Dr. Kevin Leach:  If you’ve been suffering from symptoms that you have from a concussion for more than 10 to 14 days or you’ve been diagnosed with post-concussion syndrome this video is definitely for you. Hey everyone, Dr. Kevin Leach here. Welcome to The Chiropractic Deep Dive Podcast and this is The Upper Cervical Research Show. This is show #5 so with Dr. Evans. He and I will be going over a paper going over post-concussion syndrome and how the neck is involved and most likely involved with post concussion syndrome. Okay, welcome back everyone to The Upper Cervical Chiropractic Research Show. This is episode #5. I’m Dr. Kevin Leach and I’m here once again with Dr. Tyler Evans. How are you sir? 

Dr. Tyler Evans:  I’m well, good to see you again. 

Dr. Leach:  Fantastic. This episode’s research review is titled “The Role of the Upper Cervical Spine in Post-Concussion Syndrome” by Cameron M. Marshall et al published in the journal “The Physician and Sportsmedicine” which is a peer-reviewed journal indexed in PubMed. Dr. Evans as usual you want to give us a little overview of the paper and it’s what it’s trying to explain and its goals? 

Dr. Evans:  Yes. This is an amazing paper that was done by – I believe they’re all medical doctors and the one that I know of is John Leddy. He is one of the foremost concussion specialists in the country and he was involved heavily with the NFL’s studies. When all this started to come out with the NFL it was probably 15 years ago. He’s been involved in the concussion discussion across the country now for a long time. He was the guy that developed the buffalo concussion treadmill test which is one of the kind of foundational heart rate tests for post-concussion work. I really believe in the upper cervical profession and in the chiropractic world that this is a paper that every chiropractor should know. This is a paper that anyone that deals with concussion patients, they should know this paper and they should know the information in. It can help you better take care of your patients. This paper just starts out by listing some of the statistics about concussions. Mild traumatic brain injury or concussion has an estimated prevalence of about 3.8 million per year. That’s 3.8 million people. In the majority of cases concussions symptoms resolve within 7 to 10 days. However in roughly 10% to 15% of the concussion patients these symptoms prolong and they go long longer than a month. When they do that’s what we call post-concussion syndrome. That’s an important thing because if the symptoms aren’t healing it’s really important that we take another look and we change our course of treatment or care to get the patient the best result. In our office and I’m sure in your office you probably work with other healthcare professionals who deal in this sort of realm. We worked with a guy in our area in the Seacoast of New Hampshire and he’s one of the leading head neck injury guys in the area. When a child comes in and they’ve had a concussion he checks them out and so we brought this paper to him. We wanted to make sure he was aware of it because it’s important for doctors that are dealing with these patients to know that the neck might actually have a big part to play in these symptoms prolonging and not getting better. In this paper Dr. Leddy and the handful of other doctors here, Cameron Marshall and the other doctors, they go through and really look… looking at it now there’s a chiropractor here. Department of Graduate Studies of Canadian Memorial Chiropractic College – that’s Cameron Marshall. It’s got a chiropractic filter that we’re looking through. When we look at the spine we look at alignment. If the bones in the spine are out of alignment it can affect how the body works and the nerves especially. So in this paper they immediately break down the g’s. So that the force that is put through the neck when there is a concussion and when you have a concussion you have a massive amount of energy and force that’s put through the head as well as the neck. In this they outline that roughly 60 g’s to 160 g’s is what it takes to get a concussion. That’s a lot of force. I pulled it up right here on Wikipedia which may not be the best source but I mean we’re gonna be in the ballpark here. An untrained individual not used to the g straining maneuver can black out between 4 g’s and 6 g’s if they’re in a plane. For example pilots 4 g’s and 6 g’s blacks out a pilot. We’re talking about 60 g’s to 160 g’s of force. Obviously that’s going to cause some damage. They always look in the brain. If we’re having a concussion we look at the brain. In this paper they outline maybe the neck is involved, maybe we should look at the neck and they talk about examining whiplash associated disorders. Whenever we talk about whiplash we’re not talking about the name. Whiplash isn’t the name of the problem, whiplash is the name of the way that the problem occurs. So whiplash associated disorders are what occur after you have a whiplash type accident. In a whiplash type accident it only takes 4.5 g’s to damage or change the ligaments and soft tissue of the neck. That’s a big red flag if you’ve had a head or neck injury. If you’ve had a head injury and you’ve had a concussion more than likely you have had a whiplash injury as well. A whiplash associated disorder. They’re saying if we look at these symptoms…. if you look on the second page of this paper… and if anyone out there needs access to this paper we can help you find it because I believe that it is tough to find now online. When I found it initially it was right there in PubMed.. but these symptoms overlap. When you talk about signs and symptoms of concussion or post-concussion syndrome and then we talk about signs and symptoms of whiplash associated disorders you get headache, headache, numbness, pressure in the head, headache, numbness and tingling numbness and tingling, nausea and dizziness, dizziness and unsteadiness. They’re very similar. They’re overlapping so it’s really hard to suss out unless you’re doing a physical exam on a patient and seeing – do they have a problem in their neck or is there something in the neck that might actually be going on causing these symptoms as well. Obviously the brain is a big part of this so when we have the shearing of the tissue in the brain and we have the cascade of chemicals that then are released in the brain that’s initially what we think is part of that brain concussion. We think it’s the tissue that gets injured but the neck might have a lot to do with this and a big reason why patients aren’t getting well outside of this 30-day criteria. The paper goes on and it talks about the four cases that they study. They study 4 cases where they.. sorry there’s 5 cases there.. and I believe that in almost all of those cases they had some sort of neck intervention for some sort of either soft tissue therapy or spinal manipulative therapy which would be an adjustment from a chiropractor. The patients did observe a good change in their symptoms. It’s just a great breakdown from John Leddy. A great breakdown from this amazing source of information for post-concussion syndrome. They address there might be something going on in the neck when this stuff isn’t getting better. 

Dr. Leach:  When we think about that 10% to 15% of that small percentage of concussion patients that go on to have the pcs or post-concussion syndrome it’s easy to say those are the ones that need to get their neck checked out. But as you just said 60 g’s to 160 g’s of force can cause a concussion and I think in the paper it says 4.5 G’s as little as they’ve seen to cause a neck injury it begs the necessity of actually getting everyone’s neck checked who has a concussion. I think that’s huge. With the work that we do with upper cervical chiropractic and working in the Craniocervical Junction it’s once again a missing piece of the puzzle that should be checked. I say this because even if somebody goes through the concussion and gets 100% resolution of symptoms it doesn’t mean they didn’t get a neck injury that’s just not creating symptoms now that could create problems in the future. How many times have you had a patient come in and you ask about accidents, injuries, and car accidents and they say no. I then take some x-rays and you see that they’ve definitely had damage and injury to their spine over time. Unfortunately a lot of these people they’re not told that they need to have their spine checked. They need to have their spine checked because it creates problems in the future. I always tell people it’s the straw that broke the camel’s back. They say they’ve never had neck pain until six months ago and they’re 45 but you look at the neck on the x-ray and you’re thinking this has been a problem for decades now and it’s the straw that broke the camel’s back. This is just one of the mechanisms of whiplash that people should consider getting their spine and their neck checked for an injury and get it treated accordingly. 

Dr. Evans:  Absolutely 

Dr. Leach:  I wrote down a couple discussion points here. They put in the paper the definition of pcs or post-concussion syndrome is the persistence of three or more symptoms for four weeks. Now why does it say four weeks when it says that concussion symptoms should resolve within ten to fourteen days. Why is there a discrepancy there? Do you know anything about that? 

Dr. Evans:  I think that part of the problem is that concussion is such a gray science still they’re still learning. If you talk to you know this doctor they might play under these rules of this is what concussion is or this is what post-concussion is. I’m not saying that we’re not agreeing that post-concussion syndrome..

Dr. Leach:  It makes sense with the vast amount of symptoms that you could possibly have with a concussion. Especially when you’re dealing with head stuff, dizziness, vertigo, headache, and all that kind of stuff. How many different providers treat those symptoms?

 Dr. Evans:  I think a part of the problem too is, I think in our healthcare and in our daily lives there’s a lot more emphasis put on genetics or I was made this way. This is how I was made and so there’s no way for me to do anything about this other than through drugs or surgery. What Dr. Leddy is stepping out in this paper, what he’s doing is he’s saying accidents occurring in life may actually affect the spine. There has been differences of opinion over the last hundred years as to whether or not the spine can actually even go out of alignment. I think John Leddy is probably a little bit ahead of his time in terms of a medical doctor who’s putting himself out there and saying there may be some good science behind getting the spine worked on in a conservative means to help the brain and the body work better. Where does your research come from? Where do your studies in PubMed come from? I think it just depends on the source and then what their training is and what their background is. I think Dr. Leddy has a very progressive and more conservative view. He wants to get the word out there that if this stuff isn’t getting better then go get checked out by a manual therapist. Get checked out by somebody who’s gonna work on the spine, work on the muscles, and help that part of the body. 

Dr. Leach:  Let’s go over the mechanism here. People might think let’s just connect some dots as far as a cervicogenic, meaning coming from the neck, component too. That’s what the paper is all about. It’s proposing when it’s not the brain anymore it’s the neck. You could injure the soft tissues in the neck from a whiplash, which would be a whiplash associated disorder. Just real simply, we’re not gonna get into anatomy lessons here, when you think about coming from the neck and how it can be affected the paper talks about two main ways that an injury to the neck could create these problems. The two main ways are pain related and and the other is proprioceptive related. When they talk about a pain related mechanism coming from the neck and neck pain, we know that pain from the neck can cause headaches and it’s called a cervicogenic headache. We know that those exist and we see those patience all the time. That connection is pretty simple there. Then there’s the proprioceptive related mechanisms. For those listening who don’t know proprioception or mechanoreception, these are the mechanisms inside the joint inside the body that sends signals to the brain letting it know where the body is. When we think about that mechanism being involved with dizziness you can make sense if there’s nerves and there’s things telling the brain where the body is in space… I tell patients all the time when I talk about this I just have them close their eyes. I say close your eyes and they close their eyes. Then I ask do you know where your left hand is? They answer yes. How do you know that when you’re not looking at it? Your body’s telling your brain where things are. When these proprioceptive mechanisms can be injured or interfered with that’s when you can get that sense of either a dizziness unbalanced sense of vertigo because that proper communication between your brain and wherever that injured tissue is could be interfered with. This would give you that symptom and that’s where these neck injuries can be correlated to these symptoms that people are having after that window of concussion into post-concussion syndrome. Any comments on that? 

Dr. Evans:  Yeah. I’ve sat in at the Cantu Institute. Robert Cantu, he’s in my opinion kind of the other very progressive very open conservative research guy for concussion especially for the NFL. He was right there with John Leddy I believe way back if I’m in the right zone. I believe I am but Cantu puts on once a year, at least one of the hospitals down there around him in Boston, puts on a concussion symposium. I’ve gone down to two of them and it’s fascinating because they have a whole hierarchical way that they describe concussion. I know we’ve got the neurometabolic cascade.. 

Dr. Leach:  Which is actually it described in… sorry to cut you off but it’s described as a figure one the whole cascade effect of the concussion and what happens. 

Dr. Evans: Right. It’s an energy mismatch and that’s really why we have fatigue, that’s why we have the memory loss. We’ve got all these weird brain symptoms but then why do these problems persist? If the patient doesn’t get better will they break it down and they put it into this hierarchy of how should we treat the patient? They want to get results and they see some of these cases do really great with vestibular therapy. Some of these cases do really well with ocular therapy or a special optometric help which is either light lens, different lens colors, or different exercises for the eyes. Then there are the cervicogenic ones, so maybe a chiropractic adjustment. Oftentimes this is more in the physical therapy realm so they’re talking about doing PT to the neck which is great and all but we’re approaching this from a neck situation. In this model the neck can actually drive the eyes, the inner ear, and the brain to have dysfunction. When we look at the neck it’s a big part of a “three-legged stool”. So you have the inner ear, you’ve got the eyes, and then you’ve got the cervical spine. The cervical spine drives a lot of input into the brain, into the eyes, and into the ear about where things are out in space. You can have the trigeminal cervical nucleus driving that input into the brain. The trigeminal cervical nucleus is the largest input for that nerve into the brain as well as then you can have a cervicogenic vestibular problem because the neck is actually causing the inner ear to be off. You can also have what’s called a cervico-ocular reflex. This is where the neck is causing the eyes to be off right and so then you get visual disturbance as you go. You probably see it all the time. I see it as well. I work with these therapists that focus on these areas and if I’m not getting a patient well I send them to the eye person or I send them to the inner ear person. Between the handful of us we can get good results but alone it’s not as great. This is just about getting better results for patients. We see that the neck is a big component and it can drive a lot of these other symptoms as well as a lot of these other problems that are the stool legs for balance and proprioception in the body and in the brain. 

Dr. Leach:  Just because we did the hydrodynamics paper recently.. 

Dr. Evans:  Yeah. 

Dr. Leach:  I was thinking about that choking off of the CSF fluid etc. When we look at the whole cascading effect, oxidative stress, the neuron imbalancing, and the ion imbalancing that happens with the concussion. The point is the body needs to heal through that for 7 to 14 days. The people that don’t know that the neck could be a contributing factor to these post-concussion symptoms, they talk about how there are four mechanisms to try to explain it. One of them is the continued decrease in ATP and metabolic production. Number two is the continued axonal dysfunction. Number three is a continued ANS dysfunction or autonomic nervous system dysfunction. Then the fourth one is altered blood flow. It’s important to understand that just as a real quick side note that during a concussion its mechanical damage not structural damage to the neurons. Right? If we think about mechanical meaning the ions and things that are functioning. It’s not the actual breakdown or damage to the actual nerve. So it’s not structural but it’s more mechanical.

Dr. Evans:  That’s right. 

Dr. Leach:  Anyway, it talks about that last one, altered blood flow, being a potential ongoing symptom and we can tie that into the interference of the hydrodynamics of the entire spine from the misalignment – from the injury. This means that even if it’s not an injury to the actual proprioception or the pain reception in the neck that’s causing these problems, if there was a misalignment and if that is choking off the CSF flow and the secondary venous outflow in that whole system that could lead to an extended period of concussion symptoms as well. Which could be also categorized as the post-concussion syndrome. All this is coming in full circle to explain these mechanisms and all of this makes sense to anyone who knows how the body works. I hope that this research gets more and more spread out to people, like what you’re doing and like what I’m doing, so we can co-manage these patients and really find the mechanism of that individual and get everything corrected. Doing intervention to get things back to fully functioning in every way.

Dr. Evans:  Absolutely.

Dr. Leach:  Which sometimes can be just getting rid of the cause and fixing the injury and sometimes you need more therapy. Therapy like ocular therapy, the balance therapy, or things like that to try. Retrain and rehab the body back to where it should be. So I thought that was a good point to bring up.

Dr. Evans:  Oh yes. Absolutely. That’s a great point and that’s why it’s important to understand this literature especially for the doctors. It’s still good for the patients but great for other chiropractors and other neurologists to understand. The guy that we work with here in the Seacoast area is an osteopath. He works at a rehab concussion center and this is top of the crop good research. Obviously it’s not a randomized controlled trial but there’s a great layout here of all the research to look at and in five case studies where we saw good changes in symptoms. It wasn’t just one therapy but it was many different things put together and the neck was a foundational support for it. 

Dr. Leach: That’s what they did in this paper right? With the five different patients. Sometimes it’s difficult when five or six things are done immediately for one thing to really understand what was the problem but important that they got better with whatever it was. The only thing I think about is time and cost effectiveness of potentially doing all of those things initially when maybe they’re not all necessary. However you probably agree with me about this… A lot of patients will come in and they’ll ask what are the percentages or what are the chances that this is going to help. I always tell them I can do an exam for your spine to see if there’s an issue with your spine that I can help you with to get your body functioning better. Whether that’s going to be the factor of correcting the symptom and getting that symptom correct that you’re looking to get corrected, I have no idea. We have to get your spine fixed and give it time to see how much it corrects and if it doesn’t then we can try some other things or refer you over here for some therapy or go that way. I don’t know of any exams that can really pinpoint specifically meaning you have headaches so let’s do this exam to see if it’s related to your spine. Do you see what I’m saying?

Dr. Evans:  Yeah. With concussion patients I we go through the saccades, vestibular ocular reflex, and you can test vertical and horizontal saccades. If those are popping up, if you’re having convergence insufficiency, if someone’s having a pretty positive Romberg test where they’re just off to one side real quick. That’s a very quick indicator that one they have a brain injury, two their cervical spine is probably not giving good information into their brain, their inner ear might be a little bit off, and the eyes might be a little bit off too. Then you just start a course of treatment and keep testing and see if that is changing. If it’s not then we can go down a treatment path for the issue. So I always tell my patients to give it 4 to 8 weeks and we’ll do a re-exam to see where things are at. We’ll then refer out based on how you’re feeling and what you would like to accomplish next but I always say you got to keep your neck in alignment to continue the momentum and keep the stability of what we’ve done. You want to maintain that momentum but we want to see those neurological tests get better. We almost always do. Percentage-wise I know that our post-concussion syndrome patients don’t get 100% better with us every time but we see a good 60% to 70% of people get good results. Then the other 30% to 40% they need some other therapies and maybe 10% they’re really affected in some other way. So just keeping their spine in alignment is helpful but it’s not going to be the thing that it’s going to get them to home base but it’s a big piece of the puzzle. You’re talking about the cervical spine; it’s the foundation of the head and the brain. It’s a big driver. 

Dr. Leach:  Yeah. Awesome. Any other points that you think we’ve missed with the paper? Anything else to discuss or any details that we might want to go over? 

Dr. Evans:  I think getting imaging for this is really important. Just to reiterate, we’ll probably talk about this on our next video so check out the next video, getting radiographic imaging of some sort whether it be X-ray, MRI, CT, or cone beam CT because that sort of information can help you suss out what else is going on here. Is there some whiplash problem that’s been going on for a long time and this has made it worse. We’ll talk about the importance of x-ray in the next video but for a chiropractor taking care of someone’s spine you need good imaging for measuring the misalignment, specifically in doing a specific correction and especially especially especially in the craniocervical junction where every millimeter counts and every millimeter matters. So getting good imaging whether it be upright MRI, digital motion x-ray, or good upper cervical x-rays that will give you a better treatment plan and better course of action. 

