Orthodontics and Headaches

I had 2 similar cases since the beginning of the year that made me realize it would probably worth blogging about it to let the word out. Pediatric and adolescent headaches can be frustrating to figure out. Often the easy causes have already been ruled out by the time they show up in the office.

I wanted to talk about one very specific type of headaches often affecting our young teens. These headaches tend to affect one side of the face, usually one side but sometimes both, tend to be in the temporal area, sometimes behind the eye. The pattern is random, coming in cyclical episodes that come and go. There is no other associated trigger identified, from diet, sleep, stress, cervical spine, food, etc. The only matter in which I was able to successfully identify them and treat them was in some patients for whom the location was very close to the jaw, and there was some mild painful information along the soft tissues on the side of the head. However when doing some intraoral palpation along the posterior muscles of mastication, I was able to reproduce quite a bit of the lateral headache pain pattern by findings trigger points of the posterior internal muscles of the jaw.

Some orthodontic treatments will require pretty aggressive positional changes of the lower jaw in relationship to the upper jaw, as well as some lateral shifting. This will obviously result in better long-term alignment for the purpose of not only cosmetics but also proper chewing and occlusion, and sometimes improved airway opening. However the transient stress on existing particular structures of the jaw and supporting muscles of mastication can be symptomatic in the form of headaches and the distribution of the intraoral muscles, while the jaw itself can be minimally painful during normal activities such as talking and chewing.

In the case of both patients, once we isolated the pain producing source of the headaches, we were able to track back the cyclical episodes more or less following the adjustment of the patient's orthodontics, usually 5 to 7 days after tightening the braces or adding internal banding between the top and lower jaw. The combination of trigger point therapy in the internal muscles of the jaw, gentle joy adjustment and other soft tissue supporting measures seem to be quite helpful at relieving the transient headaches episode.

Bras, neck and shoulder pain

This is a long overdue blog and patient resource video. I've been thinking about it off and on for several years every time I stare at strap grooves in my patients trapezium when I look at them from the back. Half the world is at risk of aggravating neck and shoulder pain by not wearing the appropriate bra, it should not be a mystery and I hope that the video will shed some light on the process.

https://www.youtube.com/watch?v=7tnr6cJu66I

Squatting exercises for knee problems

I frequently run into patients who tell me they have had to give up squatting exercises because of aggravated knee pain. This is extremely unfortunate since squatting is 1 of the best exercises to functionally engage the core, upper gluteal areas, lower back, and squats mimics the type of strength and stability posture we need for real-life activities.

It's all the more unfortunate since there is a pretty easy alternative to do a squat without causing me pain. Notice that you can use a ball of any size including something pretty small or even a foam roller, unlike the large ball that I use for the demonstration video.

https://www.youtube.com/watch?v=1zpZeza8lKU

Sleep

https://chriskresser.com/8-tips-for-beating-insomnia-and-improving-your-sleep/

I am rarely a big fan of these "10 things to do for XYZ" articles, but I'm going to make an exception for this 1 because it really is relevant , concise, practical and hits a few topic that are not getting enough air time as far as sleep problems.

Home soft tissue treatment for symptoms of carpal tunnel

We finally got around to recording the instructional video for patients using the Armaid tool to control symptoms of carpal tunnel associated with repetitive soft tissue strain of the upper extremity. It's going to be much more effective if we can have a 15 minutes set up time in the office, to make sure that each patient can properly locate the trigger zones, since everyone's primary area of soft tissue entrapment can be a little bit different.

https://studio.youtube.com/video/6dR7TZnJtnM/edit

Why does it always hurt here ???

scapula pain

https://www.youtube.com/shorts/lQV73P1dves

Chronic superior scapular pain is a pretty common complaint and the source is not always well understood by patients. It's really boils down to the basic mechanics and sagittal alignment of the neck shoulder and thoracic spine. When the neck is aligned over the shoulders, and the shoulder is in line with the trunk rather than rolling forward, the levator scapula, as well as the upper rhomboid muscles rest with normal tone. If the head migrates forward and the shoulder rolls forward especially if chronic such as often associated with seated posture working on computers or looking down, both of these muscles will be constantly overloaded in the static manner and develop chronic myofascial scar over time.

