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Saturday, November 22, 2014

AO treatment update

In my last post a few weeks back, I left off with mention of an upcoming appointment with Dr. Trombetta at Gentle Touch Head & Spine Center. Dr. Trombetta is a chiropractor who specializes in the Atlas-Orthogonal Technique. Here's a little introductory snidbit explanation of the AO Technique...

As an Atlas Orthogonal Chiropractor, Dr. Trombetta realigns the atlas vertebrae with a gentle adjustment that doesn’t include any popping, cracking or twisting of the neck. Instead, the Atlas Orthogonal (AO) procedure uses a percussive sound wave to realign this bone. Prior to the adjustment, Dr. Trombetta performs a thorough examination and history of each patient and takes x-rays to diagnose the misalignment in the neck causing the problem. This allows for the adjustment to be both precise and unique to each individual patient.Most patients experience very little if any discomfort during the adjustment and after the adjustment and, generally, patients experience an either an immediate decrease in severity or welcome relief of their symptoms. The speed of recovery is determined by many factors including history of injury, amount of time spent suffering with symptoms, work environment and daily activities.

My first appointment with him was spent discussing my (growing) treatment history to date and asking questions about the AO technique. Before proceeding, the first step would be to take some images of my neck. X-ray analysis is then used to determine the precise measurement for realignment. So I went back later in the week for a series of x-rays, and finally my first treatment at the end of the week.

When it came time to hear Dr. Trombetta's interpretation of my images, Craig and I were both pretty psyched to learn that some dysfunction in the c-spine was notably apparent.

To start with, he pointed out the position of my atlas. The atlas (or C1), is the topmost vertebra and along with the axis (C2), forms the atlanto-occipital joint, which connects the skull to the spine. It's a pretty interesting bone because unlike your other vertebra, it's ring shape and has no "body" because it's body is fused with the axis.

Both the atlas and axis are important neurologically because the brain stem extends down to the axis.

So, the atlas is supposed to sit at a bit of an angle, as you can see below in this x-ray of a healthy C-spine. But if you look closely at mine on the right, you'll notice that the angle of my atlas is much less...it appears to be more "flat".

Since the atlanto-occipital joint allows the head to nod up and down on the vertebral column, my "homework" is to avoid that flexion/extension motion as best as possible. That means making a really conscious effort to do some basic daily activities differently. For example, I've been trying to lift my phone up into my field of vision instead of looking down at it. Try that for a day and you'll be surprised how much time you spend "looking down" (...or take my word for it, your call).

This was an interesting observation, though, because of the basilar invagination that I've talked about before. I posted this MRI image a few months ago, but here it is again.

Notice the "kink" in my spinal cord? It's right at the level of C2. We don't know for sure, but can at least theorize that the altered position of C1 could be affecting the position of C2, which could be somehow pushing in to my spinal cord, contributing to the basilar invagination. (Side note: Every doctor I talk to about the basilar invagination seems to have a different opinion of its significance, ranging from "that's probably just your anatomy and I wouldn't worry about it" to "that's absolutely concerning". I do have an appointment coming up in mid-December with a neuro surgeon to get their take.)

How could all of this be related to my headache? Well, that's where cerebral spinal fluid (CSF) may come into play. I know you're biting your nails to know more, so here's a closer look at the function of CSF. It's actually pretty fascinating. And if you want to have your cerebral-spinal-fluid-cushioned mind really blown, watch this 10 minute Ted Talk.

Cerebrospinal fluid (CSF), clear, colourless liquid that fills and surrounds the brain and the spinal cord and provides a mechanical barrier against shock. Formed primarily in the ventricles of the brain, the cerebrospinal fluid supports the brain and provides lubrication between surrounding bones and the brain and spinal cord. The fluid also transports metabolic waste products, antibodies, chemicals, and pathological products of disease away from the brain and spinal-cord tissue into the bloodstream. CSF is slightly alkaline and is about 99 percent water. There are about 100 to 150 ml of CSF in the normal adult human body.

If you're like me, maybe you'll appreciate a visual representation of CSF.

Once you understand just how important CSF's functions are (including buoyancy, protection, chemical stability, and waste clearance), it's really not a jaw-dropper to learn that there's is a correlation between the obstruction of CSF flow and intracranial pressure headaches. There's actually an AO chiropractor in NY, Dr. Rosa, who uses the upright MRI that I mentioned in my last post, to study this very phenomenon. What their research has found is that in some patients with severe, long-standing headaches post-whiplash injuries (hey, sounds familiar!), there is a misalignment of the atlas vertbra (still sounding familiar), along with substantially reduced CSF flow at the cranio-cervical junction. When the patients undergo the AO chiropractic treatment, restoration of normal CSF flow is observed and reduction/elimination of head pain experienced.