Dr. Leach:  Yeah. So what would you say if someone’s listening to this and they are suffering with that post-concussion syndrome and they’re thinking this is me. What’s their first step to getting help? 

Dr. Evans:  Definitely look up an upper cervical chiropractor in your area. You can go to upcspine.com and then there’s a doctor/practitioner locator. Uppercervicalcare.com, that’s the other one and that has a doctor locator as well. That’ll be a good way to get started. Most of our cervical chiropractors are going to be a good guide and help you find the care that you need, especially those that are involved with NUCCA, Blair, Atlas Orthogonal, Advanced Orthogonal, EPIC, Knee Chest, and Toggle. These are the techniques that you’re going to want to look for and I hope I didn’t leave anyone out there.

Dr. Leach:  I was going to say we did a video on a Precise of Upper Cervical. So whoever’s listening that didn’t see that, they can go and listen to that. They can get a better idea of how to find and how to know that you’re in an upper cervical chiropractic office. 

Dr. Evans:  They’re gonna be a good guide for you. They’ll really help you navigate this. It’s a scary thing and I had three people this morning that have gotten fantastic results in our office as well as with some of the referrals that we’ve given them. I had a guy this morning that’s playing guitar again. It’s been three years since he got kicked in the head by a kid, he’s an occupational therapist, and he hasn’t been able to play guitar. He hasn’t been able to play with his kid and he’s playing with his kid again. He’s playing guitar. He brought his son in and his son is laughing and having a good time. It’s like people get their lives back. 

Dr. Leach:  Awesome, love it. Any last thoughts or conclusions with the paper here?

Dr. Evans:  No, I think that’s good.

Dr. Leach:  Awesome. Thank you once again for your time, good sir. Once again anybody who’s listening drop a like. Likes really really help the videos and if it’s helped you drop a like or drop a comment. Subscribe and all that. The more that you interact with the video the more people just like you if you’re getting help with this are going to find the videos as well. We really appreciate that. That’s why we’re doing this. We’re trying to bring value to the community, to the world, and to people who need this kind of help to change lives just  like you said, Tyler. Great. Thank you for your time and we’ll see you soon.

Dr. Kevin Leach:  Hey everyone. Dr. Kevin Leach here. Welcome to another episode of the Upper Cervical Chiropractic Research Show. If you are interested in neurodegenerative conditions. If you’re a doctor who treats these conditions. If you are someone/if you know someone with these conditions, this video is definitely for you. Okay! Welcome back everyone to The Upper Cervical Chiropractic Research Show. This is episode #4. I’m dr. Kevin Leach and I’m here once again with Dr. Tyler Evans. How are you sir? 

Dr. Tyler Evans:  I am well. Good to see you, sir. 

Dr. Leach:  Good to see you, my friend. This paper is titled “The Role of the Craniocervical Junction in Craniospinal Hydrodynamics and Neurodegenerative Conditions” by Michael F. Flanagan published in “Neurology Research International” if you’re interested in neurodegenerative conditions, if you know someone with neurodegenerative conditions, if you treat patients with these conditions, or if you or someone you know is suffering from these neurological conditions. This can be like migraines, seizures, mood disorders and a host of other health issues. This episode is definitely for you. Dr. Evans, before we get into discussion about it can you give us a 50,000 ft overview of the paper and maybe explain the titles. There’s some big words in there and just explain what their goals were. 

Dr. Evans:  Yeah. Absolutely. I think it’s important that you understand who wrote this paper. Michael Flanagan is a chiropractor that graduated from Sherman Chiropractic College in 1978. He produced a handful of papers but this was the biggest one and it came out in 2015 I believe. Yes 2015. Before that in 2010 he produced this book “The Downside of Upright Posture” if that’s visible there. You can see it on the YouTube video if you’re interested, it’s called “The Downside of Upright Posture the Anatomical Causes of Alzheimer’s, Parkinson’s and Multiple Sclerosis”. (Neurodegenerative conditions) Now this paper is a little more of an advancement of that book and it moves forward from the concepts he presented in his book. It’s an overview of the craniocervical junction which is the base of the skull, C1, and C2 and its contents and why its contents are so important in terms of the fluid flow, cranial spinal hydrodynamics. It’s a lot. There’s a lot of big words there. Okay. The cranial spinal part is the junction between the neck and the head. Great. That’s where we upper cervical chiropractors live. That’s what we do. We correct misalignments of that craniocervical junction or upper cervical spine being C1, C2, and underneath the base of the skull there. He discusses in this paper the importance of this because of the intense emphasis that’s placed on that area by the human body. When we stood upright in gravity the human body had to develop compensation mechanisms for the weight of the head, which is roughly 10 to 15 pounds based on the person, being directly over the spine. Now that wasn’t that way before in primates and so there is a new method of movement of fluid in and out of the brain. That’s part of what makes us special as humans is our big brain, our skull, and the pressure cooker of the fluid that’s got to get in and out of that skull all the time. Every minute and every second. If it doesn’t the brain doesn’t work right and the body doesn’t work right. So that’s where this hydrodynamics comes into play of the craniospinal hydrodynamics. Lastly the neurodegenerative portion so nerd of degenerative diseases are diseases like he lists in “The Downside of Upright Posture”. They are Alzheimer’s, Parkinson’s, and Multiple Sclerosis. (Neurodegenerative conditions) There are other ones like ALS. There’s another one with Lou Gehrig’s disease. It’s a breakdown on his take and a breakdown of the literature in a narrative review from a 30,000 ft view of what he accumulated in knowledge over his lifetime. Now unfortunately this paper came out in 2015 and this is his magnum opus. He passed away 2016 so we were sad to lose him in the cervical community because he really was a visionary and a shining light. He really helped guide the research for these neurodegenerative disorders so there’s a lot to unpack here. That’s kind of the 30,000 ft view. 

Dr. Leach:  Tyler, would you explain because the paper goes through malformations and misalignments in the craniocervical junction, in the ccj, right where the head meets the neck and how that can affect the hydrodynamics? Hydrodynamics is the cerebrospinal fluid flow and blood flow in and out of the skull. Can you maybe just talk about how we as upper cervical chiropractors would be helping that and why a misalignment in that area would be detrimental to the health in the short term and in the long term? 

Dr. Evans:  Sure. First thing we can do is just read the abstract at the start of the paper here. The craniocervical junction is a potential choke point for craniospinal hydrodynamics and may play a causative or contributory role in the pathogenesis, the creation of pathological problems, and progression of neurodegenerative diseases such as Alzheimer’s, Parkinson’s, migraine seizures, silent strokes, affective disorders, schizophrenia, and psychosis. (Neurodegenerative conditions) The purpose of this paper is to provide an overview of the critical role of the CCJ in craniospinal hydrodynamics and to stimulate further research that may lead to new approaches for the prevention and treatment of the above neurodegenerative neurological conditions. So why the upper neck might be a potential choke point is that it’s a small narrowing where everything must go down and get back up. We can put it very simply, it’s like a plumber. If the pipes are not lined up right the fluid doesn’t flow right and the head is an extreme case of sensitivity to pressure and the rest of the body is as well. The spinal cord, the dura, and the fluid that flows around it’s got to be just right. You see it in any time we have a dural leak in the spinal cord immediately there’s, or most of the time fairly quickly, there are some negative impacts. The fluid has to be balanced between the cerebrospinal fluid which is the clear liquid that floats around the brain and the spinal cord between the dura, the core, and the tissue to protect it to bring nutrients to it and away from it. Along with the arteries and the veins which bring oxygen to the brain, bring oxygen to the tissues, and then take away the toxic wastes as well. There’s a boundary and a barrier between them but that boundary and barrier can be altered by the changes in the cervical spine. When we see changes in where the cervical spine is rotated – if there’s misalignment in C1 or C2 we see this. You can see it in Dr. Rosa’s work and the upright MRI work pre and post CSF flow changes. It’s been documented and it’s in PubMed. These changes in how the brain works starts to break down the tissue and the malformations do it as well. There’s Basilar Invagination, Chiari, and a whole list of them. Those start to create neurological detriment to the brain because the brain can’t function well when the fluid is not flowing around it properly. Does that get us headed in a good direction there? 

Dr. Leach:  It does. I think it’s really important and it’s interesting to think about what you said. You said it’s like pressure inside the brain right? So that’s cerebral spinal fluid and if we can think about the head and the spine it’s almost like it’s in a capsule and that’s where the cerebral spinal fluid flow is. So when we think about normal blood pressure it’s not only do we need normal blood pressure in the body but the blood pressure affects inside the skull on the spine and the CSF actually that pressure. So it’s almost like it’s almost two pressures need to be regulated and inside the skull and inside the spine which blood pressure effects and cerebrospinal fluid flow effects. Which a misalignment in the upper neck, which we deal with and we correct all day every day, can actually affect these flows and it can create problems like these neurological conditions that we just mentioned. If left long term can start to develop and contribute to these Neurodegenerative disorders. I like your analogy regarding plumbing. Just for the listeners to get an idea for an analogy here – if you know how a faucet works you can imagine for there to be proper flow the faucet is all the way on. A misalignment malformation or something obstructing that flow would be if you just turn that faucet maybe half way off or a little bit off or a lot off it restricts that flow. That’s what the misalignment in the top of the neck is doing to that cerebral spinal fluid flow and potentially to that secondary venous outflow. Which can again create a host of problems. It was interesting when I was looking in here and I was trying to find it in my notes all five of the different ways that a misalignment and malformations can affect the health of the body. I always talked to my patients about a cascade effect of what happens. Patients say, “Oh well. You know, I have headaches but it happens when I’m stressed.” Then I try to say well if I got stressed and I got headaches maybe that would be the cause. If every person in the world when they got stressed they had headaches maybe that would be a cause but it’s an exacerbating factor. So we can think about it this way. We have a misalignment in our spine. It didn’t just get there because the body was bored. We most likely had some sort of injury or something that happened that tore loose the connective tissue in the upper neck and now we have a misalignment. That misalignment affects the hydrodynamics of the spine. That affecting and that disruption of the hydrodynamics causes five different things that they talked about in the paper. Number one being ischemia. Ischemia is lack of oxygen to the brain and to the spinal cord. Number two is edema. Edema is just excess fluid you can think about kind of like an inflammation effect. Number three is structural strain. This is like pressure and stretching. If you think about an increased or decreased pressure inside the brain in the spinal cord you could have a stressing, a straining, and a pulling of those tissues. That isn’t going to be good. Number four is pressure waves. Think about pressure waves like a water hammer effect. Every time we’ve got the blood flow and the heart beating and there’s these pulsating rhythms that happen with our cardiovascular system that helps the cerebral spinal fluid flow. If we have too much pressure/too little pressure and we have this water effect that just keeps pounding on those soft tissues of the brain and spinal cord that can create damage as well. The fifth one it’s sluggish CSF flow. It’s going to cause a problem. We need to understand the points of CSF before we get into it. Number one is CSF flow protects the brain and the spinal cord. It’s almost like a cushion effect for when we move and etc. but it also brings nutrients and takes toxins away from the brain and the spinal cord. If we have that sluggish CSF because of an obstruction in the craniocervical junction then that’s going to decrease the toxins being taken away which can cause inflammation and damage tissues. This will also not bring enough nutrients to the brain and spinal cord. Proper CSF flow can make the brain function properly and in the way that it was designed to. So when sluggish CSF flow happens we can get immediate effects like migraines and conditions like that and it can also long-term cause a breakdown. A simple explanation between maybe a neurological problem and a neurodegenerative problem is that neurological is going to be something that affects the nerve function. For example in misalignment or malnutrition etc. but it doesn’t affect the structure and the entity of the nerve so it doesn’t break down the nerve like a neurodegenerative disease does. So the neurodegenerative disease, degenerative meaning deterioration, is actually changing the structure of the actual nerve which can happen over time when there’s things like ischemia, lack of oxygen, and lack of nutrients etc. I wanted to go over that just as a basic overview of what that mechanism is doing. Any thoughts on that, Tyler? 

Dr. Evans:  Yeah. A couple of things. I think it’s really important to highlight how the CSF and the venous flow and the arterial flow work. If you want to talk, let’s first talk about the CSF. A lot of people may not even know what that is but there is this compartment in between the spinal cord and inside of the dura that is a space that is surrounded by this clear liquid. That clear liquid, cerebrospinal fluid, it is created deep inside of the brain in the ventricles. They’re called ventricles. These little red cells, they produce the fluid deep and literally in the center of the brain. In the center of the brain there’s empty space and people don’t realize this. They think your brain is a squiggly worm looking thing on the outside. No, deep inside the brain there’s actually compartments and there’s different parts to it. So what happens is this fluid is created deep inside the brain and it pushes against the tissue and that’s part of what gives the tissue its shape and size. Another thing is the brain is actually very fluid in nature. I know that you and I both have had neuroanatomy lab. We’ve dissected brains. We’ve done that. We’ve been in labs and those brains are hard because they have been hardened by chemicals but normally the structure is quite fluid. So this fluid coming out of it creates the structure partially. You need this very dynamic balance back and forth and so it’s creating this liquid and building pressure inside the brain and that’s what drives the fluid. The fluid drives down from the center, down through the upper neck, down through the rest of the spine, into the fecal sac at the bottom of the spine, and then back up and around and then it comes out through the vena system. Then that fluid gets kind of absorbed into the vena system and then it is circulated back out and reabsorbed and goes back through. Now why is that important? Well because if the upper neck is out of alignment it literally can cut off that fluid flow and now you’ve got a problem like Hydrocephaly. Now you’ve got a problem where fluid is literally pooling on the brain. We know there are papers, I can’t remember the exact name of it right now but I believe it’s “The Implications of Cerebral Spinal Fluid Stasis” it’s at least close to the name of the paper, but if you look this paper up it talks about the detrimental effects of having cerebrospinal fluid be static. It’s like a pond right rather than a river, you want flow but you don’t want too much flow. You don’t want too little and you don’t want it pounding like you said a water hammer into the tissue. That can be bad and so it’s really important to have this proper flow and when we do it takes away toxins from the brain. When those toxins sit there in stasis we get lesions. Multiple Sclerosis means multiple lesions of the brain and spinal cord. Right? So I see it all the time and I have neurologists that I work with and I love them for what they do. It’s really important and remember to have a functional perspective because the body lives in a functional world. We live in a functional world. So why are those lesions there? Where did they come from? What created them? How do we get rid of them? One way to work with that is to get that CSF to flow better. We’ve seen it in Dr. Rosa’s papers in PubMed where lesions decrease over time because we’re helping that fluid flow better. Go ahead Dr. Leach.

Dr. Leach:   Yeah. I was just going to ask, I think that paper is important but does he have one that shows this? 

Dr. Evans:  He has a paper and it’s in “The Craniocervical Syndrome and MRI” book. Yeah. As well as he just put one in the Interlochen… What it’s called inter… something. It’s a paper that he produced last year or two years ago. We can get that up 

Dr. Leach:  Got it but my question was what’s the thought process right now? This was several years ago. What’s the thought process on those plaques with multiple sclerosis being demyelination as opposed to maybe an inflammatory effect that comes up on MRIs?

Dr. Evans:  Yeah, it’s inflammation. I can’t be quoted on that right now because I don’t know exactly the nature of the lesion but I do know that they result from fluid sitting there. That is in that stasis paper that I was talking about. 

Dr. Leach:  We say that like “Oh yeah. It’s inflammation” but in the world they believe it’s demyelination. 

Dr. Evans:  Well yeah. It’s like demyelination is the downstream effect of those lesions. 

Dr. Leach:  Got it. So there’s an inflammatory effect first. 

Dr. Evans:  There’s an inflammatory process happening. It attacks. So the body attacks it, there’s inflammation and the body’s attacking it. Maybe it’s chicken or the egg, right?

Dr. Leach:  Okay.

Dr. Evans:  Which happens first? So that’s probably the struggle right now. What’s happening first? Most of the literature in the past was on the neurological demyelination because it’s studyable. You can study that. 

Dr. Leach:  Okay. Just to be clear, Scott Rosa, would he say that because of the stasis of the CSF the lack of flow/lack of toxins being pulled away creates an inflammatory process. That inflammatory process attacks the myelin on the nerves which then demyelinate the nerves which then causes symptoms of multiple sclerosis. Would that be it? 

Dr. Evans: Let’s not put that on Scott Rosa but I’ll take that one. 

Dr. Leach:  You will say that? 

Dr. Evans:  That’s what I’ve pieced together over the years. I’m not gonna put that on Scott Rosa. 

Dr. Leach:  Okay. Fair enough. 

Dr. Evans:  I’m not sure what he said in the past.

Dr. Leach:  Right. Let’s not talk for him.

Dr. Evans:  Exactly. I know that he has shown pre and post changes in these sclerosis lesions and symptomatic changes. 

Dr. Leach:  Well, let’s let’s review a paper on that 

Dr. Evans:  Oh yeah.

Dr. Leach:  We’ve got some imaging and it’s pre and post. Isn’t it pre and post adjustment..

Dr. Evans:  Yes.  

Dr. Leach:  ..where he sees that CSF flow decreased and then does it again. What’s the imaging? Is that a functional MRI? 

Dr. Evans:  That is an upright MRI. Those are created by Ray Damadian. I’m looking up the name of the paper right now and it is “The Possible Role of Craniocervical Trauma and Abnormal CSF Hydrodynamics in the Genesis of Multiple Sclerosis.”  There’s that big word again. So we can do that paper in the future.

Dr. Leach:  Yeah, let’s do that for sure.

