Ayla Wolf  00:00

When the neck is involved, the pinwheel sensation changes based on whether their head is in flexion or extension or turned to the right or the left. If that pinwheel sensation changes, that's usually one of my clues to say, Okay, there's something going on with the neck that's interfering with the sensory integration of this trigeminal nerve in the face and the head.

 

Sophia Bouwens  00:26

Welcome to the life after impact podcast where we do a deep dive into all things concussion and brain injury related. We talk about all the different symptoms that can follow brain injury, different testing methods, different types of specialists out there and different therapies available. I'm Sophia Bowens, and I'm here with Dr Ayla Wolf, and we will be your guides to living your best life after impact. Hi, Ayla. How are you today?

 

Ayla Wolf  00:56

I am good. Somebody almost ran me off the road on the way here. Oh

 

Sophia Bouwens  01:00

my gosh. What happened?

 

Ayla Wolf  01:02

I just pulled out of my driveway, and obviously it snowed last night, and the road had not been plowed where I live, and so there was a good probably four inches of snow on the road, and this car was coming towards me, and they were honestly speeding, given that there was four inches of snow on the road, yikes. And they were in the middle of the road, and I tried to get over as far as I could, and they still, just, like, would not make room for me, and so I had to literally, like, go onto the shoulder of the road in, oh goodness, just so that they didn't hit me head on people I didn't know, maybe their depth perceptions a little off.

 

Sophia Bouwens  01:38

 That's a way night really nice. We gotta give them the benefit of the doubt. As a neurotherapist, like, oh, there might be other things going on, right?

 

Ayla Wolf  01:46

You know, I hardly ever honk my horn, and much less after a car has already passed you, but I literally had a moment where I was like, I feel like I need to honk my horn in this situation, this person practically ran me off the road in a snowstorm

 

Sophia Bouwens  01:58

After my world travels, being in countries where they use, like horn honking as a discussion, like in Egypt, they use horns as a way of communicating on the street. And in Latin America, they use them all the time. I've gotten much more liberal with the horn, new thing in America. So I'm not always super shy. I'm glad you You did it, even if it was after the fact. Well, I'm excited for our topic today on neck injuries as it relates to brain injury, because it's really close to my heart and my car accident when I was hit by that drunk driver, I don't remember any of it, but I suspect my head bobbled quite a bit, hit the steering wheel, which is why I broke my jaw on both sides. I lost teeth, and I think it also snapped back pretty hard, which is how I broke my occipital condyle, right where your neck joins your head.

 

Ayla Wolf  02:46

That is a serious collection of injuries.

 

Sophia Bouwens  02:48

It was quite a mess. But I think that in my own recovery, paying really close attention to my upper cervical and my cervical proprioception, my cervical system, my neck in particular, has been really helpful, life changing for me. In my recovery, the brain injury component was huge, but also the neck injury, which drives a lot of symptoms, and I find now in my recovery, 10 years later, that if my neck is off or out, I notice, and that's my alarm. To really go in and take care of it, I have to really prioritize my neck recovery. So I'm excited to help our listeners understand how much their neck can be playing into symptoms and how it might be missed or under emphasized.

 

Ayla Wolf  03:38

Absolutely and in your recovery, what are some of the therapies that you have found most effective for you?

 

Sophia Bouwens  03:45

My life changing therapy has been Atlas orthogonal, which is a very specific adjustment to the upper cervical c1 and c2 atlas and axis. I had manual adjustments of my Atlas done by other chiropractors, who are great, but it did not do the same thing as an upper cervical specific adjustment. What I love about this adjustment is it's very gentle and very precise, but it has been completely life changing. It gave me back my ability to swallow without choking. It gives me a really nice relief of anxiety and stress when that gets high, because I notice that's one of my first signs, is like, I get more anxious about things like, Oh, I wonder if my Atlas is out, and that has been completely life changing. I didn't believe it in the beginning that it would be my friend was telling me about it, that I should do it. Finally, I just bit the bullet and did it, and it has been amazing. So that, in particular, I'm very passionate about craniosacral. And acupuncture, of course, have been very helpful as well. Craniosacral is like a light, gentle massage. You do cranial sacral work in your practice?

