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Tuesday, April 14, 2015

functional neurology and PT update

It's been about a month since my last post, but don't take my radio silence as not too much goings-on. There's actually been quite a bit happening on the treatment front, I've had a hard time getting myself into any kind of blogging mood. I think I've started about 15 times, got 3 sentences in before having a "holy shit I'm so over this" moment. Over having a headache, over thinking about my headache, over talking about my headache, and yes...over writing about my headache.

And I try my best to really understand what treatments or therapies I'm actively pusuing, how they work, exactly how they can help me, etc. But over the last month, I've struggled to conceptually grasp (at least enough to confidently articulate, that is) how some of what I'm doing is moving me closer to a headache-free tomorrow.

Ironically, though, writing it down is usually the best way for me to make sense of it all, which ultimately gives me belief in the process. And belief in the process gives me hope for the outcome.

So, bear with me.

Since my last post, I did go back to try my second ozone therapy. Luckily this time I didn't have another bizarre dizziness/vomiting reaction that night like I did the first time...but unfortunately didn't feel any improvement in my headache either.

A few weeks ago, I started seeing a chiropractic neurologist here in town, Dr. Russell Teames at Arizona Chiropractic Neurology. Chiropractic neurology, by definition, is a sub-speciality of chiropractic that focuses on optimizing the function of the nervous system using conservative, non-pharmacaeutical based methods. I'll try to simplify this explanation as best as possible. Honestly though, I don't fully understand a lot of it, but hopefully this explanation will help...

The nervous system has supreme control over the musculoskeletal system as well as the organ systems in a precise manner. Specific parts of the brain are responsible for the well being of certain regions of the body. Dysfunction in a particular brain region will then manifest itself in symptoms in the associated body areas. For example, an under-functioning cerebellum region of the brain may produce signs and symptoms related to neck pain due to the intimate control of tiny postural muscles in the neck. With brain-based rehabilitation the chiropractic neurologist will not only manually treat the area in question itself with physical medicine but will also “exercise” the deficient region of the brain to normalize function. Since the brain is plastic, with appropriate treatment it can attain optimum wellness. Treatments may entail specific types of eye movement exercises (known as “oculomotor rehabilitation”), balancing activities, oxygen supplementation, rotary activation (chair spins), eccentric fast stretching, cross cord mechanisms, therapeutic use of light, therapeutic use of sound, therapeutic use of smell, and physical activities using one side of the body.

Dr. Teames has been using videonystagmography (VNG) as a diagnostic tool. Basically I put on these crazy video goggles with infrared camera inside and go through a series of tests that require me to follow a moving dot in various directions and speeds. The VNG system uses the video imaging technology to record, analyze, and report my involuntary eye movements (which are called "nystagmus"). Based on my performance on those tests, I'm given exercises to retrain my ocular system and bring balance back to my nervous system, which could theoretically impact my postural and musculoskeletal systems. For example, let's say I'm not moving my eyes perfectly to the left...I may compensate by holding my head in slight left rotation.

The best way to think about this so your head doesn't explode (at least for me) is that just like your body can change and we use physical therapy to change it, your brain and nervous system can change (neuroplasticity) and chiropractic neurology is can be used to change it. We're hoping that as I get better input, that will bring proprioceptive, vestibular, and ocular input into better alignment, causing less "noise" in the brain, and hopefully...less pain!

I've been going a few times per week for the last 3 weeks and have made a little bit of progress with my eye movements, but not as much as he would like to see and an improvement is obviously not reflected in my pain levels, which kind of blows. I'm certainly glad we're giving it a shot because that sure beats not trying something but I'm not really sure how much longer I'll continue if I don't start making more tangible progress. I'm forcing myself to stay optimistic, but it's really challenging to maintain the mental energy and focus required to commit to any treatment path when I don't feel like I'm really moving forward.

Switching gears now...

Over the past few weeks, I've also continued my physical therapy with Jeff Beran. As I detailed in last month's post, we've been been working on getting my serratus to activate properly so that my upper trap and levator scap can...well, basically calm the fuck down. After the initial sense of "relief" I felt through my upper back and neck (which is where I left off in my last post), I seemed to settle back in to my default pattern of pain and tightness. In this time, I've had a few days here and there of reduced pain, and then what seems to be an equal number of days where my my headache is flared up up above and beyond normal.

Despite the stubbornness of my headaache, though, I have made huge improvements in my serratus activation. The greatest challenge for me has been linking that with proper torso stabilization.

So right now, the focus is on integrating those. My go-to stabilization strategy has always been more rectus-abdominus dominant (think "6 pack" muscle). When that happens, my ribs flare up and then to compensate, I end up shifting my head forward just to maintain a neutral position. This then creates a significant folcrum that my neck has to stabilize against. It should also be noted that any lack of stability in my trunk is just going to place demand elsewhere to provide that stability (i.e. higher up the chain in my upper back and neck).