Dr. Evans:  It breaks it down here but I’m not gonna get into it right now. Let’s focus on this because there’s again more layers to this. That first piece yes – CSF need to have it move right. Can’t be too slow. Can’t be too fast. It needs to be moving in the right ways and in the right places. If it’s not it starts to wear down the tissues. It’ll actually eat away bone! Not eat away but it wears it off. It’s not good to have it wearing like that. The other parts to this are the arterial and venous flow. The arterial flow we have 80% roughly goes through the carotid arteries and 20% goes up through the vertebral arteries. So we know that 20% of what feeds the brain – now which part of the brain is the important question. When we talk about the spine 20% of the arterial fluid flow to the brain goes through the spine through the vertebral arteries right through C1 and C2. Literally through them. It kind of forks around and then comes back up and goes right up through the base of the skull(foramen magnum) and when it does it comes together at the brainstem. What does the brainstem control? It has cranial nerves. It has the functions of digestion, heart rate, breathing, and immune function. You name it. All of that is controlled in that area so if we don’t have the proper fluid flow up to the brain which brings oxygen and nutrients we’re in trouble. So if C1 is rotated or C2 is rotated it’s going to affect how that fluid is flowing up into the brain. That’s documented in PubMed as well. I don’t have the names of the papers here but that is very well documented in PubMed. When we have we have twerking of the arteries around the vertebra and it slows down the fluid flow up into one side. So that’s pretty well-documented. Now, if I can just the last piece here?

Dr. Leach:  Yeah.

Dr. Evans:  The venous flow. It’s really important to understand the venous flow. The venous flow out of the brain is another magical variable piece here. If it’s not just right we get problems and it’s called cerebrospinal venous insufficiency, CCSVI. Cerebrospinal venous insufficiently. That is a whole other topic and a whole other problem but that’s part of what he’s talking about in here. He’s talking about having the fluid come out of the head, the proper venous drainage. When we talk about positioning we talk about that evolutionary adaptation to standing upright and gravity. Well, when we are in gravity the preferred way that venous blood flow leaves the skull and goes down through the neck is right through the vertebral venous plexus. That vertebral venous plexus travels right through the spine. It literally wraps and it’s like a vine that’s wrapped around the vertebral bodies. If you have misalignments in the vertebra you’re going to have trouble there. We know that. So that’s upright and gravity. When you’re laying down the preferred method of travel is through the internal jugular veins. Most people would think the larger vein would be the place normally that the blood flow goes out of. Well no. That’s not exactly true. So why does it do that? It does that because there has to be that right balance of fluid going up and you can’t just have all the fluid rushing out of the head. There has to be some pressure to keep it up there and that’s what that does. It slows it down coming down through the spine but if you have a misalignment in C1 and C2 you’re in trouble. You got a fluid flow back up into the brain. 

Dr. Leach:  One of the points that I wrote down is that we learn as chiropractors that we’re turning on that nervous system. We’re turning the power on. We’re restoring the nervous system back to its proper function. When we look at a paper like this and we look at the evidence of when we make, I just got goosebumps, that adjustment how many different things were affecting. Not just pressure on nerve, pressure off nerve, or even afferentation/ dysafferentation of the joints but how much we’re affecting with the health and the implicate that it can have on our health besides just mechanically in a biomechanical correction of the musculoskeletal system and the neuromusculoskeletal system. We think of ourselves, chiropractors, as neuromusculoskeletal doctors. We evaluate chiropractic subluxation and we correct chiropractic subluxation. What we’re affecting is just tremendous and who knows what we’ve helped. When a patient comes in with headaches, pain, they came in from a car accident, or whatever they come in for and we correct that upper cervical spine, the craniocervical junction, what else are we helping that they’re not really even feeling yet. There’s some sort of underlying process that they’re not even understanding what’s going on. When that craniocervical connection is off or obstructing it, where are those problems going to manifest in the brain for that particular person. It’s just incredible to know that the depth of what we’re doing without even knowing we’re actually doing it. 

Dr. Evans:  Oh absolutely. It’s a very good argument for preventative corrections/preventative alignment to prevent neurodegenerative disorders of the brain. The thing that drives the body from day one to the end. The thing that’s literally keeping you alive. We are helping the fluid balance so that it is getting nutrients in and out and it is properly keeping buoyancy in the brain and protecting that tissue. It’s unfathomable how many things could be connected to it. This is about brain health. What we do is about brain health. We didn’t talk about the spine. Yes, we’re adjusting this spine but this is all happening in the brain. All of this happens in the brain. It’s just really important to connect with that. There’s papers that obviously when we do adjustments it affects the neurology in the brain but the fluid flow is just as important because the nerves don’t work unless there is stimulation, oxygen and nutrients. So stimulation that’s one part of it but oxygen and nutrients coming from the fluid that’s also where we live. 

Dr. Leach:  Obviously Dr. Flanagan, in the conclusion he’ll talk about how we’d like to see more research done etc. Even though a lot of times with research it paints a pretty clear picture and we can come to our conclusions but more research obviously is better and is necessary especially for other professions to not just take our word for it but to see some evidence. Dr. Scott Rosa I’m sure is doing great research. I’m just hoping more research comes out like this that can really show what we can do to help that. Again, it’s important that our listeners and viewers understand we’re not saying come to us and we’re gonna cure your Alzheimer’s. No but the fact is that this is the way I look at it.. There’s evidence and there needs to be more research to show that and prove that evidence that we have a role to play with these conditions. Now meaning someone starts to have symptoms like Multiple Sclerosis. Maybe they don’t have plaque show up on their MRI. Maybe they’re not actually diagnosed with that. As a conservative approach and as a box on that list of “Hey, you’ve got these problems. You need to go get your neck checked out.” Maybe they need to get an MRI to make sure there’s not a tumor, a malformation, or something else serious going on. But a lot of times,I know you can relate to this, is we see patients after they’ve been to the medical doctor and after they’ve had their exams. They come into our office and they say “I’ve been everywhere. You’re either my last hope or you’re my next step.” So it’s important that we get to a point in the healthcare system where doctors/neurologists that they know that we’re on the list for getting screened for an upper cervical misalignment. A misalignment in the craniocervical junction. It’s huge. For our patients it has to be a checkmark on that list. Any other points, takeaways or last discussion points here? 

Dr. Evans:  I think we covered it pretty well. It’s a huge paper. It has I think 257 references. This is a beautiful paper. Like I said it was his magnum opus. Unfortunately, he passed away a few years ago but this guy really laid it out. Also check out his book “The Downside of Upright Posture.” It really goes into the nooks and crannies of everything that he could find on fluid flow in the brain. It’s just important to have that neck checked for prevention and for just overall healthcare. Helping the body work better. 

Dr. Leach: Got it. 

Dr. Evans:  That’s what I got. 

Dr. Leach:  Awesome but as usual our listeners and viewers give us feedback. Like, subscribe, and all that stuff with social media. Wherever you see this video or if you’re listening on the podcast, any sort of feedback in support is appreciated. We’re trying to help people. We’re trying to bring value and that’s about it. Anything else, Tyler? 

Dr. Evans:  Thanks again, Dr. Leach. 

Dr. Leach:  Awesome. Thank you for reading/watching/listening. Take care!

Dr. Kevin Leach:  11 migraine patients diagnosed by their medical neurologist received NUCCA Chiropractic Care and while secondary outcomes like less pain and a decrease in headache days was observed, there were mixed results with the primary outcome measure. Dr. Evans and I discuss the research and more on this episode of the Upper Cervical Chiropractic research show. Hi there, I’m Dr Kevin Leach here with the Chiropractic Deep Dive Podcast bringing you the most important research and information on conservative primary spine care, upper cervical chiropractic care, and traditional chiropractic care. These research reviews interviews and episodes are made for you whether you’re a medical doctor, patient, or concerned family member or friend. The goal of these shows is to bring awareness of the importance of taking care of our spine and the impact it has on our health and the hundreds of different health conditions it could cause without us realizing it. I’m really trying to bring value with these so I’d appreciate commenting on the videos, hitting the like button, and sharing them with as many people as you can. You never know who might need to see it. And consider subscribing to the channel so you can see all the other episodes and videos coming out. Thank you so so much, I truly appreciate your support. Now onto the show. Okay, Welcome back everyone to the Upper Cervical Chiropractic Research Show this is Episode 14. I’m Dr. Kevin Leach and I’m here once again with my good friend and colleague Dr Tyler Evans, how are you sir? 

Dr. Tyler Evans:  Good to see you. 

Dr. Leach:  Good to see you my friend. All right so this episode’s research review is titled “Effects of Atlas Vertebra Realignment in Subjects with Migraine: An Observational Pilot Study” by H. Charles Woodfield III, D. Gordon Hasick, Werner J. Becker, Marianne S. Rose & James. N. Scott published in Biomed Research International. This is open source so anybody can find it and anybody can read it. Before we go deep into it let me just give the 50,000 ft review of the paper just to kind of give a little overview and then we’ll get into it a little bit more. This study followed 11 patients diagnosed with migraine by their medical neurologist. The patients underwent NUCCA specific upper cervical chiropractic care with follow-up at four and eight weeks. The study was designed after findings from a case study showed decrease in headache symptoms and improvement in ICCI, which is intracranial compliance index, to see if the case study would be repeatable. Migraine specific outcome measures were used to measure patients improvement and the study showed and the study found statistical improvement, statistically significant improvement, with secondary outcome measures which were the symptoms of the migraine and market improvement in quality of life due to decrease in headache days. They did not however find a statistically significant improvement in overall primary outcome measurement of ICCI and that will be most of the discussion that we do probably today. So let’s start with the positive of the paper and talk briefly about the improvement of the secondary measurements which was improvements in the migraine symptoms. This is not new to me or to you Dr. Evans. In upper cervical offices we see a lot of headaches and a lot of migraine stuff improve but it is good to see that we have some research just showing that there’s good secondary outcome measures with these. Which again, we’ll get the word out more so we can help more people. Any thoughts on that Dr. Evans as far as in your practice, headaches/migraine, or other research? 

Dr. Evans:  Yeah. Generally when I’m in my networking circles I always try to stick to one thing that I talk about and as a chiropractor people think chiropractor – low back or neck pain. But in the upper cervical world I think that the upper cervical profession is – if we’re going to pick something that we can work on and do it well I believe that migraine headaches and headaches are a niche in the upper cervical world that a lot of people can get a lot of benefit from. So that’s something I talk about a lot and work on with a lot of different people from just little headaches to migraine headaches that have happened from a child at 4 all the way up to 60, 70, or 80 years old. It’s definitely a big part of our practice and we see a lot of great results with that and I know you do too. 

Dr. Leach:  Absolutely. Cool. All right, let’s go on to the more interesting finding. I imagine they did this obviously because they saw the case study improved with the ICCI the intracranial compliance but they found that there wasn’t a statistical improvement with that. They saw some improved, some got slightly worse, and some didn’t change at all. Before we go into this let’s talk a little bit, if you would, briefly on what is intracranial compliance. What does that mean and also why a misalignment in the upper neck would affect this and obviously why wouldn’t it be good to have a decreased intracranial compliance. 

Dr. Evans: Yeah. What I’ll just kind of preface with is in the paper in the third paragraph it says intracranial compliance, ICCI, appears to be a more sensitive assessment of changes made in craniospinal biomechanical properties in symptomatic patients than the local hydrodynamic parameters of CSF flow velocities and core displacement measurements. What that means is that in the past and we’ve actually done I think most of the studies by the upright MRI groups, Dr. Scott Rosa and Dr. Ray Damadian, because that’s amazing stuff and that all came out kind of at the turn of the millennium 2000 and on to about 2010. I know we’ve reviewed most of those papers so you guys can go back and look at those if you like them or if you’d like to. The reason we did that is because those were ground-breaking studies in this new world of fluid flow in and out of the brain. If we are talking about chiropractic historically we talked about nervous system, nervous system, nervous system, nervous system, bone pushing on nerve – cutting off nerve flow – causes problems because the brain can’t communicate the messages from the body from the brain to the body and then body back to the brain. What this new direction has kind of enlightened upon is that we’re not just talking about bone on nerve. We’re talking about literal cutting off or slowly cutting down or you sometimes literally choking off some of the fluid flow in and out of the brain, which is brain health. So when I get up every morning when I go to work every day, I’m sure this is the same with you, but I’m very passionate about what I do because I know that it changes the entire body’s function and physiology via brain health. So this is just another way that they’re trying to get to the bottom of what we’re doing in chiropractic. Dr. Rosa and Dr. Damadian they were talking about CSF flow and then they started to get into blood flow in and out of the skull. But this is talking about a little different take on that where we’re just not measuring CSF or blood flow we’re actually measuring compliance. Which is the ability of the tissue to absorb those changes in fluid flow in and out of the brain and the skull is a pressure cooker. It really is and these are things that I’ve taken from Dr. Rosa’s work and Dr. Damadian’s work is that it’s timed and pressurized perfectly to the blood coming in the cerebrospinal fluid coming in and then that cerebrospinal fluid getting pushed out and going down into the spinal cord and then back up through the venous system. The same thing with the blood and this balance, this ballet, is going on all the time which keeps us upright, breathing, digesting and functioning all day long but we never think about it. So it’s just a beautiful system, this is a little more nuanced way of measuring brain changes with compliance rather than just cerebrospinal fluid flow in and out of the brain or arterial blood flow in and out of the brain. So anyway, long story short, intracranial compliance represents the change in volume per unit change in pressure and is exactly the inverse of elastance – in other words ICCI determines the ability of the intracranial compartment to accommodate an increase in volume without a large increase in intracranial pressure. So meaning the fluid can come in and it doesn’t change the shape/form or it doesn’t change the function of the tissue in the skull. We might have a rush of blood because we either see a tiger chasing us from behind and we have sympathetic burst or what have you but your body’s more able to adapt and that’s what chiropractic does. That’s what we’re doing in chiropractic is we’re trying to help the body adapt better. So anyway, long story short, that’s where we’re going with this. We want to see intracranial compliance increase and clearly we didn’t get exactly what we were looking for in this paper but we’re going to discuss that a little bit more. 

Dr. Leach:  Well exactly. What are your thoughts? Some improved. Some didn’t. The case study did. Some didn’t change. I have my thoughts on why, we can see kind of through the spectrum here but what are your thoughts on just what happened and why they got these results? 

Dr. Evans:  Yeah. Clearly if there’s a misalignment at C1/C2 underneath the skull it’s going to change that fluid flow in and out of the skull. It’s going to change that ability of the skull to be able to adapt and if there’s a misalignment and we correct it we’re going to see a good change. If there’s not a misalign or if there were misalignments but if the misalignment wasn’t affecting the compliance initially then you’re not going to see a change in compliance. Maybe in some cases too, most of these people if they have migraine headaches – I can tell you if I took 5 of my migraine patients when they first came in they were probably on blood pressure medication and abortive medication for their migraine. Meaning I think it’s either topamax or imitrex, a preventative which is topamax or imitrex, or one of the type gabapentin, all the amitriptyline, and all these other medications that change brain physiology. Right? So we’re talking about a lot of variables here especially if somebody’s putting chemicals in their body that it changes brain function. So that would be my take on it. If things change in the neck and you’ve got more fluid coming up and then the brain tissue isn’t elastic enough to absorb that change. That may be either a problem that already existed or something that’s being exacerbated by medication that now we’ve changed one of the root causes and you’re still on that medication. Right? So anyway. Those are my thoughts. What do you think?

Dr. Leach:  Yeah. I think that’s a really important point to just emphasize that the upper cervical treatment, the upper cervical correction, to restore biomechanical function, CSF blood flow, etc. It’s not a treatment to increase ICCI. Right? That’s not the end goal. Just because we didn’t see that happen it doesn’t mean “Oh it didn’t work,” because I don’t think that that’s what their goal was but they just made the assumption that higher ICCI, higher compliance, is healthier so they were thinking if they had these misalignments then maybe it was affecting the ICCI and thus improving the biomechanical alignment function that those would improve. However, again if that misalignment only had a neurological effect and that’s why it helped with symptoms of the migraine but it didn’t increase intracranial compliance, like you just said, it probably wasn’t affecting the intracranial compliance. The intracranial compliance could have been low due to some other factor. Maybe the tissues weren’t as elastic, like you said, they weren’t as elastic as they should have been or other medications that could have been affecting that. I think it’s important to understand and this is why we do research. We do research not to just prove “Oh. Hey, this is it,” but it’s to answer questions and to ask questions and to do further research in the future. I wouldn’t see this as a failure whatsoever. I see this as an eye opening, “Hey. Okay, this is information. What can we do now?” I know they said also that just with the MRI acquisition and again even with medications there’s a lot of variables involved in this. They didn’t do a controlled study just because of the financial stuff or whatever because these were not the NIH with multi-million dollars to just kind of do research on. Anything else in regards to just those findings for the ICCI? Any other touch points as far as the research here? 

Dr. Evans:  I think that’s, without going crazy on it, I think that’s probably the high points.

Dr. Leach:  Pretty good high points. Cool. All right. Well there’s a ton more information and they did an amazing job on this paper. It’ll be interesting to see once we put this on maybe the NUCCA facebook page to see what kind of feedback we get as far as, “Hey, you should have said this.” or “Hey that’s not true.” 

Dr. Evans:  This is a high level study right. So something we didn’t say is Chuck Woodfield is the first name on the paper. So usually the first name on the paper is the heaviest researcher and then Gordon Hasick. I don’t know how long he’s been in practice but I know he’s done a ton of research and he’s been in practice for a while. I don’t know the other three docs on there but I can vouch Chuck Woodfield’s probably the greatest researcher that we’ve had for a long time in the upper cervical community. Gordon Hasick is probably one of the better docs too and this goes in a lineage of papers that the NUCCA organization has produced with Dr. Dickholtz. So this was done in 2015. This was released in 2015 I believe and Dickholtz’s backers study came out in 2007 or 2008 and this is just a jump off from… What’s that? 

Dr. Leach:  The blood pressure study. 

Dr. Evans:  Yeah, the blood pressure study. Sorry. The Dr. Dickholtz’s blood pressure study. This is trying to take that to another level and the statistical analysis in this paper is fantastic. You know when you shine a light or you look at a puddle of water with a microscope you see things that you may have never thought you would see and so this is a great paper. It just goes to show that yes, migraine headaches do respond to upper cervical chiropractic care. Intracranial compliance did increase in some people, some people it didn’t change, and some people it went down but that’s a who knows why. 

Dr. Leach:  Right. But that’s a good question of “Why?.” It’s a really good question because the takeaway for me is that it affected it and it could potentially affect it. 

Dr. Evans:  Right.

Dr. Leach:  Which is huge. Right it’s absolutely huge being a factor in something that can affect it. The idea is if it can affect it how can we best utilize upper cervical care as it means to optimize ICCI while potentially looking at other factors that could be affecting ICCI in any given patient. 

