatment. Remember that diabetes is largely preventable and do your part.