PT trip to Austin

Back from a mentally exhausting but highly productive few days in Austin. Our trip went really well...just about as well as it could have gone...with the exception of one small detail...my head still hurts (quite a lot, actually). Now that I'm writing it, it does seem a little absurd to call anything that doesn't result in my headache going away a success. But there is plenty of positive to pull from the week, including a serious possibility that pain reduction is on the horizon. And somewhere along the line, the definition of "success" has been recalibrated from "desired outcome" to the hopeful notion of "possibility".

So here's the day-to-day breakdown.

Monday:
When Craig and I arrived at my first physical therapy visit with Mark Strickland on Monday morning, he had already spent time reviewing the films, and even sharing them with several colleagues across the country who share his speciality of treating complex upper cervical cases.

Palpation of my neck confirmed what they had collectively interpreted from the images: gross left rotation of my atlas (C1) and axis (C2). The spinous process of my C2 was a solid 1/2 inch off midline, which he told us may have been the most severe he's ever seen.

Mark used some gentle manual techniques to reduce my C2 and given the severity of rotation, was surprised how easily it moved into proper position. He then used very specific and targeted dry needling to help relax the muscles connecting my head to my neck. My soft-tissue was so tense that it actually bent one of the needles sliding into it! Kind of crazy.

Of course it makes sense that these muscles (see below) have been in a chronic state of spasm because the over-shortening/lengthening that has occurred as a result of my twisted vertebra. And it makes even more sense that no amount of soft-tissue work, needling, etc. could resolve the tension if the mechanical problem causing it wasn't addressed.

There's no way to know for sure what the exact mechanism of my pain is, but Mark speculates that it's likely one of two (or a combination of both) sources:

1. The dura mater, which I've talked about before, is a thick membrane that is the outermost of the three layers of the meninges that surround the brain and spinal cord. The dura is attached to the atlanto-occipital junction (AO junction = articulation between first cervical vertebra and occipital bone), and when the vertebra is rotated, as is the case with me, it can cause a sheering of the dura. You're dying to know how though, right?

So the dura is connected to the rectus capitus posterior minor muscle (highlighted in red below) at the atlanto-occipital junction (AO junction = articulation between first cervical vertebra and occipital bone) via a perpendicular-running connective tissue. That bridge of connective tissue resists dural movement toward the spinal cord, so when my C1 and/or C2 vertebra are as grossly rotated to the left as they've been, that shortens one side of those tiny muscles and over-lengthens the other. It's that over-stretching/shortening that then "tugs" on the dura and creates the sheering.

It's still not totally clear to me how this translates to head pain, but what I do know is that the dura is a highly sensitive membrane so perhaps it's a matter of nerve irritation or maybe referred pain? If you know, feel free to enlighten me!

2. The second possible source would be referred pain to my head caused by the spasm and tension of my surrounding muscles. Remember the whole pain-spasm-pain cycle I've talked about before?

As far as expectations for the week ahead, Mark told Craig and I that although he wouldn't be shocked if my headache subsided over the next few days, we shouldn't be discouraged if it didn't. My spine had, after all, been in this position for a long time (over 3.5 years) so regaining alignment may be more of a process than an overnight miracle. (I'll take either one, by the way.)

And we did leave that first day feeling incredibly encouraged, and not just because there was a chance my pain may subside in the days ahead but because this all made so much sense. When Mark manually rotated my C2 vertebra back in place, his fingers were on the exact spot I've been pointing to for 3.5 years as the SOURCE of my headache. And it wasn't just further validation of my own intuition, but even the "findings" of other practitioners. Veronika, the visceral mobilization physical therapist I had worked with for months and her mentor, Gail, who I had gone out to see in Newport Beach last spring, had always felt this "deep dural tension" at my C2 that they just couldn't seem to get to.

Tuesday:
When he returned for treatment numero dos on Tuesday, Mark felt that my C2 had held proper alignment (yay!) but my C1 had slipped back into rotation. Upon reviewing my pre and post x-rays from this fall, he could tell that the 6 weeks of atlas-orthogonal chiropractic treatment I'd undergone had definitely improved my atlas rotation, but not fully. So I think that a slip out of alignment after just one day reinforced that this wasn't going to be a quick fix. Mark told us that he wanted to bring in a neuromuscular dentist that he works with, Dr. Ueckert to help.

You probably don't think of dentists and physical therapists collaborating all too often, but it actually makes a whole lot of sense when you understand the relationship between occlusion (meaning the contact of your teeth) and the upper cervical spine.

Neuromuscular dentistry is the science of studying the muscles and nerves of the head and neck to determine an optimal orthopedic relationship between the upper and lower jaw. This will allow the rest of the body to align properly, and may help eliminate nagging symptoms due to a misaligned bite position. When the jaw is not properly aligned, damage can be done to the teeth as well as their supporting tissues. This approach to neuromuscular dentistry presents an effective, efficient and timely solution to those that suffer.

To remind you, since my mountain bike accident in 2011, I've experienced a pretty significant "pop" in my jaw every time I open my mouth. I've sought treatment from several different dentists, orthodontists, and TMJ specialists, not because the pop is painful but because it seemed probable that my jaw dysfunction could be tied to my headache. Until now, it seems to have always been viewed as a separate issue though.

