Why does it always hurt here ???

scapula pain

https://www.youtube.com/shorts/lQV73P1dves

Chronic superior scapular pain is a pretty common complaint and the source is not always well understood by patients. It's really boils down to the basic mechanics and sagittal alignment of the neck shoulder and thoracic spine. When the neck is aligned over the shoulders, and the shoulder is in line with the trunk rather than rolling forward, the levator scapula, as well as the upper rhomboid muscles rest with normal tone. If the head migrates forward and the shoulder rolls forward especially if chronic such as often associated with seated posture working on computers or looking down, both of these muscles will be constantly overloaded in the static manner and develop chronic myofascial scar over time.

Properly stretching the scalene muscle

It's pretty routine to incorporate some degree of stretching as part of the patient's treatment plan, including in the cervical spine. Some stretches are pretty easy to remember and pretty straightforward for patients to remember when they get home. However 1 of the stretches that I find patients doing incorrectly high percentage of the time pertains to the scalene's. Doing it correctly is pretty important because failing to do so means you spending a lot of time with no return on investment, at best, and at worst, you can actually make your particular problem worse.

The scalene muscle group is located interior and slightly lateral to the cervical spine, and part of it attaches to the 1st rib. Both of these anatomical location distinctions requires some special positioning, set up, and order in which you incorporate the different directions of the stretch. Scalene muscular dysfunction is often associated not only with anterior cervical discomfort, but overload pain along the left scapula, as well as vague symptoms radiating into the upper arm, since the brachial plexus has to exit through the scalene's. If you're not setting up the stretch correctly you just don't get the results which is frustrating to the patient investing time in stretching.

https://www.youtube.com/watch?v=t6greMAkJLU

Ibuprofen use and the increased risk of chronic inflammation

https://www.science.org/doi/10.1126/scitranslmed.abj9954

After a recent trip to Europe to visit my father, I was reminded of some strong cultural differences on how we approach many different aspects of life, and in this particular instance, whether or not you view medication as mostly beneficial or something to avoid whenever possible.

In this instance the discussion centered around over-the-counter pain medication, which 1 of my family members was trying to ration pretty drastically even when facing some pretty gruesome background pain associated with transient medical treatment (frankly more drastically than I would have done under the same circumstances). This struck me since I had just been catching up on some recently published research during my 15 hour plane ride, and had a couple touchy discussions just prior to my departure with some patients who I felt were overusing Tylenol and ibuprofen into potentially harmful ranges.

Compared to other countries,the US average population reaches for over-the-counter pain medication much more readily than other counterparts around the world. Part of it is because culturally we tend to have a lower threshold for what we consider as acceptable pain, and for the fact that we consider all pain as being of no benefit and needing to be silenced at all costs. There is also a strong bias for the benefit of pain medication and a strong bias against recognizing the side effects of those medications, especially if taken within the maximal safe limits listed on the label. This is really unfortunate because the maximum safe dose listed on a bottle of ibuprofen or acetaminophen does not mean that it's safe for everyone under all circumstances, and it's definitely not to indicate that those doses are safe to take on continuously, which is what a lot of people do on a daily basis. (An acquaintance I know who's a nephrologist jokes that Tylenol pays his mortgage, since it causes so much renal failure even in moderate doses)

Another dark side of ibuprofen in particular, and actually all NSAIDs, is that they are involved in perpetuating a chronic inflammation cycle, and thus delaying recovery from an acute painful episode, possibly setting up the stage for chronic low-grade pain. This article is certainly pretty technical, but but it boils down to this: the chemistry of early inflammation that causes pain triggers a secondary response to then downward modulate that very initial inflammatory response, leading to decreased pain. If you significantly interfere with that initial inflammatory neutrophil response by doing such things as using ibuprofen, you run the risk of aborting the secondary downward modulation.

This is not to say that there's never a time and a place to use ibuprofen, but it should be done so very sparingly, and primarily as a short-term pain management when patients cannot manage some essential tasks through an acute episode. I see a lot of people who routinely start taking large amounts of ibuprofen at the very onset of a mild to moderate episode under the flawed understanding that it will be beneficial to dampen inflammation, when they are better nonpharmacological alternatives that do not interfere with the normal resolution of pain and inflammation.

the connection between the eyes and cervical muscle tightness

https://www.youtube.com/shorts/8A1YBq1lGnI

With around 70% of the US workforce using a computer for part or most of a typical workday, ( not even considering screen time outside of work), the number of patients reporting neck pain and muscle dysfunction when using an electronic device is sky high. Most patients attribute the connection to the postural strain of neck / shoulder position when facing a screen. In this blog I want to explore another mechanism by which using a computer screen can create neck symptoms.

From a neurological perspective, there is an anatomical connection in our brainstem between the neurons controlling eye movements and those controlling fine neck movement. It is an oversimplification of some complex neural pathways whose job it is to coordinate your head movement with your eye movements so that you can keep your gaze fixed on a target while either your neck or trunk are moving , or your target is moving.

If your target is moving, you need to fix your gaze on that target by moving your intrinsic eye muscles, and either moving your neck in tandem with your eyes if the target moves beyond the field of vision, or fire up the deep intrinsic neck muscles to hold your neck in place, such as is the case when looking at a computer screen.

If your neck and trunk are moving while you are keeping your gaze fixed on a target, your eye muscles have to adjust by constantly coordinating with the position sensors, primarily in your cervical facets ( a less common scenario in daily life)

If all goes well with the neurological circuit, it will be a silent background process that you will never concern yourself with. But for some of you, it does not go well, and by now I have your attention.