Dr. Evans:  Right. We’re talking about brain function. This is big stuff. So again this is another study that puts chiropractic on the map for things other than neck pain and back pain. That’s a good thing. 

Dr. Leach:  Absolutely. I might try to reach out to Woodfield to see if he’ll do a podcast and just give us the background or give us some other information on the study and his thoughts and whatnot on the study. I think that would be cool to get him on here. 

Dr. Evans:  Oh yeah. 

Dr. Leach:  Interesting guy. 

Dr. Evans:  That’d be cool learned a lot from that gentleman over the years he’s a wealth of knowledge.

Dr. Leach:  Yes. Cool. All right. Anything else before we end? 

Dr. Evans:  No, I think that’s it man.

Dr. Leach:  Awesome all right well good to see you again and we’ll see you on the next one

Dr. Evans:  Okay, take care. 

Dr. Leach:  Yep. Thanks. Okay, that’s it for this episode. So what did you learn that fascinated you or surprised you about the research today? Join or start the conversation in the comments below. Hey, thanks so much for watching. To watch more of our research shows click or tap the screen right there(on the video) to subscribe to the channel click or tap the screen right there(on the video). Until next time, I’m Dr. Kevin Leach with The Upper Cervical Chiropractic Research Show bringing awareness to conservative primary spine care, upper cervical chiropractic care, and traditional chiropractic. Until next time, take care and take care of your spine. It’s the only one you’ll ever have.

We hope you enjoyed this blog from our research podcast about Migraine headaches. Leave any comments or questions for the doctors below. Take care!

Dr. Kevin Leach:  There’s a big stigma that chiropractors cause stroke and that it might even be a common thing but this research review says it’s actually extremely rare if it actually happens. Hi there, I’m Dr. Kevin Leach here with The Chiropractic Deep Dive Podcast bringing you the most important research and information on conservative primary spine care upper cervical chiropractic care and traditional chiropractic care. These research reviews, interviews, and episodes are made for you whether you’re a medical doctor, patient or concerned family member or friend. The goal of these shows is to bring awareness of the importance of taking care of our spine and the impact it has on our health and the hundreds of different health conditions it could cause without us realizing it. I’m really trying to bring value with these so I’d appreciate commenting on the videos, hitting the like button and sharing them with as many people as you can. You never know who might need to see it and consider subscribing to the channel so you can see all the other episodes and videos coming out. Thank you so so much, I truly appreciate your support. Now onto the show. Welcome everyone to The Chiropractic Deep Dive Podcast and The Chiropractic Research Show. This is episode Number One and the first show of the series to start off the show on chiropractic and stroke. Again, I’m Dr. Kevin Leach. I’m here once again with my good friend and colleague Dr. Tyler Evans. How are you sir? 

Dr. Tyler Evens:  Good to see you. 

Dr. Leach:  Awesome, this is going to be a good and important podcast. So we have in our profession Dr. Gerry Clum is a very well respected chiropractor in our profession. He’s done a tremendous amount for our profession. He’s done several presentations on chiropractic and stroke and so what I did was I grabbed one of these presentations that he did and he mentions ten different research papers in there to support you know, evidence against chiropractors causing stroke. And again we’re not saying that it’s never happened but we do realize because we hear it from patients we hear it from colleagues that there’s a stigma that it’s a lot more common than it most likely is in and in real, not in fact, but in most likely it’s much more rare than public knowledge kind of thinks or public perception seems to think. Yeah. So we reviewed all these studies so Dr. Tyler and I have these studies. I’m going to go through each one just to kind of pin just a real quick paragraph highlight of each one and we’ll do a discussion for each. For just all of them but then we’re going to actually do each paper as well individually and break it down even more. And possibly even in the future do more studies that support what we’re talking about here. But we have a lot of the main papers and again thanks to Dr. Clum because he kind of compiled all this. He put him in chronological order. He related them and how why one study came out and so I’m just going to do a quick review about that and then we’re gonna do a little discussion at the end.

Dr. Evens:   Dr. Leach, real briefly would you just, I mean I can do it or you can do it, but give a quick background on stroke in relation to the United States? Like how many strokes are there a year, how many cause death and then how many are what we’re talking about. You want to go ahead and do that? 

Dr. Leach:  Yeah. I’ve got some of the statistics here but If you’ve got a good grasp on it.

Dr. Evans:  I mean, I think if I remember it’s roughly 790,000 – 800,000 strokes a year. That includes carotid which is the large pipe up into the brain and then the vertebral artery which is a smaller pipe that goes actually through your cervical spine up and feeds the brain stem, the back of the brain. The carotid actually feeds the larger part of the brain and when there’s a carotid artery stroke usually there’s something to do with language. And then when there’s a vertebral artery basilar stroke those arteries actually go up through the upper cervical spine up into the foramen magnum, the big hole in the base of the skull and actually feed the base of the brain. And then the cranial nerves which then you’ll see problems with eye, nystagmus, and problems with vision balance things like that. So those are things that we’re looking for in our practices on a regular basis to really try to weed out – is this something that might be occurring. But it’s a very very small amount so when you talk about the vertebral artery strokes versus the carotid artery strokes what is it like, it’s like 5% of the total are vertebral artery strokes? 

Dr. Leach:  So 1 in 230 strokes. 1 in 230. So less than 99% of strokes are the vertebral..

Dr. Evans:  Oh wow. 

Dr. Leach:  ..basilar artery stroke that we’re referring to here. And I’m actually glad you brought that up because just to clarify the claim of chiropractors causing stroke is because it is a force issue. And so obviously when the vertebral artery is up here and the chiropractor even another physical therapist or osteopathic doctor doing a cervical manipulation or a chiropractic adjustment they think that the force is causing the stroke. And so a lot of this research, some of it is epidemiological, some of it is looking at actual force and geometry and blood flow in different things. And so the claim is is that the force that’s being put into the neck is causing the stroke and this is the research is seeing okay is that true is that possible is that what’s happening or is it like you said these patients are coming into the office they’re already having a cervical dissection which leads to a stroke and obviously an adjustment is not going to stop that. And so what this research looks at is, is there a causative relationship or is there an associative relationship. So is it association or causation and so that’s what Dr. Clum did. He broke all these studies down to really see what the evidence was showing and the evidence supports very strongly that if it does happen it’s extremely extremely rare and as we go through the papers here you’ll start to understand why.  

Dr. Evans:  Yeah. And it’s a thing where like I have patients that are nurses that you know they came in and they were suffering from post-concussion syndrome and other migraine issues all kinds of problems right. They get well under care but initially they’re very afraid because you know they work in a place where there’s a lot of already we call it “already always listening” there’s this already in the air kind of talk about how if someone had a stroke better ask them did they see a chiropractor right before they came in because that’s probably what caused it. And that’s real and so you know there’s a pervasive story about this and it’s been going on since I think Dr. Clum said in the video like the 70’s or 80’s that’s when that started. And back then we didn’t have the literature to refute it and now we do a lot of these papers are from 2000 and on. And so Dr. Clum does a great job and let’s get to it. 

Dr. Leach:  Awesome. So let’s just get right into it. The first paper is called “Chiropractic Manipulation and Stroke” by Rothwell et al. Published in the medical journal “The American Heart Association” and this was in 2001. And this paper was the research that led to the landmark Cassidy study in 2008 that we’re going to talk about in a moment here. So what the Rothwell study showed was that for patients under 45, patients were five times more likely to have a stroke if they visited a chiropractor prior to their stroke. Now this obviously raised a lot of ears and eyebrows saying, “Wow, like  chiropractors are causing stroke.” Now the problem with this paper is that Rothwell didn’t ask what else that patient did prior to the stroke. So what the paper showed was an association not a causation. So what they found was evidence that yes, patients were five times more likely to have a stroke if they saw a chiropractor but that just says there’s an association it doesn’t say causation. So the big question that the future research needed to attempt to answer was, “Is there evidence that chiropractors are causing stroke or is it just an association?” 

Dr. Evans:  And that leads to the Cassidy study Dr. Leach while you’re pulling that up… 

Dr. Leach:  Yeah   

Dr. Evans:  A couple of things about that Rothwell study and what they didn’t study that’s the real takeaway from that paper is okay we found this data. But they go and point directly at chiropractors and just go and make this claim that oh well chiropractors must cause stroke. When in reality they didn’t study things like were these patients smoking, were they on birth control, how many times had they been to a medical doctor. A lot of other statistics that may have affected what was actually happening right. And so it’s a story of missed data right and so it was unfortunate but then it led to all this work that these other Canadian researchers did that Cassidy et al. They really did some great work and have them to thank for that so. 

Dr. Leach:  Absolutely. Yeah absolutely.  So this paper by Cassidy “Risk of Vertebral Basilar Stroke and Chiropractic Care” This was in “The Journal Spine” again by Cassidy. Now what Cassidy did, which is why we can thank Rothwell, Cassidy grabbed Rothwell, the researchers, the medical doctors from that study.. 

Dr. Evens:  Dr. Sundi 

Dr. Leach  ..they took the data, they took the time, they took everything from that study and asked the question also what was the likelihood of those patients to see a medical doctor. Now what they found was the same risk factor meaning they were five times as likely I think actually in this one they found three times as likely for both. So I need to dig a little bit deeper in there why it went down to three compared to the five. But either way they found it was the same. Meaning patients were more likely to have a stroke if they visited a chiropractor or a medical doctor. And we know medical doctors like 99.9999% of them don’t do cervical manipulations. 

Dr. Evans:  Right

Dr. Leach:  So now we have an association, this is the big findings of the Cassidy study, we have this association of – okay these patients that are leaving are having a stroke eventually whether they see a chiropractor or whether they see a medical doctor. Now it would lead to suggest that if chiropractors were causing strokes then there would be a higher incidence of strokes from the chiropractor than the medical doctor but that’s not what they found. And this was a massive study. This was 110,000,000 patient person years.. 

Dr. Evans:  Right 

Dr. Leach:  ..under over like 10 years like it was a massive pool of epidemiological study looking at that. And so that was a huge – that was a huge finding with that cast the first Cassidy study in 2008. Any comments on that one? 

Dr. Evans:  Yeah. Just that that was on the vertebral artery. Exactly. Exactly. Because the one in the future I’ll mention in a second here was for vertebral and carotid. And so just to kind of review again we talk about cervical arteries. There’s cervical arteries and then there’s the carotid and the vertebral. And like Dr. Evans said before carotid’s in the front is 80% of the blood flow and then the vertebral is 20% in the back. And again the chiropractors are accused of causing the vertebral artery one because it’s close to the atlas bone and it can be stretched and a lot of force on there so that’s what the claim is again. All right so next study is “Chiropractic Care and the Risk of Vertebral Stroke” by Koslov, et al published in “The Chiropractic and Manual Therapies Journal.” The purpose was to repeat the Cassidy study that was done in Canada in America to see what the claim was. And what they found was even better than the Cassidy study. That not only – so just to review just to repeat one more time here, the Cassidy study showed no increased risk of stroke by seeing a chiropractor or medical doctor. There was an increased risk by seeing either one of them but no increased by the chiropractor. What the Koslov study is showing is that there was no association between vertebral basilar stroke and chiropractic care regardless of the age group. And because actually the Canadian study was below 45 and there was no excess risk above the age of 45 and I know you’ve got some thoughts on that as far as why – you know why that could be as far as under the age of 45. But maybe we’ll get into that in a little bit here. Next study is “Systemic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation.” That’s in the title that’s a huge – typically findings aren’t put in the title you know this one was put in the title. 

Dr. Evans:  And just defining causation and correlation you know causation is one plus one equals two. 

Dr. Leach:  Right. 

Dr. Evans:  Correlation is one and then one over here and there might be a two somewhere in around but it’s not an algebraic equation. 

Dr. Leach:  Right. Right. And so this one was by Church, et al published in “The Journal Cureus” and the importance of this study was this was done by neurosurgeons. So this wasn’t even done by chiropractors. This was done by neurosurgeons and they found again no evidence for causation. The next study was again done by Cassidy and I think this one was done in like 2016 or something and this is “Risk of Carotid Stroke After Chiropractic Care: A Population-Based Case Crossover” study published in “The Medical Journal Stroke.” So I don’t think the other one was published in a medical journal this one was published in a medical journal and they did vertebral and carotid. And they found the exact same thing with the vertebral – with the carotids as they found with the vertebral. And I think it’s really important to again emphasize it’s always been the claim that chiropractors are causing the stroke because of the pressure put on the vertebral artery or vertebrobasilar artery not the carotids. Is that correct? 

Dr. Evans:  I would say that anyone that knows the literature and understands anatomy and physiology would not put blame on chiropractors for the carotid 

Dr. Leach:  the carotid 

Dr. Evans:  being so far away. However, I’m sure over time that that has happened it has come up. 

Dr. Leach:  Yeah. Well and the point that I was trying to say is that if they found the exact same thing with the carotids. So again just like the association of chiropractors and medical doctors if we have the same thing from the vertebrals and carotids then it’s like well there doesn’t seem to be a causative factor or evidence for a causative factor to be claimed there. 

Dr. Evans:  Right 

Dr. Leach:  Okay the sixth paper reason Dr. Clum obviously talks about all this. He talks about a paper that Koslov referenced in his paper “Cervical Arterial Dissection and Association with Cervical Manipulative Therapy.” This was by Biller published in “The American Heart Association.” Now the big finding here was that again the medical journal medical association concluding that there is no causal relationship. So again the medical profession – the medical profession is saying that there’s no causal relationship here. So. But they would still recommend an informed consent because they say that there’s no causal relationship but they’re saying they’re still open to the potential that it may have and it could be very rare. And again it could happen and we haven’t even touched on this with an unhealthy artery, something with the dysplasia, the marfan syndrome, or some sort of connective tissue type disorder. 

Dr. Evans:  Yeah

Dr. Leach:   In that case a chiropractic adjustment could actually potentially cause something like that but there’s no evidence that’s been found in a healthy individual that would cause this. 

Dr. Evans:  When it comes down to it when you look at chiropractic malpractice insurance versus medical malpractice insurance, the insurance companies know who has more lawsuits filed against them, big ones. So again being generous and being kind I think it’s important to just put it in perspective right and that the risk and the informed consent paperwork the risk that you’re taking on and signing that informed consent paperwork or as a chiropractor having that informed consent paperwork it is not a plea of guilty. 

Dr. Leach: It’s exactly what informed consent is. It is that this has been claimed. There’s an association there. It’s a possibility even though it’s extremely rare. That’s what informed consent is. 

Dr. Evans:  Yeah. Malpractice insurance for the medical field is ten times higher than what it is for a chiropractor and absolutely that’s clear in the data. So if there really were a huge problem here the malpractice would reflect that. 

Dr. Leach:  Absolutely. Absolutely. Cool. So we’re getting into those papers now that focus more on the mechanisms of injury. So the ones that we just did were more epidemiological meaning they’re looking at populations and they’re saying what’s the incidence of these things happening association, correlation, causation things. These next papers look at oh they actually studied and looked at the mechanism that’s been claimed for the manipulation to cause stroke. So this paper here is “Internal Forces Sustained by the Vertebral Artery During Spinal Manipulative Therapy” and this is by Herzog, et al published in “The Journal of Manipulative and Physiological Therapeutics.” The study was done on cadavers to test the mechanism believed to cause strokes during manipulation. Which would be the stretch force to the vertebral artery or vertebrobasilar artery during the manipulation. Now what they found was that the artery could be stretched 139% at minimum before any damage was done to it. 139% damage. They also measured how much manipulation stretched the artery. And so it was 7.5% of its length was the maximum stretch that a manipulation would cause to an artery. 7.5% for manipulation. 139% before damage was done. So the manipulation only caused 6% of the stretching that the artery could withstand before a failure. So this is a huge study and granted it was on a cadaver which isn’t a live human being but that’s what most soft tissue studies are done for so that’s kind of – I don’t know if it’s the gold standard but it’s very common. So that’s a huge study right there. 

Dr. Evans:  Definitely. Good data. Very good data. 

Now, the next one here is “Biomechanics of Vertebral Artery Segments C1 Through C6(so those are the neck bones) During Cervical Spinal Manipulation(neck manipulation)” by Herzog and Wuest.. I think that is how the name is pronounced, excuse me if I mispronounce that. This was published in “The Journal of Manipulative and Physiological Therapeutics” as well. This was done in response to critiques of the Herzog study to measure the forces at the attachment points of the arteries meaning where they were anchored. So they were saying, “Oh you’re just measuring where -not where it’s going through the transverse process, not where it’s connected to the bones.” And so they did that and not only did they find that it didn’t matter but they actually found in that study that during cervical rotation, just cervical rotation, puts more strain on the artery than the manipulation does. 

Dr. Evans:  Yep. So in an exam. 

Dr. Leach:  Well so and that’s the next study here. So this one showed that it was just cervical range.. 

Dr. Evans:  Yeah. 

Dr. Leach:  ..and I had to kind of hone in and kind of figure out what the differences were on these two studies there. But I think it’s – yeah so the next study looked at – they went into a range of motion exams. Right. So I think the first one was just rotation. They just did rotation and a manipulation. They found that the manipulation wasn’t as powerful, or strong, or as forceful. And then the next study here so “The Vertebral Artery Strains During High Speed Low Amplitude Cervical Manipulation” by Herzog in “The Journal of Electromyography and Kinesiology” the conclusion is similar to the Wuest study, “Range of motion testing forces exceeded the amount of force that during spinal manipulation.” So again the stretching forces what they’re seeing is that the manipulation is lower than just a person moving through their range of motion with their neck. So another huge finding to imply it’s not the forces aren’t enough to to really cause this damage here. 

Dr. Evans:  Yep. 

Dr. Leach:  And the last one here is an interesting one and I’d never heard of this until Dr. Clum talked about it. So there’s something called “Bernoulli’s Principle.” 

Dr. Evans:  Yep. 

Dr. Leach:  And so it’s like when you kink a hose, the pressure builds up, and then you let it go and there’s a forceful shooting out. A mechanism of causal of stroke has been said that it’s the blood shooting through and damaging the inside of the arteries. And what they did was they measured this. They measured during different positions, they measured during the adjustment, and after the adjustment. They found that there was no significant change in that velocity – of that. To again indicate there’s no change during the adjustment so that mechanism doesn’t really make sense either. And that’s it for the review here. We will have all these in the description below for links that you can go and you can get these as well. But Dr. Evans, what do you have as far as maybe discussion on any of this? 