 

Ayla Wolf  04:52

I do some of it, and when I feel like people need a lot more of it, I tend to refer out just because I don't have a lot. Of the time to do the deep focused, you know, hour-long sessions. But I did, I've studied it and a number of different ways, through both the Upledger Institute. And then I did some biodynamic craniosacral training as well with Todd Jackson out in Portland, Oregon, a long time ago. And I do find it to be very powerful. I also, because of your introduction to Atlas orthogonal, I have found that to be helpful for me too. Because I have a what they call a military neck, I have completely lost the cervical curvature in my neck. When you look at my X ray, it's pretty crazy. It is just perfectly straight, right? And what I have noticed is that there are times in CrossFit where if I'm doing a lot of overhead lifts, where I'm having to catch the barbell above my head, you tend to land with a bit of a forward head posture. And when I do that repetitively, sometimes it throws my neck out in a way where, when I try to swallow, I literally feel like I've got a vertebrae jamming in the back of my throat. It's very yucky, scary feeling, and that's when I know I'm like, Okay, time to go to the chiropractor.

 

Sophia Bouwens  06:07

a specific one, right? Particular about that. Well, I think this is really important. A lot of our neck injury symptoms can mimic concussion symptoms, which I think is overlooked a lot by medical providers and by patients not understanding fully that connection. So I would love to dive in, just like defining first what neck injuries are. I think it kind of goes hand in hand. Many people know. But then some of the nuances about different types of injuries, whether it's tension or maybe a visual, proprioceptive components that are different, which is like where your head is in space and how your eyes move with it, and then joint position sense. There's a lot to dive into there.

 

Ayla Wolf  06:49

There's a ton. And I think big picture, it makes the most sense if we stop thinking about the brain and the neck as being two completely different things, yes, and recognize that they are constantly working together in terms of all of our different sensory systems, and so when we start to look at it more from a sensory integration lens, then a lot of the therapies that are most effective and most helpful start to make more sense too. But I think that you know, for for me, I have a very long giraffe neck, and I spent 15 years doing martial arts and so, and I was in a position where I was often training with men, because there weren't any women where I was training, and I was working, or I should say, I was training with younger men. I, you know, I was in my 30s. They were like teenagers or, you know, and they were, they didn't like training with a woman like the ego was a little bit, you know, not fully developed to the point where they could, like, tone it down. And so I was getting punched in the face really hard by these 18 year olds who had a chip on their shoulder about even being paired up with me just to practice,

 

Sophia Bouwens  07:55

oh, my goodness.

 

Ayla Wolf  07:56

And I have such a long giraffe neck. And I believe that at the time it was, it was very weak back then, and so I was actually getting a lot of concussions and sub concussive hits to the head and a lot of trauma to my neck as part of this repetitive training in an unprofessional environment, really, where, you know, my safety was really not a concern. Clearly, yeah, and I was just trying to hold my own and not doing a very good job of it. And so I have come to, you know, pay much more attention to a lot of the research that talks about the importance of neck strengthening, especially for like female soccer players, or just women in general, tend to have longer necks, thinner necks, and not as much neck musculature.

 

Sophia Bouwens  08:42

And the PT world, where I work a lot alongside of them, strengthening component is huge, but I think that can be undermined, because, as you said, this study showed that soccer players who did neck strengthening exercises had less incidences of concussion.

 

Ayla Wolf  09:00

statistically, they were finding that the athletes that did consistent neck strengthening exercises ended up not experiencing as many concussions. So they were finding that strengthening the neck was a preventative factor for concussions in that sport. And it makes perfect sense that the stronger your neck is, then the less force you have in terms of your head bobbing back and forth, right if you can actually brace your neck muscles, I think that, you know, when I look at some of these UFC fighters that have a very long career in fighting, they've got no neck, right? Like, it's just literally a head and solid muscle, right? And so I was like, okay, like these, these people with barely no neck, or incredible neck girth, right, where it's just this huge neck that's all muscle. Well, that's actually a protective factor that's helping them to have longevity in their sport where they're getting punched in the face repeatedly. And so I think that, you know, the the MMA world has really acknowledged the importance of neck strength, and I think that especially with female sports, we they've been a little slow to catch up to that, but I think that the awareness is growing and that neck strengthening is hopefully starting to be a much more regular thing within female sports. But so many of the patients that I work with were in car accidents. They're just average people. They're not athletes. They were in bad car accidents where they had really bad whiplash, like you just said. I mean, you were hit by a drunk driver. Your head slammed into the steering wheel and back again, possibly a couple of times, with enough force to break your jaw in two places. I mean, that's a lot of trauma to the ligaments in the neck, the musculature. You said you broke the condyle in the back.