During this second session, we introduced some corrective exercises that use muscle energy to help reinforce the re-alignment that Mark was manually putting me in. The lighting's a bit dark but here's a video below.



We finished up Tuesday's visit with some dry needling of my inferior neck and face. Some of the needles didn't feel too bad but my masseter (muscle connected to mandible and cheek bone) was quite painful.

Wednesday:

On my third day, Dr. Ueckert was kind enough to meet us over us over at Mark's office. It was clear to both of them that the retrusion of my lower jaw has been compressing my temporomandibular joint (TMJ). He explained that he would make me an appliance that moves the contact points of my teeth forward, which would keep my jaw from sliding back. This, in turn, would help to hold my upper cervical vertebra in optimal position.

If you're trying to grasp how your bite and upper cervical spine position impact each other, try this: look straight ahead and tap your teeth together a few times. Notice where the contact points on your teeth are. Continue to tap your teeth together, but now rotate your head from side to side, then look up to the ceiling and now down to the floor. Notice how the contact points change as your spine moves?

To ensure that the molds were taken while I was still in the correct position from Mark's treatment (if we had driven over to this office, I may have slipped back out) Dr. Ueckert took them right in the PT treatment room. First though, he hooked my face up to a tens machine to help relax the muscles and get into a more reflexive bite pattern. The actual appliance wouldn't be ready until Friday but he was able to make me a temporary splint right then that I would wear for the next few days to optimize my chances of "holding".

As soon as I had the temporary splint in, I could open my mouth without my jaw popping! That may not seem super significant, but it's literally the first time in over 3 years I've been able to do that. And to confirm that we were on the right path with this whole approach, they sent me over to get x-rays on Wednesday afternoon after first going to Dr. Ueckert's office to finish the rest of my impressions. Both Mark and Dr. Ueckert were excited by the findings. Check out my pre and post orthotic images below. The improvement in my temporomandibular joint space once the appliance is in my mouth is impressive. You can imagine the how easily the compressed joint (on the left) could have been causing significant tension, which would of course be feeding the pain-spasm-pain cycle.

Mark didn't do any dry needling on Wednesday and actually told me to discontinue the corrective exercises I had been doing every few hours since our last session. Now that I was in proper alignment, the splint should theoretically take care of the holding.


Thursday:

After a full day and night of wearing my temporary splint, we were all happy to learn that I had held alignment on Thursday morning. Mark continued with some of the manual work and the dry needling. At this point, I still wasn't feeling any improvement and a sense of general exhaustion was building up...I think it's due to my realization that I likely still had have quite a ways to go before I'm pain-free, but everyone assured me that there was absolutely no reason to feel discouraged.

Friday:

Our last day in Austin had arrived and the hours leading up to our flight home was jam-packed. It started with my final session with Mark. My upper c-spine was still holding, which was great, and he showed Craig and I how to tell whether it was slipping back once we got home (see video below). If that does happen, the first step will be to re-start the corrective exercises.



From there, we headed over to Dr. Ueckert's office to make the final adjustments on my orthotic, which took a few hours. He had to replicate the process of relaxing my muscles and getting me back into a reflexive bite pattern and then tweak the splint over and over again until my conscious bite matched up to my reflexive bite.

And THEN we raced to the airport to catch our flight home. Side note: Austin is a sweet city! We didn't have too much time to explore because Craig was working when we weren't at my appointments but we stayed right near Zilker Park, ate at the flagship Whole Foods at least...uh, 200 times, checked out the infamous food truck culture, and managed to catch this beauty of a view from the top of Mount Bonnell.

So, the plan moving forward is as follows:

1. I'll wear the orthotic 24 hours per day for the next 6-9 months. Depending on what happens to my pain between now and then, there would be 3 potential scenarios. The first would be weening off the orthotic. The second would be neuromuscular orthodonture, where they would use orthotonduure to create an optimal bite for my c-spine. I'm not able to think, read, or write too much about that one without having a minor meltdown so .... moving on to the third scenario, which would be restorative dentistry. That would consist of actually building up my teeth to achieve the bite. One day at the time though.

I can't say I'm super pumped about sporting a sometimes lisp-inducing mouthpiece and I can't say I didn't cry in frustration trying to eat my first kale salad with what feels like a f-ing soccer mouthguard covering my teeth...BUT...Craig has reminded me over and over again that once I start feeling some relief, I'll have an entirely new context for tolerating it. I can't argue with that. And honestly, I'm so desperate for pain relief that I can't afford to be annoyed by something so insignificant.

2. We'll travel back to Austin in 2 months to get the orthotic adjusted and will also have a follow-up with Mark at that time.

3. Craig and I will keep checking to make sure I maintain my alignment.

4. I'll modify my activity to minimize tension in my traps and neck (I knew that was coming).

5. I'll start re-introducing some soft-tissue work in my weekly routine. Now that my bones are where they should be, my muscles should theoretically have an actual chance of settling down. Ideally, that will disrupt the pain cycle.

6. Both Mark and Dr. Ueckert have told us that 3-6 weeks would be a reasonable time frame to start experiencing some changes, so we'll be praying with every ounce of our beings that I start feeling some pain relief in the next few weeks!