Neck and ear pain

It is the usual cattle prod at my office this week, with a couple back-to-back cases leading me to finally whelp a long-awaited blog on a subject.

I've had 2 patients asked me the same question this week, which basically could be summarized as following: can a neck problem cause pain and abnormal sensation in the ear? And the answer to that is actually a resounding yes. The 1st patient who asked had had a slightly frustrating encounter with an ENT who found nothing wrong with the ear in spite of some continued sensation of prickling and tingling affecting the entire external ear area. The 2nd patient had more of an inkling of the correlation, since the ear pain and the neck symptoms seemed to come hand-in-hand.

The anatomical correlation between the cervical spine and the ear is multifaceted. The upper cervical spine, especially the facet joints of C1 and C2 articulation, can radiate to the area just below the ear, the pointy bone called the mastoid. That's probably where we're going to find more than half of the referred ear pain. The other half of the problem is often going to come from an area a little more remote, but still within the cervical area, just behind the SCM muscle: the auricular nerve. The auricular nerve has a sensory branch that travels up from the lateral side of the neck into the external part of the ear. It's a sensory nerve, meaning that they will primarily give abnormal sensation. Some of it is painful but it's often mostly described as a sensation of burning, tingling, pricking that comes and goes and is often triggered with rapid motion of the cervical spine and head away from the shoulder. The auricular nerve exits superficially posterior to the SCM muscle, which is a large superficial muscle that controls head rotation. It's a muscle that's often injured in injuries combining rotation and extension, such as whiplash type forces.

Resolution of the ear pain associated with the neck pain obviously depends on the offending structure. Cervical adjustments will resolve about half of them, but specific myofascial release of the posterior part of the SCM at the auricular nerve is a little more tricky and often overlooked as a source of continued superficial ear symptoms.

NEUROTRASMITTER TESTING: UNDERSTANDING WHAT IT ACTUALLY MEASURES

I'm very fortunate to have worked for over a decade with both his ZRT and Genova labs, which offer a variety of integrative functional testing, ranging from hormone testing, G.I. functional markers, food reactivity testing etc. I look back to the last 20 years with a sense of wonder at the technology and methodology of the labs, which have increasingly become more precise, and start measuring new metabolites which help shed light on some chronic health issues.

When I think back over the last 5 years, of all the new testing that has come online, I would have to say that"neurotransmitter" testing is probably the one lab that has given me the most new insights.

There is a lot of confusion and misrepresentation of the testing. First of all, I hesitate to use the term "neurotransmitter". Neurotransmitters are types of biological molecules that carry signal and information between cells and tissues. We think of them as being brain-based, which is obviously 1 of the areas where we find them, but they are found in many other tissues throughout our bodies, especially the gut which holds 95% of all major neurotransmitters and neuro hormones. (Serotonin and melatonin for example). The neurotransmitter panel that we use in reality measures a variety of molecules involved in signaling: this will include traditionally considered neurotransmitters as well as all of their metabolites, neuro-hormones, neuro-immune molecules such as histamine metabolites. The test uses urine samples since all of the metabolites are excreted through the kidneys. While it does not directly measure the neuro- signaling molecules of the central nervous system (those would be separated from the rest of the body in specific neural tracts via the blood brain barrier), research has shown a strong mirroring pattern between central nervous system and G.I. neuro-metabolites. The test is complex and has to be carefully interpreted to understand its significance, in particular what factors influence imbalances in neuro- signaling molecules, thus leading to use best practice interventions to bring about balance. It has a broad spectrum of application in the area of chronic mood imbalances, chronic pain, as well as chronic functional neurological symptoms.

The dark side of "benign" Tylenol use: liver failure

https://www.ncbi.nlm.nih.gov/books/NBK441917/

In an all out effort to reduce prescription pain medication dispensing and usage, particularly opioid, the medical establishment is redirecting patients to over the counter, NSAIDS like Tylenol. After all, they have been around a long time, tried and true, and can even be used in pregnancy. A lot of well intended patients have thus assumed that Tylenol is always a safe bet and can be taken routinely at the maximum doses indicated on the back of the bottle.

The reality is more somber and more complex. The truth is that most people can have a low dose of Tylenol occasionally and not encounter any issues. But there is a real dark side to Tylenol and it can  harm the liver surprisingly easily. As of right now, acetaminophen accounts for over half of liver failure cases in the US ( and self harm overdoses account for a small percentage of that half). Liver toxicity is cumulative, meaning that all substance you ingest at the same time will compound each other: other prescription medications, alcohol, over the counter medications and even some supplements.

As a consumer, you should not underestimate the potential toxicity of Tylenol and pursue non-pharmacological ways of pain management as well as genuine resolution of pain producing conditions

What are soft tissue manipulation instruments ?