 

Sophia Bouwens  10:57

Yes, I did.

 

Ayla Wolf  10:58

That's a lot of trauma.

 

Sophia Bouwens  10:59

It is a lot. And that enough is that is enough to drive a lot of the symptoms that come after a head injury or concussion as well, because the brain stem comes out of the brain and into the neck, so that's where they're so intricately connected. Those cranial nerves are those areas that feed all the sensory information in from our face and our face into our brain make a huge difference in how our brain operates and how we interpret the world, how we experience the world, and how we feel right with our head in particular, and the rest of our body as well.

 

Ayla Wolf  11:34

Yeah, so I thought it would be a good idea to talk about some of the tests that we do that have a little bit of a functional twist on them that can tease out the integration between some of these different aspects, between, say, headaches and neck trauma, or even eye movements and the neck as a way of, kind of highlighting how we do things a little bit differently to See this connection. And then when you have a lot of different what I call biomarkers that you collect during these functional exams, those then help to check back in with to say, Okay, I'm seeing this thing in my exam. If we then do a therapy, does this abnormal finding improve? And the more biomarkers we can collect, the more clues we get to then say, is our therapy the right therapy, and is this person actually getting better?

 

Sophia Bouwens  12:29

Which is so important, because oftentimes we just give a broad spectrum treatment and you get some improvement because you're doing a little bit for some parts of it, but when you can tease out exactly what might be driving what and how, then you can intervene more specifically and possibly do less and get better outcomes.

 

Ayla Wolf  12:50

Yeah. I mean, I Well, this is kind of getting into the weeds a little bit, but I had found that with some of the testing that I do, it actually guides me to say, oh, like at this point in time, I should not do acupuncture on the right side of the neck, based on this exam finding, but I'm only going to do acupuncture on the left side of the neck until these things equalize, and then we can start to, you know, do both sides. And so the clues have actually led me to perform very different treatments as well, which I think has lent to some good success and some good outcomes. So let's dive in.

 

Sophia Bouwens  13:26

Yeah. Let's dive into some of the symptoms that can come from neck trauma. Yeah.

 

Ayla Wolf  13:31

So first of all, I think one of the most common ones is probably dizziness, or what we now call cervicogenic dizziness, which is dizziness as a result of trauma to the neck, or something wrong with the neck, some kind of neck pathology, and

 

Sophia Bouwens  13:44

why and how can that come up? Because I don't think of the neck as being something that drives dizziness. You think of the head or the vestibular system.

 

Ayla Wolf  13:52

Yeah, it all comes down to receptors. So we've got different receptors in the skin of the neck, the muscles of the neck, the joints in the neck, and sometimes those receptors, if they're not functioning correctly, they can actually be sending the wrong signal to the brain in terms of how the neck is positioned, or how fast or how far it's turning, and what that can cause is a sense of dizziness. If there's a sensory mismatch occurring where the brain is constantly taking information from our visual system, our eyes and what the what we're seeing in the world, as well as from our inner ear and the signals from our vestibular system in the inner ear, and then it's taking information from those receptors in the neck. And it's saying, are all of these systems telling me the same information? And if they're not, because maybe the receptors in the neck are giving the brain the wrong information because of trauma, then all of a sudden there's a sensory mismatch, and the brain is saying, wait a minute, I'm getting two sets of data that don't add up, and now I'm not quite sure what. I am in space, and if I can trust my balance,

 

Sophia Bouwens  15:03

and that's super stressful for our systems, we can get a lot of anxiety or other symptoms like dysautonomia that can drive that as well as dizziness. And the neck locks down the muscles to control one of the systems too. So we can have a lot of neck tension and neck tightness, because the brain, or the brain stem, almost says, is how I interpret it almost says, like, we can't always trust this, so we're just going to control it, lock it down, make it tight.