We may end up going to NY to have the MRI done, but in the meantime, can only speculate that my CSF flow could also be obstructed. Either way, the goal of the these AO treatments is to improve that.

Another quick data point to interject...In October of 2013, I had a pretty scary pain spike reaction (remember I described it as feeling like I had an electric mixer in my brain?) to a cranial sacral session. The PTs who were working on me had speculated that it was somehow due to CSF flow and I ended up back at Mayo getting an MRI to rule out a CSF leak.

There are a few more images we looked at too. This next one shows a misalignment of my head on my spine. It's pretty clear if you just follow the axis down. Theoretically, this could be a result of the atlas misalignment.

Lastly, this view further shows the misalignment. There should be 4 right angles, but because of my head tilt, that's clearly not the case.

I've been seeing Dr. Trombetta three times per week for almost a month now. Each visit, he checks to see if I've "held" (which he determines by manually palpating my neck and measuring my leg length). I've been "holding" about the half the time I see him...a response he seems to be really encouraged by. The million dollar question though...am I feeling better? Drumroll...

Eh. No...not yet at least. But there was a glimmer of hope after my second adjustment. I had my first one on Friday 10/31, had an awful flare-up weekend, went back Monday and was "out" so had a second one, had a bad flare up Tuesday, and then Wednesday I woke up with the lowest pain in 2 years (even lower than magical marijuana Sunday earlier this fall). It was pretty amazing. Amazing enough that this time, Craig cried happy tears as we hugged goodbye in the driveway before he left for work. And then something even more amazing happened...I woke up the next morning and STILL. FELT. GOOD. Holy shit, right?

By Friday, I was back up to my "normal" pain. I've experienced a few "low end of normal pain" days since, but nothing close to that level of relief. Heartbreaking...yes, but I was (still am) unwilling to discount its significance.

Despite my frustration in not making better pain progress these past few weeks, this is truthfully the most hopeful and optimistic I've felt in a long time. That's because I finally feel like the intuition I've had about my headache for 3 years and 3 months is substantiated. How many doctors offices have I sat in, pointing to C1/C2 on my neck and saying, "my headache is coming from right here!"

While it's a good sign that I'm holding at all with the AO treatments, the goal is to get me holding longer between treatments. So right now, I'm trying to just maintain my optimism and take the AO treatments day by day. Aside from focusing on my postural adjustments, I've been modifying my physical activity too (ugh!). No lifting...no riding...basically nothing that takes my cervical spine out of a neutral position or creates tension in my traps and neck. Luckily, I've managed to continue some Pilates with those modifications in mind.

Two weeks ago, I had a previously scheduled follow-up with Dr. Dodick (neurologist at Mayo). Understanding the predicament I'm in with my lack of response to...well, basically everything we've tried...Dr. Dodick was totally aligned with and supportive of my course of AO treatment. Just because I've never tried it before (and because "I've never tried it before" has sort of become the qualifying criteria for trying something new), he wrote me a prescription for another migraine drug, Amerge (Naratriptan). I've been on it now for almost a week, but haven't felt any changes so will likely discontinue when my trial dose is gone in a few days.

So THAT is what I've been up to. That, and a whole lot of this...


  1. Hi. I'm a follower of your blog, and after reading this post a few months ago I booked an appointment with Dr. Rosa in NY. His research and upright MRI / upright Cine MRI are really amazing. It was especially cool to see the difference in the MRI's pre and post treatment. He was also able to identify injuries to the ligaments of my c-spine that were never seen from typical MRI's. I haven't had any pain relief yet (only been a few days) but I understand after years of constant pain it can take a while for the body to recalibrate itself. I also have a much more targeted plan of attack now. I just wanted to say thanks for leading me on the path to him and I highly, highly recommend him as a doctor. Goodluck.

  2. Hi - thanks so much for leaving your comment. I'm so glad to hear that you had a positive experience with Dr. Rosa...from what I have heard about all that he does, it does sound really amazing. I'd be interested in knowing what kind of injury/symptoms you had if you were open to sharing more...and would of course love to know how what your response is after some time. I can definitely appreciate the complexities of chronic pain and knowing that even when you are on the right track, it's still a process and not an overnight miracle. Thanks again for following my blog. When I'm having a particularly rough day with my head (which today happens to be), it makes a huge difference knowing that I've possibly helped someone somewhere just by sharing my story. If you'd like to stay in touch, my email is kathrynLdalton@gmail.com.