Dr. Evans:  Yeah. I think, great job you really went through all those papers well those are the highlights. You nailed it. One of the things that Dr. Clum pointed out was just the amount of time that a correction might be or an adjustment might be. It’s about six milliseconds or something like that versus the amount of time it would be for a patient to turn their head in range of motion. It might actually be about six whole seconds. So if you talk about the differences in pressure in Bernoulli’s and in just in millimeters of mercury, or however they measure the tension, that it would be tremendously higher just in range of motion testing than it would be in a manipulation. And so that’s another point, I can’t remember which paper that was in, but I remember him talking about it. 

Dr. Leach:  Yeah I think it was the one where they did, it was the second to last one here. 

Dr. Evans:  The exam.

Dr. Leach:  Where they did the, yeah, range of motion testing forces exceed the amount of force of the artery during spinal manipulation. And again we mentioned it just in passing before but it’s important to understand that these healthy individuals. So what they found is, and I think Dr. Clum mentioned it in his presentation, I think 80% of strokes have some sort of connective tissue.. 

Dr. Evans:  Disorder. Yeah. 

Dr. Leach:  …disorder of some kind. He mentioned EDS type 6, marfan’s, fibromuscular dysplasia. I think that’s the one he said there was 80% have some sort of fibromuscular dysplasia that have stroke. So I think the main takeaway, and you said it in the very beginning, is these patients that are having a dissection, they seek medical care, whether it’s from a chiropractor from a medical doctor, and they go on a stroke. And again it’s not what the chiropractors are doing but it’s what’s walking through the door. 

Dr. Evans: What’s walking through the door. Yeah. 

Dr. Leach:  And again you can’t prove a negative by saying it’s a manipulation from a chiropractor, from osteopath, from anybody has never caused a stroke. But what the evidence is showing is that if it happens it’s extremely rare and it’s for somebody who doesn’t have healthy connective tissue and maybe has a connective tissue disorder, which actually many people don’t even know that they have. Right. 

Dr. Evans:  Right. And I believe it was that many people have strokes all the time and they aren’t diagnosed. I don’t remember the statistics on how many. Do you remember him saying that? 

Dr. Leach:  I don’t remember but yeah that’s what he was saying is that a lot of people have these dissections and they don’t even turn into a stroke they just they heal naturally. 

Dr. Evans:  Yep. Like it happens frequently and  most of the time they’re not diagnosed and they’re not recognized. And so these things are happening in nature. They’re happening in life and then to go and pin it on someone. Yeah, of course we all want to have a reason and objectively identify what caused things to happen when they go wrong. But pinning it on a treatment that is so low in… 

Dr. Leach:  Risk. 

Dr. Evans:  ..risk versus another treatment that the risk is so much higher of other problems that might incur something like cervical surgery of the spine, or lumbar surgery of the spine, or even just taking daily NSAIDs or Ibuprofen. The side effects of these medications and then you get into the side effects of other medications. The risk just mounts right and some simple things like smoking and birth control, those two things together. Those really create a big problem for those under 45. Dr. Clum talked about how as we age we actually build a protective factor into our bodies as things start to stiffen up and become harder. That could be a reason why, under 45, these people are usually on birth control and more often people under 45 would be smoking. That’s where that breaking point comes from. 

Dr. Leach:  So yeah. And again for anybody watching this, this information is really not that readily available and that’s one of the reasons why I wanted to do this and why we’re doing this. We’re trying to disseminate this information to people because chiropractic can truly help thousands and thousands. I mean it’s an incredible profession it can help people but if people have the stigma of this worry of an extremely rare event that could potentially happen to them and not get the help that they need. I mean that’s a problem. That’s a huge problem. So just awareness and some in-depth knowledge really about the risk here is super important for everybody. Just getting rid of some of the stigmas that are involved with the profession here. 

Dr. Evans:  Absolutely. Yeah. 

Dr. Leach:  Yeah. Cool. 

Dr. Evans:  Great job. 

Dr. Leach:  I’ll just link each of the studies and they’re going to go to different places. A lot of them are open access so they’re going to be free. I think some of them you have to pay for. 

Dr. Evans:  Yeah. But you can see the abstracts. 

Dr. Leach:  And you can see the abstract. Yeah. For sure. 

Dr. Evans:  And if you would, link Dr. Clum’s video in there too if you can.

Dr. Leach:  For sure. And for those listening, Dr. Clum is speaking to chiropractic students during this presentation so it’s not necessarily to the public. So just kind of keep that in mind.

Dr. Evans:  Yeah. 

Dr. Leach:  Yeah. Yeah. There might be some terminology and some things in there or some boring things that people don’t want to know. 

Dr. Evans:  Yeah. 

Dr. Leach:  But yeah. It’s absolutely an incredible presentation and he’s done a lot for the profession. We thank him very much. 

Dr. Evans:  Yeah. 

Dr Leach: Cool. All right. Anything else doc? 

Dr. Evans:  Nope. Great job. 

Dr. Leach:  Good stuff and we’ll talk to you soon. Thank you. Okay so that’s it for this episode. So what did you learn that fascinated you or surprised you about the research today? Join or start the conversation in the comments below.  Hey. Thanks so much for watching. To watch more of our research shows click or tap the screen right there to subscribe to the channel. Click or tap the screen right there. Until next time, I’m Dr. Kevin Leach with the upper cervical chiropractic research show. Bringing awareness to conservative primary spine care, upper cervical chiropractic care, and traditional chiropractic. Until next time, take care and take care of your spine. It’s the only one you’ll ever have.

Dr. Leach:  So again this episode is kind of in conjunction with 17 where we already talk about the role of the cervical spine in post-concussion syndrome but I wanted to do this with Dr. Chapek because we worked together with different patients and he works on the brain component obviously with the concussion rescue and working with the brain healing so I wanted to get his take on this. Hi there. I’m Dr. Kevin Leach here with The Chiropractic Deep Dive Podcast bringing you the most important research and information on conservative primary spine care, upper cervical chiropractic care, and traditional chiropractic care. These research reviews, interviews and episodes are made for you whether you’re a medical doctor patient or concerned family member or friend. The goal of these shows is to bring awareness of the importance of taking care of our spine and the impact it has on our health and the hundreds of different health conditions it could cause without us realizing it. I’m really trying to bring value with these so I’d appreciate commenting on the videos, hitting the like button, and sharing them with as many people as you can. You never know who might need to see it and consider subscribing to the channel so you can see all the other episodes and videos coming out. Thank you so so much. I truly appreciate your support. Now onto the show. Well welcome back everyone to The Upper Cervical Chiropractic Research Show, this is episode 17B. I am Dr. Kevin Leach and I’m here with a good friend and colleague Dr. Kabran Chapek and Dr. Chapek is a staff physician at the Amen Clinics. He is a naturopathic physician with a primary focus on mental health and brain health. His prior psychiatric experience was in working at a treatment center with an integrative team and he is also the author of “Concussion Rescue” and we’ve got right here. We’ll probably get into that a little bit. We’ll put a link in the description below for anybody who’s interested. It’s highly recommended and very very informative. How are you this morning doc? 

Dr. Chapek:  Great to see you Kevin. I’m doing good. Pleasure to talk with you.

Dr. Leach:  Yeah. Awesome. Awesome. Awesome. And so again this episode is kind of in conjunction with 17 where we already talk about the role of the cervical spine in post-concussion syndrome but I wanted to do this with Dr. Chapek because we’ve worked together with different patients and he works on the brain component obviously with the “Concussion Rescue” and working with the brain healing so I wanted to get his take on this. So if you want to check out the episode and how the next related to post-concussion syndrome that’s episode 17. This is episode 17B but Dr. Chapek I guess give me just a brief background about how you got into focusing on the brain and you wrote a book on concussion. How did you get into doing this? 

Dr. Chapek:  Kevin, I think it started working at that treatment center. I had all this experience working with patients with mental health issues for six years. Patients are struggling with severe depression, they’re suicidal, they’ve just come out of the hospital and then I started working at Amen Clinics the past eight years and part of our work there is doing brain imaging. And when you look at the brain we would have patients come in who had had chronic depression for many years. We’re sort of a clinic of last resort often and so why aren’t they getting better then we image their brain and we can see there’s been this clear brain injury and they didn’t know about it. And so we picked this up in a number of patients and I found and realized that brain injuries are a major cause of mental illness and no one has realized it. So that was for me the “aha moment” and I had to know more. Had to learn more. And then people who have had brain injuries have not gotten better. That’s why I wrote the book.

Dr. Leach:  Yeah, so you were with the clinic that was focusing on the treatment center

for the suicide, for depression, anxiety that kind of stuff and then you just started to realize hey there’s more, there’s more things going on with the brain. How do we heal the brain. And so was that during your time there you did that or did you leave to start pursuing that because that kind of wasn’t an option where you were? 

Dr. Chapek:  Yes. I left and when I found out that we could do brain imaging for people and the way that we’re doing it at Amen Clinics is very unique, I just had to check it out. And so I left and now thinking back to all the patients that I could have helped more if I would have known what was going on with their brain and how it’s being missed all the time. And mental psychiatry and mental health in general there’s not a lot of biochemical or physiological. There’s no testing. It’s just talking prescribing. You’re depressed here’s an antidepressant. It’s terrible.

Dr. Leach:  Yeah. 

Dr. Chapek:  There’s more going on. 

Dr. Leach:  Yeah. So how do patients find you because I have a very strong feeling that even the Amen Clinics and yourself specifically, just like with upper cervical chiropractic, it’s not like the medical profession just knows about us and like oh you need to go here. People have to find us through circuitous routes, so  how do patients find you typically? How do they get to you? 

Dr. Leah:  Referrals from other providers like yourself or internet searches. Dr. Amen is a celebrity at this point. He’s a very famous psychiatrist and has been on PBS. So he’s written many many books on the brain and how we should be using brain imaging to help people. And brilliant books Change Your Brain Change Your Life was the first and I think that’s how many people find us is from his PBS and his talks and going on tv and stuff.

Dr. Leach:   Yeah. For sure. I’m hoping that I’m doing these podcasts to obviously create awareness and get people that need our help. If one of those patients has been searching and they’re dealing with this and they’ve tried the traditional medical route and they’re still kind of suffering what would you say to that patient just to kind of say hey listen this is a possibility this is how this could potentially help you? 

Dr. Chapek:  Right. So brain imaging I think about it for two reasons. First is that it’s diagnostic. It’s helpful to figure out what’s going on with someone and this kind of imaging is looking at blood flow. What’s working well. What’s not working well. The major brain regions. It doesn’t tell us everything but it does tell us some really important pieces. It also is useful therapeutically. So if patients have struggled with brain injury, they know they’ve had a brain injury, or they have some other mental or brain problem and it hasn’t gotten better family members may not understand what’s going on with them they may not understand what’s going on with them and to see that injury is very therapeutic and encouraging/motivating. People have used substances. The treatment center I worked at a lot of substance abuse, a lot of denial around alcohol, or cannabis or other various drugs. Seeing your brain full of holes is how it looks on the scan it’s just – there’s no denying that. Just breaks through denial in seconds what previously took months and months and weeks. 

Dr. Leach:  Yeah it makes me think of when Dr. Evans and I did the other podcast on the role of the cervical spine and post concussion syndrome and they talk about the medical field talking about a psychological reason or a psychological and or physiological component. It’s almost like it shows them a reason that hey there is something that says something’s wrong not just oh it’s in your head or go see a psychologist or something like that. It’s validating that they’re not just going crazy or they’re not just pushed to the side and saying oh it’s in your head and there’s no answers. 

Dr. Chapek:  Yeah. If the brain isn’t working well how are you supposed to feel good and happy and so seeing that is just so affirming. So there’s that and the diagnostic first so put the two together it’s a very powerful tool. And then the next key is really understanding what’s going on but then putting together a plan and over the past you know six to eight years I’ve done that because I’m a naturopathic physician. I want to treat all of the causes contributing factors and when it comes to the brain as you know well it’s not just one thing that helps cure someone. It’s not just take this supplement or medication or just do this treatment, it is really putting all the pieces together. 

Dr. Leach:  When I did the last episode with Dr. Evans over his years of treating post-concussion syndrome he’s talked about neurofeedback. He’s talked about obviously the upper cervical spine. What would you say are kind of the major treatment approaches that are kind of the big guns that you’ve seen that probably pretty much anybody with a brain injury probably needs and could benefit from? I know everyone’s like you said everyone’s specific and needs certain things and diagnostics are important but what would you say are some of the big things that you’ve seen? 

Dr. Chapek:  Yeah. I’m glad you asked that. That’s what I really wanted to share with people because this is really important, the upper cervical work that you’re doing is key. It is actually one of the first things I think of to rule out, assess and rule this out. I refer to you and other upper cervical chiropractors across the country. If they can’t come see you and say Dr. Leach is one of the best in the area, best in the business, why not see him but some people are in Michigan. 

Dr. Leach:  Of course.  

Dr. Chapek:  And you can’t supplement away upper cervical problems. Hyperbaric oxygen will not heal upper cervical impingement of cerebral spinal fluid flow and blood flow. It’s just you have to do this or else nothing else will really.. so actually in the past few weeks I had a couple of patients call in and do a pre-consult before getting the evaluation just to see “is this right for me?” I’ve been having these severe headaches and migraines every single day for years. They’re in this pain and nothing has worked. They’ve seen neurologists everything. I say before even coming to see us I want you to go have this checked out. Go to one of the best upper cervical chiropractors in your area and just rule this out, this could be what’s going on for you before we’re investing in all of this. So I really put that as one of the key pieces and I was missing it to be honest with you Dr. Leach. I was missing this for years before. 

Dr. Leach:  A lot of people do and that’s why I’m trying to do this podcast and trying to get the information out because unfortunately it’s just still the idea and I think it’s just kind of the way that the medical doctors are kind of trained. They’re not really finding a nuance misalignment in the upper neck. For them it is just like “ah” because they’re looking at tumors and infections and fractures and dislocations and things that are severe. They think something like that is completely insignificant and so.. 

Dr. Chapek:  We have our place for that severe but then if people aren’t getting better.

Dr. Leach:  Absolutely. 

Dr. Chapek:  Let’s look further. So upper cervical is one of the first things, and I talked about that in the book, is the structural piece and naturopathic medicine. We have correct structural integrity as a foundational piece of helping people and for some reason I missed it for the first few years. Like hey! Why was I thinking about that with the brain but any case I know now. There is our diet. So our brain uses 20% to 30% of calories in our diet, a quarter of our plate of what we eat goes to our brain. It’s so hungry. It’s 2% of our body weight. It’s amazing and the article you sent me, we know that after an injury it needs more fuel. In the healing state of post-concussion state it actually has a higher need but yet it has less ability to utilize glucose, glucose. Transporters are damaged, there’s less blood flow. You’ve kind of burned out your ATP and mitochondria because of this ion exchange and so there’s actually this energy deficit. So you’re in this very difficult state and so I’ll often recommend a ketogenic diet to bypass those glucose transporters to use ketones for fuel to help the brain. That’s the highest recommendations, not for everyone ketogenic diet but diet in general is really key after a brain injury. It’s hard to heal if your diet is poor. Sleep, everyone has to have solid sleep to heal. It’s a no-brainer in some ways but it’s really true and 50% to 70% of people after a brain injury will have sleep problems. It’ll either be daily – during the day really sedated or at night just can’t sleep. So getting that corrected. Some of the therapies beyond that are supplements. So certain key nutrients and supplements to help the brain sort of quench that inflammation, that oxidative damage and inflammation that has been smoldering like a fire that hasn’t been put out continues to go on for months and sometimes years in the brain. There’s key nutrients there. 

Dr. Leach:  We can definitely say years. I did a SPECT scan with you and we saw my brain and I’ve had a history of playing football and there was some evidence. 

Dr. Chapek:  That’s exactly right until it’s corrected. So we should rescan you and see where we’re at.

Dr. Leach:  Yeah. 

Dr. Chapek:  But in any case it can continue. If I had only one treatment to give people to help them feel better and improve it would be hyperbaric oxygen. There was one only one thing. Now I don’t think hyperbaric alone. I’ve seen this many times where people get excited and they’ll do hyperbaric and their symptoms will improve. They’ll do maybe even 20 to 40 sessions and then they will go back and regress after stopping. Then we’ll come to find out they’re very deficient in iron, zinc, B12, they have a lot of inflammation still, or they have hormonal deficiencies. 25% to 50% of people with a history of brain injury have pituitary damage. Master hormone gland. If it’s not working or it’s taken out you may have for men low testosterone, for women low estrogen/progesterone which can affect the menstrual cycle. There can be low growth hormone which will cause many of these post-concussion symptoms – fatigue and so that’s another key piece is ruling out hormonal deficiencies and nutrient deficiencies. So those are kind of the big ones.

Dr. Leach:  Great. Awesome. Tell us a little bit and again I’ll put the link in the description below but tell us a little bit about the book. When was your “aha” moment like you know what I need to write a book? This is going to benefit how many thousands and thousands of people for years to come. So give us a little background on that. 

Dr. Chapek:  So I was giving a lecture at a brain injury conference down in Portland and it was all about natural treatments for healing concussions. Afterwards many people came up to me and said, “Oh my gosh I didn’t know there were natural treatments.” There’s good research on many nutrients for healing the brain and they weren’t aware so that was one. And then many people who have had concussions and brain injuries have often exhausted their resources. They can’t work, they’re on disability, they don’t have enough money to come and see us at Amen Clinics or to get more care. That was my “aha” moment. I turned my lecture from that day into a book.

Dr. Leach:  Beautiful.

Dr. Chapek:  It was the format for that. It took several years. Learning and researching. I added more pieces such as a structural piece and more about hyperbaric. The field continues to evolve and we learn more. As I have been going to my career it’s like okay it becomes more nuanced and specific and we’re always trying to make things easier so people can do it and be more compliant. But the hard part is it’s not one thing, it’s sort of a whole program that tends to help and getting the book and doing most of it you can often get a lot better. And so I’ve been seeing patients who have started things from in the book… 

Dr. Leach:  Great.

Dr. Chapek:  ..and they’re getting better. And then I see them and then we can sort of just go to the next level. 