 

Ayla Wolf  15:30

Yeah, if it's not really trusting the information that is this unconscious response is to say, let's just shut down our neck movement as much as possible by tightening all these muscles, or in a sense, by tightening up the muscles. You're trying to like the brain's almost trying to like up, regulate the information coming from those muscles by tightening them down. And so that's where I think that when the brain is having these unconscious responses that are causing the neck tension. Sometimes, if people say they've been in a car accident and they've had whiplash, and so then they're going to get massage therapy. I think in some cases, this is why people say, Well, I go, I get the massage done, and I feel good for an hour or two after, but then everything tightens up right away. And so whenever I have a patient come in, I always ask them about what therapies they're doing and how long of a relief they get. And if they're telling me that, you know, they do something, whether it's massage, acupuncture, a chiropractic adjustment, and then they're like, Oh, I feel good for a couple hours or maybe a day, but then everything tightens up again. Usually, the things that have been missed in that equation are the role of the eyes and the visual system and eye movements, in addition to maybe the instability coming from the neck or something going on with the vestibular system. And so usually this integration of senses, if these sensory mismatches are not cleaned up, that's often a scenario where people are not getting good relief from what should be, you know, some very great hands on therapies that otherwise people would would get really solid relief from.

 

Sophia Bouwens  17:08

And one thing, not to make any more complicated is we're not talking about yet, is the jaw, how the mouth can play a big role in that too. So neck tension, or jaw tension, clenching the teeth or having that can also make a big impact on balance. Yeah,

 

Ayla Wolf  17:24

and one of the tests that I like to do is I always grab my pinwheel and I test the three different branches of the trigeminal nerve on the face, and I ask the patient, you know, does this pinwheel, which is supposed to mimic pain by being just kind of sharp and Pokey, but in a controlled manner. So I'm asking the patient, you know, does this pinwheel sensation feel about the same on the the left side of the forehead compared to the right side, or the the right side of the cheek compared to the left cheek or the jaw right? So we're doing these three areas of the face and comparing right to left. And a lot of times it people might say, Well, yeah, it feels equal when their head is neutral. But then you have them turn their head and you do the same test, and all of a sudden something feels sharper, right? Or you have them open their jaw, and all of a sudden, maybe what once felt sharp now actually doesn't feel sharp, and so you can sometimes see that when the neck is involved, the pinwheel sensation changes based on whether their head is in flexion or extension, or turn to the right or the left. If that pinwheel sensation changes, that's usually one of my clues to say, Okay, there's something going on with the neck that's interfering with the sensory integration of this trigeminal nerve in the face and the head, because anatomically, you shouldn't really see a change in the trigeminal nerve based on head position. And so what we're really testing is more of this sensory integration at a you know, central nervous system level, right? How is this information being interpreted? Diving deeper, yeah, and with the jaw, you know, if people have a lot of jaw tension, what? What initially clued me into the importance of that was a paper that was looking at balance and people that had whiplash injuries, and they were putting in an intro, they call it intra oral dental appliance. So they were having people wear some kind of mouth guard that was customized to each individual. Wasn't just they popped the same one in everybody, right? So this was like individualized dental appliance that people were then wearing, and they were having them stand on a balance plate. And so these computerized balance plates can give a very high level interpretation of how much somebody is swaying when they're balancing, sure by measuring changes in their weight shifting in their feet. And so they could measure the degree of sway as somebody was trying to balance with their eyes. Eyes closed on this balance plate, and then they would pop the intra oral dental appliance in, and like, boom, there was an immediate improvement in their balance. And so it got me wondering, as somebody that practices acupuncture, well, it's like, I know that acupuncture is great for TMJ dysfunction and for jaw pain. And I yeah, I mean, I treat jaw pain all the time. But then I started to wonder, well, what happens if I have somebody with poor balance, and I'm doing assessments on their jaw, and I'm seeing that, oh, they have a lot of jaw tension, this pinwheel sensation is changing based on whether their jaw open or closed. And then I started to do acupuncture in points on the jaw and different muscles that we use for chewing, knowing that those muscles have an integration into the midbrain, and then this very specific pathway into the cerebellum that then is involved in balance and maintaining balance. And so I was having people do computerized balance testing, and then I'd get their score, and then I'd put the needles in, and then with the acupuncture needles still in their jaw, I'd have them do the same balance test, and I'd find that their balance immediately improved with these needles in their jaw. Wow. And so I was saying, Okay, well, you know, this could be a cool party trick, if it's only something that once you take the needles out, then their balance, you know, gets worse immediately. But so that's why, you know, again, I'm not into party tricks or magic. I'm trying to make lasting changes for people. But what I found was that when we would, you know, do several different treatments with needles in their jaw and work on their neck, that over time, indeed, these people's balance were consistently improving over time, good.