Properly stretching the scalene muscle

It's pretty routine to incorporate some degree of stretching as part of the patient's treatment plan, including in the cervical spine. Some stretches are pretty easy to remember and pretty straightforward for patients to remember when they get home. However 1 of the stretches that I find patients doing incorrectly high percentage of the time pertains to the scalene's. Doing it correctly is pretty important because failing to do so means you spending a lot of time with no return on investment, at best, and at worst, you can actually make your particular problem worse.

The scalene muscle group is located interior and slightly lateral to the cervical spine, and part of it attaches to the 1st rib. Both of these anatomical location distinctions requires some special positioning, set up, and order in which you incorporate the different directions of the stretch. Scalene muscular dysfunction is often associated not only with anterior cervical discomfort, but overload pain along the left scapula, as well as vague symptoms radiating into the upper arm, since the brachial plexus has to exit through the scalene's. If you're not setting up the stretch correctly you just don't get the results which is frustrating to the patient investing time in stretching.

https://www.youtube.com/watch?v=t6greMAkJLU

Ibuprofen use and the increased risk of chronic inflammation

https://www.science.org/doi/10.1126/scitranslmed.abj9954

After a recent trip to Europe to visit my father, I was reminded of some strong cultural differences on how we approach many different aspects of life, and in this particular instance, whether or not you view medication as mostly beneficial or something to avoid whenever possible.

In this instance the discussion centered around over-the-counter pain medication, which 1 of my family members was trying to ration pretty drastically even when facing some pretty gruesome background pain associated with transient medical treatment (frankly more drastically than I would have done under the same circumstances). This struck me since I had just been catching up on some recently published research during my 15 hour plane ride, and had a couple touchy discussions just prior to my departure with some patients who I felt were overusing Tylenol and ibuprofen into potentially harmful ranges.

Compared to other countries,the US average population reaches for over-the-counter pain medication much more readily than other counterparts around the world. Part of it is because culturally we tend to have a lower threshold for what we consider as acceptable pain, and for the fact that we consider all pain as being of no benefit and needing to be silenced at all costs. There is also a strong bias for the benefit of pain medication and a strong bias against recognizing the side effects of those medications, especially if taken within the maximal safe limits listed on the label. This is really unfortunate because the maximum safe dose listed on a bottle of ibuprofen or acetaminophen does not mean that it's safe for everyone under all circumstances, and it's definitely not to indicate that those doses are safe to take on continuously, which is what a lot of people do on a daily basis. (An acquaintance I know who's a nephrologist jokes that Tylenol pays his mortgage, since it causes so much renal failure even in moderate doses)

Another dark side of ibuprofen in particular, and actually all NSAIDs, is that they are involved in perpetuating a chronic inflammation cycle, and thus delaying recovery from an acute painful episode, possibly setting up the stage for chronic low-grade pain. This article is certainly pretty technical, but but it boils down to this: the chemistry of early inflammation that causes pain triggers a secondary response to then downward modulate that very initial inflammatory response, leading to decreased pain. If you significantly interfere with that initial inflammatory neutrophil response by doing such things as using ibuprofen, you run the risk of aborting the secondary downward modulation.

This is not to say that there's never a time and a place to use ibuprofen, but it should be done so very sparingly, and primarily as a short-term pain management when patients cannot manage some essential tasks through an acute episode. I see a lot of people who routinely start taking large amounts of ibuprofen at the very onset of a mild to moderate episode under the flawed understanding that it will be beneficial to dampen inflammation, when they are better nonpharmacological alternatives that do not interfere with the normal resolution of pain and inflammation.