Left to its own device this could be a very long and complicated blog, but we decided to record a short instructional video primer instead. Soft tissue instruments used for the purpose of soft tissue therapy have a very long history dating back several thousand years in Asian manual medicine, but have enjoyed a modern resurgence in many branches of physical medicine. They are often associated with trademarked techniques (Graston, Faktr, Guasha). Soft tissue instruments are just that, instruments that have to be used with a high degree of skill and expertise to augment the possibilities of specific soft tissue therapy beyond what can be done with hands alone.

https://www.youtube.com/watch?v=EQzXfD1u4AU

Lumbar traction-decompression : inversion table versus prone kneeling traction

This is another one of these are long overdue blogs that finally bubbled up to the surface after 3 patients asked me the same question in less than a week.

There is a lot of interest decompression traction device. And there is a lot of confusion and chaos about which ones are safe and effective and for whom.

Inversion tables are very popular, and successfully used by a lot of patients. However I always caution people who asked me about it depending upon what I know of the underlying condition. This blog is to describe the difference between inversion tables, which are easily accessible over the counter at a lower price point, versus more sophisticated device that we recommend for our patients.

The concept of traction decompression is not new. We have records of Egyptian doctors using crude form of traction 5000 years ago, by hanging people from a rope underneath their shoulders and attaching a weight to their feet. 1st of all, let's describe what traction decompression may be used for. Lay patients will use them for just about anything that feels like a low back pain when stretching it feels good. In our practice, we will use traction decompression primarily for 2 conditions: either a chronic or acute disc prolapse that is associated with nerve root compression down the leg, and responds to flexion decompression challenge in the office. (And have no contraindication to traction, which unfortunately are quite many). The other indication is for people who have degenerative stenosis, whether central and sometimes lateral. In the 1st case, the traction will usually be used for a defined period of time, with option to repeat during relapses. For the latter, patients usually need to use that as an ongoing maintenance tool to manage their condition.

Inversion tables and prone flexion decompression units such as the NUBAX (the loaner equipment we have at the office) try to achieve the same goal but with some notorious differences:

– inversion tables will maintain a lordotic curve and in many cases accentuate the lordosis (if patients have any sort of anterior hip soft tissue or muscular tightness). The NUBAX allows for partial flexion of the lumbar spine away from lordosis in addition to axial decompression. Being able to add flexion can be extremely helpful in stenosis in particular, since extension aggravates central canal narrowing. It can be helpful with disc herniations depending on the location and shape of the prolapse as well.

– Inversion tables will have a much longer and thus less accurate traction lever since the capture the patient either at the knee or at the feet and has no 2nd point of traction. The NUBAX isolates the traction levers right at the lumbosacral spine with the hip strap, as well as the level of the shoulders with the shoulder pads.

– The inversion table requires the patient to be head down for prolonged periods of time, which can be a huge problem and contraindication with patients who have certain types of vertigo, cardiac, like circulation, brain and other neurological issues

– the inversion table with its long lever at the knee or ankle is actually contraindicated for patients with most joint replacement at the knee or hip, something that is not broadly recognized by a lot of patient who self prescribed the unit.

In the end, traction inversion can be a very powerful tool when selected for the right patient, but it's not a panacea for everyone. Once we determine that a patient may be a good candidate for trial of decompression traction, will set them up at the office to learn how to use the loaner unit which they can have for 30 days before deciding if it's something they should purchase for themselves.

https://www.youtube.com/watch?v=_yCYi2ruMN4

Food reactivity testing just got easier

IgG food reaction testing has been a useful test in our practice for many moons. The immune inflammatory cascade triggered by an antibody based reaction to foods can impact a variety of tissues and system well beyond the GI: chronic soft tissue pain, mood disorders, skin outbreaks, chronic rhinitis, fatigue and poor immune resistance just to name a few. Up until recently there have been some logistical barriers to complete the test, namely the need to get a regular blood draw. Genova had recently expanded their offerings to include a home blood spot option for the routine 70 antigen food IgG panel. It only requires a finger prick and collection of blood spot onto a paper blot that is mailed directly to the lab.

YOUR HEAD IS A BOWLING BALL

Maria and I had fun with her grandmother's bowling ball that was collecting dust in a closet, to record a video illustrating the impact of anterior head posture on the neck and shoulders.

https://www.youtube.com/watch?v=DN-nT3w6SFQ

https://www.youtube.com/watch?v=DN-nT3w6SFQ

Wearing sandals that fit heel lifts and orthotics

This blog entry may seem a little untimely since this cool morning hints of fall, which will eventually retire our sandals. However this is also the time of the year when high-quality sandals come on sale, and a good opportunity to stock up for the winter vacation and the following summer. By now most of my patients seem to understand that they can continue wearing their orthotics in the summer by fitting them in orthotic compatible sandals. I keep a document with a list of some common brands and model that fit the bill, (although in the fashion world I'm constantly reminded that I have to update it). What has not always been made clear is that you can actually wear an orthotic combined with a heel lift or medial pronation wedge in a sandal as well, if you know what shoe to look for. That particular sandal will need to have a heel cup instead of an open back with a simple strap. There are several models on the market, they are often found under the definition of a Roman sandal or fishermen sandal (although the example listed below is actually not tagged as such on the website). Our orthotic compatible sandal document has a subset of models with heel cups. The shoe industry has really stepped up to the plate in the last few years by offering routinely models that are orthotic compatibles, broadening the choices to remain well supported with your custom appliances year-round.