So we've been working on changing my stabilization strategy to that of more global recruitment. I recently shared this timely article, How are we still getting it all wrong: abdominal hollowing vs. bracing on my Facebook page, which does a great job of explaining how the abs-pulled in (i.e. "hollowing") strategy is all wrong. It activates a single muscle in isolation, rather than as a team, which is of course how they work in real life. So every time I think I'm "activating" my core, I'm essentially turning single muscles on at the expense of turning others off. The end result is far from stability.

It's taken some time for my body to figure out this "bracing" thing, but with some practice, I do feel like I finally got it. Here's an excerpt from the article above...

Think about what you would do if you were to prepare yourself for someone to punch you in the gut. You would immediately tense and stiffen you core to brace for the impact. This is exactly what abdominal bracing is, a term first coined by Dr. Stuart McGill of Canada, a leading expert in spine mechanics.

In abdominal bracing, you are simultaneously co-activating all layers of core muscles (remember the anatomy lesson?), in addition to activating your lats, quadratus lumborum, and back extensors. This means the entire abdominal wall is activated from all angles, sides, and directions, causing the three layers of the muscles to actually physically bind together.

This binding enhances the stiffness and stability of the core to a much greater degree than what would otherwise be produced by the sum of each individual part. This is what McGill refers to as superstiffness. It is this stiffness that provides us with 360 degrees of spinal stability, making us injury resilient and helping us achieve optimal performance.

You see, stiffness is actually key for spinal stability and spine health. Having a stiff core eliminates micro-movements in the joints that lead to spine and tissue degeneration. Without stiffness, these micro-movements would gradually gnaw away on our nerves, eventually causing pain and even disability. Stiffness braces these micro-movements and takes away the pain, essentially building a spinal armor.

Now, I can actually work on integrating my serratus activation with my improved torso stabilization.

If your brain works in any way like mine, you may be wondering how the hell this all ties into my headache. What it comes down to is the reality that the body is a working system, not a bunch of isolated parts and sometimes to get individual parts working optimally and feeling better, the system as a whole must become the focus. The logical part of me knows this, and appreciates this holistic view beyond belief. After all, I've had so many needles stuck in my cervical spine to target one nerve, popped so many pills to try knocking out my pain, seen so many doctors who specialize in the "neck up". If those things had worked, I probably wouldn't be complaining...but they didn't, so here I am. I can't afford to not step back and say, "ok, we know it's all connected so let's fix all of this dysfunction, improve my total-body mechanics and have faith that my headache will resolve". I have days where this approach feels more overwhelming than I can even explain. It's hard to measure progress, after all, by anything other than my headache improving. But I know it's the path I need to pursue, so I just push through the moments and hours and days that feel overwhelming and give myself credit for the biomechanical progress that I am making (I love you, Craig).

Speaking of that progress, yesterday's PT was a definite feel-good visit. All of the time I'm spent at home practicing has clearly been paying off, as evidenced by the improvements in both my torso stabilization and shoulder mechanics. We decided today that it was even time to start challenging my body a little more (cue the celebratory music).

Over the past few months, I've progressively scaled back my activity level. First I stopped lifting, then mountain biking, and now even the most basic Pilates exercises have been modified to avoid creating excess tension that could be feeding the pain loop. I was even advised to stop my sprints on the versaclimber and Keiser bike. Mentally, exercise has has been the strongest, most effective medicine for me through it all. In the same way that a solid night of shut-eye (compared to pulling an all-nighter) enables you to handle the stressors of a busy day ahead, exercise arms me with the resilience to mentally "deal with" the reality of a 24/7 headache.

But even though restrictions on my activity level have taken a toll on me, I'd willingly hop into a full body cast if it meant getting rid of my pain. The problem is, even with all of these modifications, I haven't felt an ounce of improvement. And this isn't an isolated experience - last winter I spent 9 weeks in a cervical collar to restrict movement and the same held true.

So even though I'm not ready to jump on my mountain bike quite yet, Jeff is totally aligned to my thought process and now that we have improved some of my foundational stability, he's helping me to start re-introducing some exercises back into my rehab to progressively challenge my system. This morning I started some overhead pushing, and last night Craig and I went over a few strength exercises for me to start at EXOS, most of which will use compressed air resistance to help minimize stress on certain parts of my body. It takes a little more creativity for metabolic workouts, but between sled pushing (which is actually great for helping to keep my serratus activated, the Woodway Force, and a few other power exercises using some of the Keiser equipment, I've got plenty of tools in the toolbox. And having to figure that out is pretty much the best problem I could have right now :)

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