 

Sophia Bouwens  21:45

So what do you think are some of the things that people might not suspect are symptoms from their neck? What

 

Ayla Wolf  21:52

the there is research looking at neck trauma that says that people can actually have changes in their vision, in terms of blurry vision and changes in depth perception from neck injuries. And I think that most people might not make that leap to say that if they're having blurry vision, it's because of trauma to their neck. So those are two that I think are kind of important to highlight. Is that actual vision changes can even arise from neck trauma, from

 

Sophia Bouwens  22:19

neck alone, so not the optometrist might not be helpful or as helpful

 

Ayla Wolf  22:24

Well, I think that's where I've heard a lot of people go in they say, you know, I'm having some of this blurry vision, or these vision symptoms after my concussion, and I went to my eye doctor and they tested my visual acuity, and they said that it's normal. And so I think what's happening in a lot of cases is that people are only having one small part of an eye exam performed, which is visual acuity. But what isn't being fully assessed is these, this broad range of different eye movements. And so I think that what again might be getting missed is that if people's eye movements are not being fully assessed, then eye movement disorders are getting missed, and the association between how those eye movement disorders affect the neck are then also getting missed. And so, for example, if somebody has an ocular misalignment where, say, their left eye becomes positioned more outward or laterally deviated, they might unconsciously want to turn their head to the right to try to, like, bring the world back into alignment. And so sometimes you can have somebody walk into your clinic with a constant head tilt to the right, which would then, of course, throw off the muscles in the neck and cause chronic neck pain. Or you can have an ocular misalignment in the vertical plane, where, if one eye is positioned higher, somebody might tilt their ear towards their shoulder to try to, you know, unconsciously bring the world into a even horizontal plane and not even realize they're doing it. And so if somebody's walking around with either their head, you know, turned one way or tilted one way, that's going to cause a lot of chronic neck pain. And if the eye alignment issue is not getting identified and corrected, then that just sets people up for chronic neck issues. So for

 

Sophia Bouwens  24:14

that kind of therapy, my intervene with eye movement exercises or visual components neuro optometrists or occupational therapists who are well versed in eye movements. Who would you think would be some of the go to therapists to look for that?

 

Ayla Wolf  24:27

I think it's really important that people do find some kind of eye doctor who specializes in concussions and brain injuries, whether that's a neuro ophthalmologist or neuro optometrist or just an optometrist who's done additional training and has more experience analyzing different eye positions, eye movements, even within the world of eye movement disorders and kind of this ocular motor system, I would say there's a bit of a argument on. Going argument over, what does it make sense to just immediately put somebody in prism glasses to correct a misalignment of the eyes, versus having them do vision therapy? And for me, and you know, the way I've approached medicine my whole life, is even if the vision therapy is more work and more time and more money, it makes more sense to do that, versus giving somebody a band aid that corrects their vision for them and then allows those muscle the muscular imbalance and the misalignment to remain. And so vision therapy. But again, it takes time, it takes money, it takes commitment. And so I think that, you know, my preference would be for patients to do the vision therapy and see if they can correct their misalignments of the eyes through actual exercises versus just wearing prisms. But I also recognize that there are times when there may be other things going on that need to be addressed first. And so like, for you, I mean, if you have brought these broken bones and broken jaw and you know, you might need to be like doing other things that take precedence over vision therapy right, right out of the gate, make sure I can walk and dress Right exactly. Yeah, let's make sure you can walk, talk and dress yourself and eat before. You know, throwing you into eye exercises, sure,

 

Sophia Bouwens  26:21

but then once you get that correction with the visual system, a lot of things can get cleaned up too. So it's, it's a balance kind of binding the pathway forward, having someone who's well versed in those kinds of things and helping with that can make a big difference for recovery.

 

Ayla Wolf  26:41

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