Dr. Leach:  Nice. Awesome. Cool, is there anything else you kind of want to either tell either patients that might be watching this or even other providers who maybe don’t really co-manage concussion or even post-concussion patients? I’m trying to get the word out to medical doctors and providers all the time that we can help people with this and that it’s not just a psychological thing. Especially the ones that are the 10% to 15% of the concussion cases that become post-concussion cases. So do you have anything else that you’d want them to know or?

Dr. Chapek:  Absolutely. So one thing is we tend to minimize the effect of brain injury and concussions and that you don’t necessarily have to be knocked out to have had a concussion. As you know you played football and hadn’t had a brain injury. We know that just playing football sub concussive hits to the brain can damage it. It’s terrible. 

Dr. Leach:  With the CTE and the NFL. That’s one of the reasons why that I’ve looked into my brain more because I played football for so many years. I never got knocked out but I’ve had my bell rung several times. I played quarterback. I played safety. How many hits did I take and I’m thinking I’ve already had some brain fog and sleep issues and things in the past and I’m just thinking what’s going on with my brain. I need to look at my brain. 

Dr. Chapek:  Yes, because half of us will have dementia by age 85. We all want our brains to be healthy.  You’ve invested so much in this. This is who we are. So this is why I’m so passionate about this. We want to think about our brain and protect our brain. Think about the fact that it doesn’t have to be knocked unconscious. We tend to minimize and we ask patients 10 times when they come to see us, are you sure you’ve never had a brain injury? Never fallen out of a tree? Had a bike accident? Car accidents are very common but may not only have whiplash. “Oh I was fine I didn’t hit my head,” but whiplash is enough to jostle your brain. 

Dr. Leach:  That’s a huge point and back when I played football a concussion was you got knocked out. You lost consciousness. It was never like you could have a concussion. And I think that’s fairly recent isn’t it about finding out that you can have a concussion and not actually lose consciousness? 

Dr. Chapek:  Yes. Absolutely oh get back in there you’re fine. No. This second impact syndrome is devastating. 

Dr. Leach:  Yeah. 

Dr. Chapek:  People get hit again and so we ask people 10 times and think back over your history. So have I ever? Was I worse after? Did I get diagnosed with ADD after I started? I just got to tell you this one story. 

Dr. Leach:  Of course.

Dr. Chapek:  We’ll call him Jeremy. He came to see me when he was 21. He was this jazz drummer, super wiry, sort of active kid but he had been depressed, suicidally depressed, since he was about 14 years old. And he had tried every class of medications. He had tried many different types of therapy. He was referred by a great therapist and the only thing that helped him was smoking pot. He could drink. He was in a terrible relationship, a very toxic type relationship. When we scanned his brain it was clear he had damage to the left frontal and left temporal lobes. And I said Jeremy you didn’t list any head injury on your history and your intake. When did you have a head injury? And he said I never had a head injury. What are you talking about? Okay and went through the list. Have you ever fallen out of a tree? Had a car accident? His mom said remember you started playing football contact sports when you’re about 13 years old. And he was this little wiry kid matched against the coach’s son, super big kid already, and just get knocked around. He’d have headaches and stuff after practices but they thought it was fine. And that next year he was diagnosed with ADD. He also started having depression and it progressed to having suicidal thoughts every day. So we gave him treatment – supplements, change in diet, you have to stop smoking pot. And over the next several months his suicidal thoughts went away. His mood improved. He broke up with the toxic girlfriend. He left his band that wasn’t going anywhere. He went to music school and now he’s graduating from the Berkeley School of Music. 

Dr. Leach:  Nice. 

Dr. Chapek:  I think he just graduated this past spring. 

Dr. Leach:  Cool. 

Dr. Chapek:  Doing well. 

Dr. Leach:  That’s great. I love it. 

Dr. Chapek:  Think back – do I have any problems? What was going on at the time? Just knowing that brain injuries, you don’t have to have a scan always it’s that history that’s often as important as imaging. 

Dr. Leach:  Yeah. Absolutely. I know in consultations one of the things that always pops into my head whenever somebody indicates anxiety, depression, anything like that I always ask them is this because of something that’s going on in your life or is this something that you’re not really sure why it’s happening? And when people say, “Oh my mom just died.” It’s like okay. Well you’re not really depressed, you’re grieving. Things are tough right now, that’s fairly understandable but it’s the ones that say “I’ve just always kind of been like this” or “oh it’s been for five years. I’m just always kind of this way and I don’t really know why.” My mind obviously goes to the misalignment in the upper cervical spine but obviously it could clearly go to the brain injury as well. And so I think that’s important for people to understand if you’re not really sure why you’re having this mental stuff going on you probably had a brain injury, even if you don’t remember it. People come in all the time and I show them their x-rays and I’m like look right here this is damaged and the rest of your spine is fine. This doesn’t just happen because of nothing so something happened. And they’re like “Oh I don’t remember.” It’s okay. It doesn’t matter. This is what we need to do. We need to fix it. We need to treat it, right?

Dr. Chapek:  Yes. And do you find that half the time you see them a few weeks later and “Oh yeah I forgot to tell you I fell out of a two-story window.” 

Dr. Leach:  Yeah. Maybe even the next visit. A lot of times just the next visit oh yeah I remember blah blah blah. 

Dr. Chapek:  We blocked it out. 

Dr. Leach:  Yeah. Especially when we’re young and and dumb. 

Dr. Chapek:  Right. 

Dr. Leach:  So many things when we’re younger. We are just young and we bounce back. Oh that was fine. Oh I’m fine. I’m cool. Do I still look cool? 

Dr. Chapek:  That’s what matters. The other thing is it’s never too late to try and help heal someone from injury. At least to try. We may not be able to get you back to pre-level of functioning. We’ve seen this. We did some studies at Amen Clinics with football players. We took 30 of these NFL guys. They had depression, they were foggy, they had memory problems, they were angry and we put them on a program and had before and after scans. There was improvement in cognition. And really it was supplements, diet, exercise, treating if they were heavy/overweight weight loss, treating sleep apnea and that was it. And 70% of them improved. They hadn’t played for 20 years. So it’s not too late and of course you don’t have to have played football. You can have a car accident. 

Dr. Leach:  Even other sports. Soccer. Anytime you’re even hitting your head. Things like that. 

Dr. Chapek:  Soccer. Think about misalignment. I’m just thinking about it. 

Dr. Leach:  I always think about it. I’m not a huge soccer fan but when the world cup comes on. When it’s really really good sport. I love it. I watch it. So I’ll make a point to watch it. And the goalie does his goalie kick from the goal to pass the half court line or whatever it’s called and these guys are heading in. I can’t imagine what their necks look like when they’re hitting this huge ball that’s flying, anyway. It’s crazy. 

Dr. Chapek:  I played soccer as well. I need to get in and have my spine checked. I just realized that. 

Dr. Leach:  You’re a busy man. You’re helping lots of people. Okay cool. So where for you and anyone in just the greater Seattle area – where can people find you? Where are the resources? How do people find you? 

Dr. Chapek:  Yeah. So we’ve got a clinic in Bellevue, Washington just on the east side of Seattle. So people come from all over the northwest to come see us. And basically if you wanted to come for an evaluation it’s a couple day process. We do virtual meetings. We scan the brain. We have a meeting to figure out and create a plan. That’s really what I do so you can just google Amen Clinics Northwest. Phone number is 425-455-7500. 

Dr. Leach:  I’ll put all this information in the description below too as well but in case there are any other resources or things for people to know about. 

Dr. Chapek:  That’s great. Thank you. 

Dr. Leach:  Of course. 

Dr. Chapek:  The book on Amazon. There’s a course that I did based on the book “Concussion Rescue,” that’s it. MindWorks, you can google that and it’s at Amen Clinics. You can listen to the book. Often people with having had a brain injury have difficulty reading and so you just listen to it on audible. That’s a really good place to start I would say. 

Dr. Leach:  Cool. Great. Awesome. I’m really glad we did this. Hopefully a lot of people that have been suffering with just even concussion post-concussion syndrome and even if they’re not diagnosed with post-concussion syndrome specifically if they’re having depression anxiety things like that they can hopefully find and get some help from this and get some good information from this. 

Dr. Chapek:  Absolutely. Thanks for doing this. 

Dr. Leach:  I’m really glad we did this.

Dr. Chapek:  Honor to be here. 

Dr. Leach:  Yeah. Absolutely. Any last thoughts or anything for anybody watching this about just anything that they could know? Any last thoughts here?

Dr. Chapek:  It’s all about thinking outside the box. Trying new things. Being open to new ideas and that it’s never too late to heal your brain from injury. It’s a major cause of brain problems/ mental problems. We are our brain in many ways and so having a healthy brain is going to improve and optimize your quality of life so much. 

Dr. Leach:  Absolutely. 

Dr. Chapek:  Don’t wait.

Dr. Leach:  Don’t wait. Yeah. Oh that’s just such a good point people. Don’t wait, literally do it now. Go in the description and call now. If you don’t do it now, tomorrow you can be like “Oh yeah I listen to that thing” and then the next day it’s going to be even further back in the rear-view mirror. Just do it now. Get some information. Get some help. It’s going to help you. It’s going to help your family. It’s going to help everybody around you. Super important. 

Dr. Chapek:  Well said. 

Dr. Leach: Cool. Yeah. Absolutely. Awesome doc thank you so much. I appreciate you. Again all the links and of everything I’ll put in the description below. I’ll share the link with you. You can share it with your community as well and we’ll try to keep getting the word out there. 

Dr. Chapek:  Thank you. 

Dr. Leach:  Awesome. Thank you. Okay that’s it for this episode. So what did you learn that fascinated you or surprised you about their research today? Join or start the conversation in the comments below. Hey thanks so much for watching. To watch more of our research shows click or tap the screen right there. To subscribe to the channel click or tap the screen right there. Until next time, I’m Dr. Kevin Leach with The Upper Cervical Chiropractic Research Show bringing awareness to conservative primary spine care, upper cervical chiropractic care, and traditional chiropractic. Until next time, take care and take care of your spine. It’s the only one you’ll ever have.

Dr. Leach:  Okay this podcast is a bit heady. It’s about ligaments of the upper cervical spine. How they’re important, if they’re injured what structures they protect, and all of that nerdy geeky stuff. Super important but not the most exciting thing in the world. So if you’re interested I hope you enjoy it, if not wait for the next podcast to come out. Thanks.Hi there. I’m Dr. Kevin Leach here with The Chiropractic Deep Dive Podcast bringing you the most important research and information on conservative primary spine care, upper cervical chiropractic care, and traditional chiropractic care. These research reviews interviews and episodes are made for you whether you’re a medical doctor, patient, or concerned family member or friend. The goal of these shows is to bring awareness of the importance of taking care of our spine and the impact it has on our health and the hundreds of different health conditions it could cause without us realizing it. I’m really trying to bring value with these so I’d appreciate commenting on the videos, hitting the like button, and sharing them with as many people as you can. You never know who might need to see it and consider subscribing to the channel so you can see all the other episodes and videos coming out. Thank you so so much. I truly appreciate your support. Now on to the show. Okay. Welcome back everyone to The Upper Cervical Chiropractic Research Show. This is episode #15. I am Dr. Kevin Leach. I’m your host and by now my good friend and colleague Dr .Tyler Evans is probably the co-host. We haven’t really made anything official but you’ve pretty much done almost every single one here with me and he is also here today so welcome, Tyler. 

Dr. Evans:  Thank you. I look forward to this one.

Dr. Leach:  Yeah me too. Tyler this is a paper that you really wanted to do. You recommended it for one of the next ones that we do here. The title of the paper is “Ligaments of the Craniocervical Junction: A Review” and this is by Tubbs et al. and it was published in The Journal of Neurosurgery. So this is a neurosurgeon who published this and what the paper pretty much does is it brings together a lot of other research to really go into what’s going on with the ligaments and other structures that are going on with the craniocervical junction. So where the head meets the top bones in the neck. And he goes over the importance of it, the biomechanics, the anatomy and really goes over that. and you sir wanted to go over this. Why don’t you just tell the audience why you feel this paper was important and really really important for not only patients but doctors and upper cervical chiropractic but just for everybody to understand the importance of this. 

Dr. Evans:  Sure. So I think it’s really important to understand that the craniocervical junction – so cranium skull, cervical spine, the upper cervical spine, the junction between the two is where they connect. That’s where Dr. Leach and I work every day that’s what we do. We correct that upper cervical spine to release tension and allow for the messages and signals from the brain down to the body, body back up to the brain to be as clear and and open as possible as well as the blood flow the cerebral spinal fluid flow. And in this paper we’re going to talk about the ligaments and how they play a role in all that and this paper actually came to me back in 2014 or 2015 from the upper cervical diplomate program that I did. And it was a really foundational piece in that program actually it was on our final exam and so today when I was reviewing the paper I was like, “Oh man this takes me back.” So it was a lot of fun to go back and review this stuff but it’s funny how now going back looking at it again after another five years of or six years of experience there’s some new things that I got out of it and just good reminders. And so this podcast is for someone anyone who is just one, interested in what upper cervical chiropractors do and how they help. Two, people who have been in car accidents or kind of intense head and neck trauma or just have had repetitive head and neck trauma and they’re suffering from post-concussion syndrome what we call cranial cervical syndrome and they’re not getting a lot of answers. This is where we really shine in the upper cervical profession within chiropractic because when we talk about the upper cervical spine it’s the most complex joint in the spine, this paper actually outlines it says, “the atlanto occipital and atlantoaxial joints house the spinal cord, multiple cranial nerves, and many important blood and lymphatic vessels that supply the head and neck. The CCJ must protect its contents while simultaneously allowing significant mobility.” So it’s got to be mobile and it’s got to protect the spinal cord, the brain stem. And so that needs a specific correction and that’s what we do and we want to stabilize that joint because this joint is made of muscles, ligaments, and tendons. It is not held together by bony locks like the rest of the joints lower down below C2 and so that’s where this paper comes in. They talk about two main ligaments. The one being the transverse ligament and the second one being the alar ligaments that limit a lot of motion there. I believe it’s collagenous. There’s a lot of collagen in them so it makes them very dense and very stiff. The other nine ligaments that are discussed in this paper are what we call accessory ligaments and just kind of help those other two ligaments limit motion. And really one of them, the apical ligament, may even just be left over from remnants of evolution and they didn’t even really have a reason why it’s there. And one of the ligaments, the posterior atlanto-occipital membrane, actually attaches and is what we call a myodural bridge from a muscle, the rectus capitis posterior minor, at the base of the skull from that outside muscle all the way through – goes through the ligaments and attaches into the dura of the spinal cord. Which that’s a big deal because if the bone is off and that ligament attaches to the bone it attaches to the muscle and there’s tension in that muscle that’s where upper cervical chiropractors, that’s where craniosacral therapists, and massage therapists come in huge when you are working to relax those muscles-balance the joints to take pressure off the brain stem and the spinal cord so that the brain can heal and the nervous system can heal. And so that’s where upper cervical really comes in and it was interesting because they talk about the p-a-o membrane and they say well it doesn’t really have much value. and I’m like, “That’s what we do.” Right. That’s where we fit in. So anyways real quick that was kind of my summary. I just want to run through some of this stuff kind of pick apart some of the ligaments. The two main ones – the alar and the transverse off the top and then I’ll talk about the other nine ones in brief. So the kind of biomechanics of the ccj. The ccj is composed of the two major joints we talked about that. Prominent movement at the a-o joint, so the atlanto-occipital joint, between the skull and C1 is a flexion and extension. So this movement. Flexion and extension. That’s the primary movement there. The primary movement at the atlanto-axial joint is rotation. And so the numbers that we get from this for the flexion and extension, let’s see. It’s the various movements at the joint occur because the condyles glide in the sockets of the atlas and that’s flexion and extension occiput to atlas. Adele found the atlanto-occipital joint to be responsible for 27 degrees of flexion and 24.9 degrees of extension and then a little bit of 8 degrees of axial rotation there at C1 under the occiput, under the skull. And then down further we talk about the atlanto axial joint we actually have mostly rotation there and that joint we found between atlantoaxial rotation was 23 to 38.9 degrees. And then if you take those two those two make up, so between the occiput and C1 – C1 and C2, we have roughly 50% of the range of motion in the cervical spine comes from how that head moves on that top neck joint. And so that’s really really really important when we’re talking about function of the body and just alignment in general. If that upper neck is out of place it’s going to translate all the way down the spine and cause issues even down into the lower spine, hips, and legs. The first ligament we want to discuss here is the transverse ligament which holds the dens, which is this top – this vertical bone here, it’s C2. It’s the pike that the ring of C1, this back piece here and the front piece here, sit around/sit on top of and there’s a little synovial disc between the two bones right there and this transverse ligament is right here, this this kind of thicker blue area right here. And what it does is it limits the motion of C1 forward away from the den. So that’s flexion away from that bone. And that’s really important because one of the things that we actually work with all the time in chiropractic is we’re trying to reduce the anterior motion or rotation of that bone away from C2. And so if you understand where it sits and the problems that can arise with it, which they actually talk about later on the paper and I’ll just kind of add this in here so we don’t have to hit it later, but rheumatoid arthritis is where a lot of people will run into issues with that ligament. Where it will get inflamed and degenerated I actually see it a lot on what we do is called cone beam CT in our office where we take a 3D dental x-ray and you can actually see that ligament as you can slice through and see when that ligament has ossified and hardened on the back of the dens. And so it’s something that we’re taking into account in terms of how we care for people. It’s really really important that that ligament maintains its structure because it’s one of the strongest ligaments in the spine. It’s actually the strongest ligament in the craniocervical junction. Which is important to know and second to that are the alar ligaments which actually attach.. So what they do is they’re called the check ligaments. So alars here. So what they limit is lateral flexion and rotation, where the head is bending side to side or turning. They’re actually limiting the movement of the skull away from C2 and the cervical spine. because they attach down from the base of up inside of the skull here, in this what we call the the foramen magnum, they actually attach right up here at the base of it this hole and attach down at that dens that top of that bone here that I was telling you about a minute ago and they limit movement. So if you tip your head one way the one on the other side so the one on the other way from away from where you’re moving actually gets tight and holds that dense to the skull. Now if there’s a problem with that in a lot of accidents and injuries where someone might have their head turned in a car accident or a fall where they hit their head that ligament can be damaged. And so it’s really important that if there has been a head or neck injury we do something called T2 weighted MRI where, and I always remember this from my diplomate days, we would talk about T2 MRIs or the terminator T2 the one that mostly looks like water and that’s how we know a T2 weighted MRI is where we’re looking at water in the image and so you’ll see ligaments light up more and if they’re dark or if they’re black they’re separated and that’s bad. That’s really bad. And you’ll see that sometimes in alar ligaments in and a lot of people they have these big car accidents and injuries where they don’t have a lot of evidence to support what they’re feeling and what they’re going through. But then if you do one of these two T2 weighted MRIs and look at their alar ligaments and their alar ligaments might actually be completely separated or blown as Dr. Rosa said a lot in our program and that is a court case winner right there. I mean if those ligaments are gone that’s a really important thing to document. So just in terms of car accidents that’s a big deal that limits that rotation lateral bending of the head and the neck and that’s something that we’re not looking at it on a regular basis in our chiropractic offices but if there’s a problem we know to look for that. So one way that we can in our chiropractic offices is we can do lateral bending, APOMs, AP open mouth. Where actually the person opens their mouth and then you have them tilt their head and you can see C1 would slip off of C2 quite a bit on one side and that would open that up for quite a bit of movement. And so that’s just something that we look at and we’re keeping an eye on in terms of craniocervical junction instability. And so one of the main points here of the paper is that there are other ligaments, there are nine other ligaments, but those two are the main stays of the upper cervical spine. There are nine others and they go from the transverse occipital ligament. Which is a tiny little guy that actually sits right behind the dens and that is actually attaching from the base of the occiput on one side over to the other side. And that limits some more of that extension and flexion. Holding things in place there. And then it’s, “TOL is a small accessory ligament of the CCJ located posterior superior to the alar ligaments and the odontoid process..  it limits.. sought to have similar functions to alar ligaments actually limits lateral flexion and possible rotation as well.” So good to know there. Then the accessory atlanto axial ligament. This one was kind of an interesting one to me because I forgot about it but what it does is it actually attaches down lower on the base of C2 and goes all the way up into the skull and attaches on C1. So it literally holds everything together and stabilizes it all together in flexion and extension and so that’s important to know. They even said that this structure may be important for conveying blood supply to the base of C2 or the top of C2 area. And then let’s see the lateral atlanto occipital ligament. This one was another kind of funny one and what was interesting about this guy, this is out on the transverse process of C1. So this is looking all the way out on the edge and it attaches from C1 up to the base of the skull. I completely forgot that guy existed but it sits right behind this muscle here, which is called the medial rectus capitis lateralis. And I didn’t even know that muscle existed because I looked it up, it said it in the paper and what’s fascinating is this is another one of the little upper cervical muscles, the suboccipital muscles. These four muscles here and then this guy right here. They don’t do movement so much as they are sensory in nature and limit motion. So they’re all there to basically tell your brain where your head is sitting on C1 and C2. And so that little ligament the lateral ligament there, the LAO, it’s sending a lot of information into your brain about how C1 is sitting under your skull and that ligament limits lateral bending of your head too they kind of found that. So just fascinating stuff that I didn’t even know that existed. 