The two symptoms you are most likely to experience with a lack of proper coordination between your visual and cervical control system look like this:

• gradually worsening sensation of neck tightness when looking at a screen, or reading a book, regardless of the ergonomics of your set up. Especially if the screen is displaying rapidly moving multiple targets ( video games, action movie), or scrolling. Not responding to muscle therapies.

• gradually worsening eye pain, headaches behind or around the eye, when doing the same activities as above. It will often be much worse on one side. Not improved by glasses and no abnormalities detected on optometry exams.

Why does the cervico-ocular reflex gets disrupted ?

The system can be functionally injured primarily via either head injuries or cervical injuries ( whiplash type injuries being the most common mechanism, as described in the research article below). It is helpful to differentiate the mechanism of injury to direct the rehab to the right structure.. For primary visual control injuries, as is very common with even mild TBI, very slow progressive visual exercises are needed. For primary cervical injuries, traditional proprioceptive retraining of the cervical facets will reestablish a proper cervico ocular reflex loop

https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-016-1284-4

In depth leg stretch for tight legs, calves and plantar fascia

There are couple of exercise handouts frequently coming to my office that I wish I could add to the burn pile - a very big burn pile. 1 of those is the simple calf stretch that most people do for heel heel pain and diagnosed plantar fasciitis. Not that it's never appropriate, but that its very often inadequate to address the problem.

The posterior leg muscles, wether hamstrings, calves, are connected via an overarching fascia layers that starts in the lumbar spine (technically the fascia layers connect all the way to the skull, but for the lower extremity sake, you can do a very effective stretch from the waist down), extends through the buttock muscles, hamstrings, deep and superficial calf muscles, to the plantar fascia layers of the foot all the way to the under surface of the toes. In some people, myofascial tightness will be limited to one muscle group and doing a calf stretch will be effective, but in my experience of chronic leg tightness, recurrent injuries, chronic foot pain, the dysfunction spreads along the fascial chain. And as such, you cannot effectively release a local muscular area without doing a stretch that involves all of the parts of that chain together.

The "leg up the wall" stretch aims to do just that. It requires to wiggle your buttocks all the way to a wall, try to straighten out the knees as much as possible, and apply some gentle downward pressure on the toes using a strap or a long towel. It's incredibly intense. It's also incredibly effective. The connective tissue of the fascia does not release in 30 seconds, it needs at least a minute of slow steady hold without bouncing, with some deep breathing, in order for those connective tissues to start to lengthen. I tell people to have patience. Often it will feel intense, and not releasing for a couple of weeks before the patient can get in that position and feel some normal flexibility. The rewards are worth it.

MOLD RELATED ILLNESSES

MOLD RELATED ILLNESSES

I hesitated to post this blog because the subject of mold related illnesses feels like a bottomless pit. But we have had several cases back-to-back of people with mysterious prolonged illnesses that involved, among other symptoms, some pretty severe and unusual pain pattern distributions. And since none of the neuromusculoskeletal workups and lab markers shed any light on the problem, we had to consider other diagnoses including mycotoxin illnesses.

A biotoxin illnesses is a health problem caused by the byproduct of a living organis (bacteria, parasites etc.) a more straightforward example would be the severe diarrhea and bloody tools called by a food poisoning bacteria. A mycotoxin illness is a health problem caused specifically by the byproduct of a fungal exposure in a patient's environment or a fungal infection within a person's body. Mycotoxin illness is not the same thing as mold allergy, the latter being very similar to other airborne allergic reactions and not involving the level of chronic inflammatory systemic response. Mycotoxin illnesses can be incredibly frustrating for several reasons: they're not well understood by the majority of health practitioners (and I would include myself in that category), all diagnostic testing and labs can look completely normal unless you very specifically test mycotoxin markers (and these are very unusual labs), patients can get really sick from mold exposure while the remainder of people in the household appeared to be completely fine (owing to specific genetic markers that make some patients susceptible to mold illnesses and not others). The process of mold biotoxin illness identification is only the 1st frustrating part of the rest of the journey, since treatment can be also very touchy.

Some colleagues who work for an advanced diagnostic lab recommended this most recent clinician and patient guide on mycotoxin illness, which I have found very useful to review the up to date medical research and best practice approach. I have recommended that as an accessible patient read when someone's chronic health illness remains unexplained and the differential diagnosis of mycotoxin illness should be considered. It is important to note that not everybody's chronic, ill-defined health issue is mycotoxin illness. A lot of chronic vague health issues share common symptoms, although a few of them are more specific to mycotoxins. However it appears that mold biotoxin may truly be on the rise, because of a variety of environmental factors (change in average temperature with more thaw and refreeze cycles favorable to mold growth), and change in construction practices that involve material more susceptible to water damage and mold retention.

For patients who are interested in testing more specifically for the potential of mycotoxin illnesses, LabCorp offers several of the markers recommended, including MSH, C4a, VIP, and Great Plains Lab offers the urine mycotoxin excretion testing. The visual contrast sensitivity test can be done online at a nominal cost, and is often a good way to screen in the possibility of mold biotoxin illness, although not specific to it.

https://www.amazon.com/Mold-Mycotoxins-Current-Evaluation-Treatment-ebook/dp/B09NS23YRQ/ref=sr_1_1?hvadid=241619291020&hvdev=c&hvlocphy=9019661&hvnetw=g&hvqmt=b&hvrand=5846100143426192&hvtargid=kwd-298165115217&hydadcr=20835_10175407&keywords=neil+nathan+mold+and+mycotoxins&qid=1680187244&sr=8-1&asin=B09NS23YRQ&revisionId=c0abbf18&format=1&depth=1

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.