Dr. Leach:  Before you continue doctor, when I was looking at this as well and just reviewing that exact ligament that you just talked about. I can’t help but to think of one of the key concepts we look at in upper cervical chiropractic is laterality. Meaning for everyone listening meaning which way the atlas has displaced left or right compared to the head, compared to the occiput. So it makes me wonder if those ligaments would actually be able to be red with a T2 weighted MRI as injured as part of the mechanism of the misalignment that we’re actually correcting. For example if there’s a right laterality is there damage to the left ligament or is there damage to the right it makes you kind of think. And obviously there’s different levels of sprains to a ligament. There’s three different levels so it makes you wonder you know when there’s a misalignment maybe it’s only a grade one. Maybe when there’s a significant grade two or even a grade three that’s when really really bad things will happen. It just makes me kind of wonder. I wonder what that T2 MRI would say. 

Dr. Evans:  Yeah and that’s actually a good point and I think what would probably be the outcome is just that the accessory ligaments are quite a bit less dense. So this is one of the accessory ligaments, it may be quite hard to see and that might be why we don’t talk about it too much. But again it limits movement and you may be able to pick it up on an MRI. I just haven’t seen anyone talk about it or study it so that might be something to look at. That’s a good point though because that is an important piece to what we do. Moving on to the barkow’s ligament, which is the sixth ligament in the in the eleven that we’re studying here today. This ligament is located just anterior to the superior aspect of the den. There’s actually a picture just for the barkow’s ligament. It’s real small and this is in the paper but this little picture right here so this little band that runs across from one side to the other. Now this is in front of the dens where the.. Oh gosh, what was the name of the other one? I believe it’s the posterior. What was it the..

Dr. Leach:  Transverse occipital. 

Dr. Evans:  Yeah transverse occipital. That’s actually posterior to the dens. Nice catch Dr. Leach. So you can see that there’s a lot of emphasis placed on this craniocervical junction to maintain the relationship of the dens, to C1, to the base of the skull. There’s all these tiny little ligaments that hold all of this together.

Dr. Leach:  One of the things that I saw while reviewing this that was super interesting is they talk about the barkow ligament. So I’m going to use my coffee cup for the dance. So you’ve got your barkow ligament that’s on the front and then what they say is that in order for that to actually do its job for holding things in place as we bend our head back the transverse ligament behind it actually has to be intact. So not only are these ligaments supporting structures and making sure we have mobility and stability but they’re actually working together.

Dr. Evans:  Yes

Dr. LEach:  Which is just.. It’s crazy. It’s incredible how amazing that is. That they’re actually working together to prevent that lack of motion and just how intricately they all work together to give us the mobility we have while protecting all the structures in there and it’s just incredible. Dr. Evans: That’s a great point that actually was in there. I remember that. So good catch. 

Dr. Leach:  Yeah. 

Dr. Evans:  And that one mostly limits flexion and extension right? 

Dr. Leach:  So yeah. I think it’s the barkows for the extension but for it to not go too far that transverse ligament has to be behind it.. 

Dr. Evans:  Right 

Dr. Leach:  ..intact in order for it to. Because if it wasn’t there then there wouldn’t be anything for that pressure to anchor on and it would  just keep pushing back. Yeah. 

Dr. Evans:  Yeah. Yeah. Which would not be good right because that dens is sitting right there and it’s right by your base of your brain stem. So if that then slips back that’s right in the brain stem. So your body is.. 

Dr. Leach:  Nothing good will come from that. 

Dr. Evans:  Yeah. Your body is protecting yourself there. So then we have number seven is the apical ligament. The apical ligament is this tiny little ligament right here. Which is actually probably not the best picture to use. So I can see it. Right there. That little guy right there, just behind the transverse occipital ligament. And what that guy does.. So if we look at it from this picture. This is a better picture. You can see right here from the dens up to the base of the skull that guy again limits motion; however, they actually said in the paper that it’s not taught in most of the cadavers that they studied. Well maybe in real life it is but you know in the cadavers that they studied I believe that most of the time it wasn’t even really holding tension. So they kind of said well it probably doesn’t have much reason to be there these days but I’m a believer that the body has everything for a purpose. And again that motion it would limit, it’s there to stop motion going forward. 

Dr. Leach:  Yeah even if it’s a backup. 

Dr. Evans:  Yeah. Right. 

Dr. Leach:  It’s gonna prevent excessive excess motion. 

Dr. Evans:  Right. Exactly and so that’s kind of how you and I look at stuff. Well it’s there at least to prevent big injury.

Dr. Leach:  Right. 

Dr. Evans:  There might be a problem because you and I look at millimeters in a misalignment, millimeters of problems. Where if there’s a few millimeters of play it may not be a medical problem but to you and I that’s millimeters of brain stem pressure right. That’s a problem. 

Dr. Leach:  Yeah. 

Dr. Evans:  So all right. So that’s the apical ligament and then number eight is the tectorial membrane.  It’s like a big flowing cover that goes on the back of the anterior portion of the cervical spine. And what it does is it lays. So it’s like this. It lays. It’s the orange one or kind of red colored one here and that lays across all of these other ligaments to kind of glue them onto the bone and hold them on there together so that they play together. And it’s made up of a little different structure. “A description of the tectorial membrane are insufficient and inconsistent with regard to anatomy and function; some authors have reported this. This membrane is an accessory ligament that restricts flexion others describe it as a primary stabilizer of the CCJ resisting extension.” So basically they just couldn’t come to an agreement based on all the papers that they reviewed what it actually does.  But it’s there again. It’s kind of holding everything together. It’s the glue on the back of the front of the canal. So you’ve got the hole and so here you’ve got all those ligaments we were talking about on the front of the cord in the canal and then it lays on that and then you have the spinal cord in the center and then we have the back of the canal and the bones on the back of the canal. So then we talk about number nine is that..

Dr. Leach:   Can I say one more thing about that? I think this is super important to understand we’re getting a little bit outside of the upper cervical spine. But the tectorial membrane it says, “Worny has also described the tectorial membrane as the well-developed superior continuation of the deep layer of the posterior longitudinal ligament.” Now this is super important especially in whiplash injuries. When we see an anterolisthesis or posterolisthesis of the lower cervical spine during whiplash that posterior longitudinal ligament can be torn and then you’ll get a shifting and that’s another, again whether it’s from radiographs or from MRI, to show injury in a med legal case to support the patient’s injury. I just wanted to kind mention how those are kind of one and the same. It’s just a continuation of that but it’s a super super important structure of what gets damaged and what protects the lower cervical spine in head/neck injuries and whiplash injuries.

Dr. Evans: Yeah. That’s a good point. That was something that I noticed and I’m glad you picked that up. I forgot about that. Good job. 

Dr. Leach:  Yeah. 

Dr. Evans:  One of the last ones here is the POA membrane. So the posterior atlanto occipital membrane. So this is that one that it’s the myodural bridge and it actually attaches from the base, so the the top of the atlas to the base of the skull, and then it actually goes into the dura of the canal and out to the rectus capitis posterior minor, which is this muscle out on the back of the bones. And so we talked about that earlier but if that muscle is tight or if that bone is misaligned that ligament actually attaches all the way into the dura and that can affect the spinal cord. And so that’s how we know. Dr. Leach and I are always checking people’s low backs and their hips to see if their neck is misaligned. Well that goes along with our dentate ligament theory that we talked about a long time ago in one of our other podcasts and that all kind of goes together with how someone might get symptoms that go up into their head or go down into the lower part of their body. If that ligament is attaching into the cord itself then you could have an issue in any one of the tracks of the spine that go up and down at that area so by correcting that upper neck you can literally change the entire neurology above or below. Were you going to say something, Dr. Leach?

Dr. Leach:  Yeah. I was curious why wouldn’t they have on the picture here the myodural bridge going into the duras? Are they just focusing on ligaments? Is that kind of why? 

Dr. Evans:  Yeah well, there’s papers on that. We can do a paper on that in the future. They just didn’t show it. Yeah. They actually talk about it so there’s a part here where they say, it’s in the kind of breakdown later on of the importance of.. 

Dr. Leach:  Now is that myodural bridge? Is that just another function of stability and control to make sure things aren’t compressed and to anchor? 

Dr. Evans:  Yeah. 

Dr. Leach:  It seems like it would be important on flexion to make sure that the spinal cord and brainstem don’t get bent. It’s almost like anchoring it from a superior aspect, like a tent kind of thing. Yeah? 

Dr. Evans:  Yeah and I think there’s a lot of place put on this that is more signaling to the brain about where the bones are at in place and so it can tell. It gives input into the brain. Unfortunately in these big head and neck injuries it gives bad information and that’s what we want to fix. That’s what upper cervical chiropractors want to fix and reduce that tension at the bone and the spine. But their comment here was, “a study conducted by Hack et al reported the presence of a connective tissue bridge joining the rectus capitis posterior minor muscle to the spinal dura in all catavaric specimens.” Yeah and then this other guy found, “connective tissue bridge to be present in 67% of cadavers indicating that this represents normal anatomy rather than a rare anatomical anomaly.” Which is really cool to hear because that’s what we do. That’s where we live. That’s what we do and we see changes in hips and low back all the time we see changes in the mid spine we see changes in brain function and so if there is a ligament that’s attaching all the way into the dura well that could be a big reason as to one of the big reasons why we’re seeing changes elsewhere in the body when we correct the upper neck. Okay. So that said the anterior atlanto occipital membrane. This guy right here. So this big guy right up here. So it attaches from the front of C1 so what’s called the anterior arch up to the base of the front of the skull. That ligament or membrane as it’s called, “..is a thin structure that attaches the anterior aspect of the atlas to the anterior rim of the foramen magnum.” It says Tubbs et al noted that, “aao membrane may function synergistically with the barkow ligament to limit atlanto occipital extension of the head.” So again not an extension of the head. It’s holding things down kind of locking them down in the front. So there’s a lot of strength and weight put on holding that C1 down to the dens into the skull on that front end because things go backwards. That’s not good. And that happens a lot in accidents, whiplash accidents. That’s where people get really severe injuries and trauma and that’s why that ligament’s there. So the nuchal ligament is the 11th ligament. The nuchal ligament is on the back of the cervical spine here and actually lower down when it goes into the thoracic spine we call it the spinous ligament. And so this nuclear ligament is actually full of what they said, “Intuitively the nuchal ligament restricts hyperflexion of the cervical spine. Interestingly, some have identified a greater concentration of proprioceptive fibers in this structure and that it may play a role in maintaining proper alignment of the cervical spine.” So again. We’re talking about information heading up into the skull up into the brain. If the vertebrae are off it’s going to send bad information up into the brain and that’s what this ligament is doing it’s actually kind of a GPS unit for where things are out in space. So that’s an important thing to remember. Then it goes into histology of the craniocervical ligament. Where they come from. How they’re made. One of the important things they said in this little piece is just that, “The histology of these ligaments are that they are mainly composed of collagen fibers with minimal elastic fibers in their periphery. The degree of elastic tissue present varies from ligament to ligament. For example the transverse and alar ligaments contain very few elastic fibers.” Which is why they’re so dense and strong. They’ve got to be strong to prevent that movement. Okay so with that said then it goes into what are some of the problems that could happen. They discussed rheumatoid arthritis, down syndrome, calcium pyrophosphate, dihydrate crystal deposition. Which I actually had a patient that had that. We identified it through our radiologist, Matthew Richardson, who’s an amazing guy down at Palmer, Florida Chiropractic College. He identified it and we got that patient a medication and I’m you know not a guy that tells people to go get on medication but what’s pretty cool is that was a life changer for that guy. Because some of these problems, some of these more like autoimmune diseases, are really tough and just a good review of the spine can give a lot of great information and so we were able to help that gentleman in that situation. And then the last thing is whiplash and they talk about whiplash for a big chunk of the paper here. And just says that,  “Prevalence of whiplash associated disorders has drastically increased over the last 20 years.” So basically that the CCJ is the most commonly injured joint in the spine during whiplash injuries. “Alar transverse ligaments are the most likely to be injured from a whiplash associated disorder. Trauma resulting in whiplash associated disorders often involves the transfer of large amounts of forces across the atlanto axial joint resulting in rupture of these two key ligaments.” So just really important stuff there to know if you’ve been in a car accident or know someone that hasn’t they’re suffering from all kinds of symptoms and problems very well likely could be that they’ve either had injury to these ligaments or they are stretched and there’s a big misalignment in that craniocervical junction and that’s what we do. That’s where we live. We want to balance that craniocervical junction to bring order and restore function back to the joint so that the brain can communicate with the body again. And that’s where we live. In this paper they actually talk about how rheumatoid arthritis is one of them but a lot of times they’ll talk about stabilizing C1 and C2 and the cervical spine to the skull and it’s like they say here an anterior subluxation of the atlas is a big deal and it may require surgical fixation. It’s like hey! What about trying to conservatively correct that misalignment? Trying to conservatively reduce that. So that’s what we do. With all that said.

Dr. Leach:  Yeah I think a good thing that.. a couple things. And again when they talk about subluxation in this paper they’re referring to a medical subluxation not a chiropractic subluxation., meaning ligament laxity. Meaning a displacement of the bone. When chiropractors talk about subluxation if it’s a full spine chiropractor they’re talking about more fixation and more of a stuck/immobile joint and then upper cervical we’re talking about that also that stuckness out of place but not from a medical standpoint of ligament laxity. Maybe kind of to bring things full circle, maybe a slight ligament laxity. Just commenting about what we talked about before as far as maybe there’s a grade 1 or even smaller tear to the ligament that allows a slight displacement of that vertebra but not to the degree where it would be diagnosed as a medical subluxation. That’s number one. And the second thing just to kind of review here is you talked about craniosacral therapy earlier and massage therapy and then chiropractic and it’s important to understand the difference between all these. 

Dr. Evans:  Yeah 

Dr. Leach:  For the layperson for medical doctors. What we’re doing is not something physical therapists, massage therapists, or soft tissue therapists of any kind do. Which is addressing maybe the fascia or maybe the muscles or just to get things functioning properly that way, whether there’s adhesions and they’re doing massage or trying to restore function that way. Especially as upper cervical chiropractors we’re dealing with the bones in the joints. And then the nerve function, whether it’s coming from the joint or around the joint in the brain stem or the spinal nerves or what have you. So it’s important to know that all of these providers working together to figure out what the exact problem is is the most important part. Because again if we have these tiny injuries to these ligaments that are causing a misalignment the upper cervical spine which are causing problems with the patient and that patient is only getting care to treat the muscles that are in spasm because they’re trying to brace and protect the spine you’re just relaxing a muscle that the body is telling to spasm as a protective mechanism. Right. So if we can get the alignment and the joints back into alignment and back to functioning properly, that in and of itself will allow a lot of the muscle and soft tissue to self-correct. But then there’s always that well how long has it been there is more soft tissue therapy needed. So these cases they can be pretty complex and Dr. Evans I’m sure you’ve had patients that have just literally gotten 100% better just by correcting their atlas. Tons of things get better. They’re feeling phenomenal but then you have other patients where you correct them and then there’s other things going on. Okay let’s get some massage in there. Let’s get some soft tissue work, some physical therapy whatever those may be. So I just kind of wanted to point out that there’s a really important understanding of where the value of upper cervical chiropractic really comes in as a missing piece for most people most providers to really know about the value of what it is that we’re doing and the intricacy. And obviously with these 11 ligaments just of the upper cervical spine the importance obviously that we know that the body knows that we have in that area with all these ligaments and stability and the brain stem being right there and just being an important area. Yeah, anything on that Dr. Evans? 

Dr. Evans:  No I think that’s really important and you’ve covered it well.

Dr. Leach:  Fantastic. Any closing comments about anything with this paper about what people would like to know? I’ll link the paper or link a link to the paper in the description below for people to go find it so they can read it on their own. Any last last input? 

Dr. Evans:  Maybe one thing. I was calling back I was talking about the APOM and open mouth and just thinking back that it’s the relationship between the dens and the atlas, you can see how the dens is moving inside of C1 not how C2 is slipping off of C3 or C1 slipping off of C2. But there are ligaments that you can look at ligament damage there and see if there’s instability and then you can then make maybe imaging protocols from that. 

Dr. Leach:  Yeah. Got it. Perfect. Fantastic. Okay. Well thanks everybody for listening. Comment. Like the video. Share the video. We’re trying to bring value as always and let us know if there’s any other papers or questions or anything that we can review in the future. Until then thanks so much and thank you Dr. Evans and we’ll talk to you soon. Okay that’s it for this episode so what did you learn that fascinated you or surprised you about the research today? Join or start the conversation in the comments below. Hey thanks so much for watching. To watch more of our research shows click or tap the screen right there. To subscribe to the channel click or tap the screen right there. Until next time, I’m Dr. Kevin Leach with The Upper Cervical Chiropractic Research Show bringing awareness to conservative primary spine care, upper cervical chiropractic care, and traditional chiropractic. Until next time, take care and take care of your spine. It’s the only one you’ll ever have.

Dr. Leach:  Hot flashes gone with NUCCA Upper Cervical
Chiropractic care. A potential mechanism of how Dr. Slagel and I discuss his
research and more on The Upper Cervical Chiropractic Research Show. I’ve also
done an interview and summary video you can find on the channel if you’d like
to see that. Hi there. I’m Dr. Kevin Leach here with The Chiropractic Deep
Dive Podcast bringing you the most important research and information on
conservative primary spine care, upper cervical chiropractic care, and
traditional chiropractic care. These research reviews interviews and episodes
are made for you whether you’re a medical doctor, patient, or concerned family
member or friend. The goal of these shows is to bring awareness of the
importance of taking care of our spine and the impact it has on our health and
the hundreds of different health conditions it could cause without us realizing
it. I’m really trying to bring value with these so I’d appreciate commenting on
the videos hitting the like button and sharing them with as many people as you
can. You never know who might need to see it and consider subscribing to the
channel so you can see all the other episodes and videos coming out. Thank you
so so much. I truly appreciate your support now on to the show. Okay welcome
back everyone to The Upper Cervical Chiropractic Research Show this is Episode
12. I am Dr. Kevin Leach and I’m here once again with Dr. Jason Slagel author
of today’s research we’ll be reviewing. So Dr. Slagel is a NUCCA doctor who
practices in South Florida. Dr. Slagel has his level 1 NUCCA certification and
currently working on his level 2. And he’s the proud husband and father of two
little boys and pregnant wife at home. Thank you for joining me again, sir. How
are you?

Dr. Slagel:  I’m doing great it’s great to be back.

Dr. Leach:  Awesome. Good to have you, sir. So today’s
research review is titled Resolution of Hot Flashes in a 57 Year Old Female
Undergoing Upper Cervical Subluxation Based NUCCA Chiropractic Care the Case
Report and again this is by Dr. Jason Slagel published in The Journal of Upper
Cervical Chiropractic Research a McCoy Press. So I know we were talking just
before the recording here doc about just why you wrote this up and the
interesting findings. You want to just give us again an overview of what just
what this is about?

Dr. Slagel:  Yeah. Absolutely so this is more – this is less
of like me taking a stance I think this is what happened. It’s more so like a
hey something happened let’s just take a look at it and sort of bring it to
people’s attention so we can all kind of keep an eye on this together and maybe
put some ideas together. I mean, I have my theory but I’m not married to my
theory. So yeah. We can talk about that but it’s a little bit more ambiguous I
guess and more like that just dipping our toes into it.

Dr. Leach:  Hey that’s what research is for right? So
hypotheses and asking questions and seeing what answers we can get. So why
don’t you give us just a little bit of about the background about the hot
flashes and just you know who has them and what not.

Dr. Slagel:  Yeah. So hot flashes are pretty benign right. So
if you get hot flashes you’re not at like risk for a death or it’s not a
disease or anything. It’s the most common symptom in the menopausal process and
some people view it as a problem, some people view it as natural. You know that
I think it’s kind of out for debate but the it’s interesting to me because the
people who are affected classically according to the research people who are
affected most by hot flashes are obese women, smoking women, and African
American women. Okay. So the patient that I had who’s hot flashes went away was
Caucasian, fit, and lean and never smoked. Okay. So I’m thinking possibly if
this same woman would have had the same misalignment, the same subluxation, all
that stuff and I adjusted her except for she had all those risk factors then
maybe the hot flashes wouldn’t have went away. So it’s just like there’s all
these questions that I have about it.

Dr. Leach:  Got it.

Dr. Slagel:  But this lady was having ten hot flashes a day
and after a few weeks her hot flashes all stopped. She hasn’t had any hot flashes
since. So pretty interesting. Yeah.

Dr. Leach:  So with with hot flashes, you know, you hear and
we learned that it’s hormonally related. What are your thoughts on if it’s
hormonally related why would the obesity – and again I would have my theories
to – obesity, smoking, and African American – the African American one I’m not
sure about that one – but obese and smoking those definitely affect hormones.
But any ideas on African American? Why that would be more so?

Dr. Slagel:  I honestly have no idea.

Dr. Leach:  Okay. But in the research that shows that’s a
risk factor.

Dr. Slagel:  Yeah. For some reason it’s a trend. It’s a risk
factor for some reason.

Dr. Leach:  Got it. Okay. Well, why don’t you give us just a
little bit more history about your patient and tell us what happened.

Dr. Slagel:  Yes. So she was 57 years old and she came to me
for sciatic pain was her main thing. Hot flashes weren’t really – she didn’t
really – we talked a little bit about it but it wasn’t really a thing. She
mostly came to me for sciatic pain. So at six weeks her sciatic pain was at fifty
percent which is cool. Pretty good improvement and that’s when she first told
me, at six weeks, that her hot flashes were gone. Hold on. Wait. What?

Dr. Leach:  She never said anything about it prior?

Dr. Slagel:  No. No. It wasn’t her main concern so it’s not
what we talked about on her daily visits. So that one kind of blindsided me and
I had to start thinking through like what could be going on with that you know
is it just a coincidence, which it very well could be, or is it something
physiological that happened that allowed that to sort of balance back out.

Dr. Leach:  Before I forget I want to interject with a crazy
story I had about hot flashes. When I was – let’s see this is probably…

Dr. Slagel:  Did your hot flashes go away?

Dr. Leach:  No, my hot flashes did not go away. However I had
a patient, I want to say eight years ago, he was an ex-captain of the police.
So he was your alpha-male “take no crap from anybody.” He was having
hot flashes. He was having hot flashes several times a day. We’re talking 15-20
times a day. He had been to medical doctors, all kinds of people, and then he
came again for neck pain or something you know he came in the office and one of
his main one – he had neck pain or some other condition but his number two
or three were these hot flashes that just nobody could figure out. And after
the first adjustment they were almost all gone and then after the second one
never came back.

Dr. Slagel:  Okay.

Dr. Leach:  He was obviously happy but he was angry because
he was like, “None of these doctors, none of these specialists, nobody I
went to helped me out with this thing. And then you move this little bone in my
neck and it helps.”

Dr. Slagel:  It’s funny when I did my literature review, when
I wrote up this paper, I didn’t see that one. Did I miss it?

Dr. Leach:  No. No. We didn’t. That’s anecdotal. That’s just
a patient I had years ago. I didn’t write it up or anything.

Dr. Slagel:  That’s too bad because I feel like these things
happen but then people are just kind of like meh. Like okay cool and then they
move on. If we were actually reporting these things I feel like a lot of NUCCA
doctors have stories like that.

Dr. Leach:  Yeah.

Dr. Slagel:  Okay. It’s a conversation that needs to start
happening because the reason that I decided to write it up was because I
think that this opens the door to a bigger conversation. A more important
conversation than hot flashes. Hot flashes are cool if we can get rid of hot
flashes women everywhere will love us but the bigger idea with health and
physiology is not with the hot flashes in particular but with hormone
regulation. Right and that’s the thing that I was thinking through this seems
like a peek through the door and we need to open up the door and look what’s
going on with this. Can I go into a possible mechanism?

Dr. Leach:  Absolutely.

Dr. Slagel:  So I don’t know, have you read this book “The
Downside of Upright Posture?”

Dr. Leach: No but Dr. Evans and I have discussed it and it’s
on it’s on my reading list.

Dr. Slagel:  Okay. Bump it up higher on your reading list
because it absolutely blew my mind and then Michael Flanagan’s second book.
This one’s a lot. This one’s super dense and super heavy nice “Craniospinal
Hydrodynamics in Neurodegenerative and Neurological Disorders.” Okay so both of
them mind-blowing. Okay so based off of that that stuff that Michael Flannigan
wrote up I’m thinking something along these lines; the head and neck get
shifted out of place there’s the misalignment the subluxation and it affects
hemodynamics and hydrodynamics in the head and in the spine. So CSF flow and
blood flow in and out of the head is affected. Which is easily shown in any
study. So then what happens with a baby let’s say the CSF is not draining out
of the head properly is the head starts to swell out because the skull is
infused, we call that hydrocephalus or water head. Right. So then with an adult
the skull is fused so instead of that pressure pushing the skull outward it
actually starts crushing the brain inward. Okay. So we call it in an adult
where that’s happening over time chronically would call it normal pressure
hydrocephalus. Yes, it’s a type of hydrocephalus but it’s normal pressure so
what happens is inside the skull if you would measure the pressure inside the
skull at any point it’d be normal normal pressure hydrocephalus but there’s
more and more CSF being backed up in the head and it’s crushing the brain in.
Now depending on where that happens to impact the brain is where you’re going
to start to see symptoms showing up. Okay so what Michael Flanagan is saying is
that this is probably linked to things like dementia – alzheimer’s things like
that. MS is a big one. The demyelination. So all of those things probably this
is one of the players going on and I’m thinking that with hot flashes this
could also be a player going on. Because you have the pituitary and
hypothalamus controlling regulating hormones and if that normal pressure
hydrocephalus happens to be impacting that area of the brain you’re going to
have dysregulation of hormones and they’re going to be just like going haywire.
And then you have hot flashes and things like that. So I’m leaning towards that
type of an explanation which I think can be a really cool investigation for
people to do that are much smarter than me and have really crazy awesome
technology that can measure those things.

Dr. Leach:  Right and I love as much as probably you love the
idea and knowing the mechanism of this, however; I think a really big takeaway
potentially for any woman suffering with hot flashes is that hey we’re not
saying it’s gonna get rid of them but it potentially could. NUCCA care or upper
cervical chiropractic care.

Dr. Slagel:  Yeah if a woman would ask me if I can help with
her hot flashes my response would be NUCCA has helped with hot flashes before
why not again.

Dr. Leach:  Right.

Dr. Slagel:  I don’t know.

Dr. Leach:  Yeah.

Dr. Slagel:  The other explanation that I
think is a lot more simple that most NUCCA doctors would tend to gravitate
towards is more of an explanation of biomechanical stability. So if the person
has their head and neck shifted out of place and it’s causing a certain posture
pattern to develop in their body. Then their energy resources have to go to
staying upright and once you get this fixed and their body straightens up they
have all that extra energy to go towards healing in their body and regulation
and stuff like that. Which is also a good theory. I just wonder if that’s all
of it.

Dr. Leach: And that’s the traditional chiropractic because
traditional chiropractic is our neuromuscular skeletal system. Right. There’s
chiropractic subluxation in our spine. Is it going to affect the nervous
system? That’s traditional chiropractic but as we’ve seen lately with Dr.
Rosa’s with Flanagan’s all these authors and all these researchers we’re seeing
that when we correct the upper cervical spine it’s not just the neurology that
we’re affecting. We’re affecting the hemodynamics and the hydrodynamics just
like you said. Dr. Evan and I have done a lot of this research review on this
show already and so it’s interesting to think about both of those
possibilities. Could it be one? It’s potentially both. Neurologically speaking
we could potentially find the pathways of what could be going on with potential
pressure on the brain stem or dysafferentation from the upper cervical joints.
There could be a multitude of explanations which further research could
identify.

Dr. Slagel: Yeah. The bigger picture with the hormone
regulation thing is think of all the other different hormone issues that people
have. A lot of different hormone imbalances and things. There’s all kinds of
secondary and tertiary conditions created from all of that.

Dr. Leach: Absolutely.

Dr. Slagel: So if we could pinpoint certain trends in
hormone conditions that we can consistently help with I think it’s just better
for everybody. But we haven’t really started down that road yet as far as
research with with upper cervical, especially NUCCA, we haven’t started with
that research into hormone regulation as a result of correcting that subluxation
yet.

Dr. Leach: Right. It’s interesting, again this is completely
anecdotal not in the research, but another patient that we had around that time
he reported that he had tried everything to lose his last 5 to 10 pounds that
he could never get rid of and he said NUCCA care was finally the thing that
helped him lose that. And you think any regular person is going to say what?
How is adjusting the neck help you to lose 5 pounds? But it has to do with
hormones and they understand now the way that you work out, the way that you
challenge your body, has an effect on the hormones. The way that you eat. The
frequency of eating. All these different things that have an effect on your
hormones to all of their risk factors; smoking and obesity. Obesity obviously
there’s a metabolic issue there and that’s gonna affect hormones. And smoking
with all the toxins could potentially affect hormones and all kinds of
different things. And not to mention the stimulant of the nicotine and how
that’s going to affect cortisol in the body etc.

Dr. Slagel: Yeah

Dr. Leach: So yeah. A lot of different things here.

Dr. Slagel: Yeah. So if this is a piece of the puzzle that
needs to be fixed and we got to figure out how this works so that we know who
we can help the best and then we can get them the care that they need.

Dr. Leach: Yeah. It’s interesting to think about to, I try
hard to make sure I don’t over promise things to my patients. It’s real easy
when they come in, “I have neck pain. I have headaches.” All these
things that we’ve helped out with so much to be like – Yeah. We can help you.
It’s always that caveat to say, “If your headaches are related to the
misalignment in your spine and then obviously we’re going to help because
that’s what we’re going to get corrected.”

Dr. Slagel: Yeah.

Dr. Leach: So it’s always thinking about getting to the
cause of why the body is having these symptoms, or conditions, or problems and
that’s why the caveat statement of, “Can we help?” Well. We’ve helped
before but we don’t have an exact test to show that beforehand – yes this NUCCA
care will help, yes this upper cervical care will help with your hot flashes.
It’s like well we can see if you have a misalignment and then we can correct it
and see if you get better. Yeah.

Dr. Slagel: How cool would it be if we had like an upright
MRI or something that measured the hydrodynamics so that we could see..

Dr. Leach: See exactly where.

Dr. Slagel: That’s where it is. Yeah. So then when we
correct this we should see that’s flowing. Proven.

Dr. Leach: That would be phenomenal and it’s possible.
Technology gets better and better every year you. There’s Blair doctors out
there that have cone beam CTs in their office. Who could have imagined ten
years ago that that would happen. So imaging is getting more available. It’s
getting more affordable for smaller clinics to have so the potential there is
pretty good. Maybe not immediately but eventually.

Dr. Slagel:  Yeah. I’m hoping that this
paper just starts to spark some interest in it. I understand this is one case
study and it doesn’t really answer a whole lot of questions. It’s just like –
Hey guys look at this. This happened. Cool. Let’s look at it. So I hope that
sparks interesting and can grow and develop what we do so that we can get the
right people in the door.

Dr. Leach:  Absolutely. I hope it can definitely spark that
research but I hope that it can actually spark those patients that potentially
are significantly suffering from hot flashes. It doesn’t sound like – oh that’s
a big deal – but sometimes it’s really bad and women are off to dinner
with their friends or family and they had this hot flash and they’re just
profusely sweating and it’s embarrassing. It could really help the quality of
life. So yes this is a case study of “N” equals one. There’s
anecdotal stuff but anybody who’s desperate enough that sees this they could
potentially say, “Hey I’m giving it a shot. I’ve tried everything else and
nothing’s helping. I’m going to give this a shot.” And it could
potentially help them. If we can help that one person that’s worth it.

Dr. Slagel: Yeah and I would also say that if anybody has
any other theories, or ideas, or possible mechanisms let me know because I’m
really interested in trying to parse out what exactly is going on here. So
that’s the open invitation.

Dr. Leach: Absolutely. Yeah we can get a conversation going
in the comments section below that would be pretty cool. For sure. Any last
thoughts on the summary about your patient here doc?

Dr. Slagel: That’s all I got I just wanted to make that case
known. So here we are.

Dr. Leach: Awesome. Well thanks for coming on. I appreciate
you sharing your research and writing this up and taking the time. You don’t
get rewarded for this kind of stuff but you put the effort in so I appreciate.
I appreciate it. We appreciate it and I’m sure the people that this is going to
help do appreciate it as well.

Dr. Slagel: Absolutely, man. This was fun thanks for having
me.

Dr. Leach: Awesome. Absolutely we’ll talk to you soon all
right.

Dr. Slagel: All right.

Dr. Leach: Okay. That’s it for this episode. So what did you
learn that fascinated you or surprised you about their research today? Join or
start the conversation in the comments below. Hey, thanks so much for watching.
To watch more of our research shows click or tap the screen right there to
subscribe to the channel. Click or tap the screen right there. Until next time,
I’m Dr. Kevin Leach with The Upper Cervical Chiropractic Research Show bringing
awareness to conservative primary spine care, upper cervical chiropractic care,
and traditional chiropractic. Until next time, take care and take care of your
spine. It’s the only one you’ll ever have.