Palatal Myoclonus Can Be Corrected!

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Rhythmic palatal myoclonus (RPM) is a rare movement disorder consisting of continuous synchronous jerks of the soft palate, muscles innervated by other cranial nerves and, rarely, trunk and limb muscles.  Patients with essential RPM usually have objective earclicks as their typical complaint which is rare in the symptomatic form. Eye and extremity muscles are never involved. I am a Chiropractor and work mainly with chronic neurological conditions such as PM. I have developed a method called functional cranial release that has given PM sufferers their life back. Please feel free to look over some of the video’s on this site explaining what I do and some testimonials from PM patients I have treated. John Lieurance, D.C.  

How does FCR help PM?

The tensor veli palatini is innervated by the medial pterygoid nerve, a branch of mandibular nerve, the third branch of the trigeminal nerve (CN V) – the only muscle of the palate not innervated by the vagus nerve.

A focal, hyperintense, nonenhancing lesion and enlargement of the olivary nucleus with a coexisting pontine lesion suggest an injury of the dentato-rubro-olivary pathway, findings that are consistent with hypertrophic olivary degeneration). (3-5)

Hypertrophic olivary degeneration is a form of trans-synaptic degeneration caused by an insult to the neuronal connections of the dentato-rubro-olivary pathway (i.e., the triangle of Guillain and Mollaret) by a primary brainstem inury. (1,2) Disruption of this neuronal pathway affects the reflex arc that controls fine voluntary movements, resulting in signs and symptoms such as palatal myoclonus and dentatorubral tremor. (2,3) This type of astrocytic degeneration has been reported in both children and adults; there is no predilection to either sex. (4)

At any given time following a primary brainstem injury, there may be focal enlargement rather than atrophy of the inferior olivary nucleus. This finding is characteristically identified on MRI. However, failure to properly identify the enlargement may result in a misdiagnosis (e.g, a tumor or multiple sclerosis). (1,5,6)

The Guillain-Mollaret triangle is composed of the dentate nucleus, the red nucleus, and the inferior olivary nucleus. The red nucleus and the ipsilateral inferior olivary nucleus are connected via the central tegmental tract, and the dentate nucleus connects to the contralateral red nucleus through the superior cerebellar peduncle. There are no direct connections between the inferior olivary nucleus and the contralateral dentate nucleus. (1-4) While hypertrophic olivary degeneration can occur with any focal lesion that involves the dentato-rubro-olivary pathway, it is typically associated with lesions that involve the superior cerebellar peduncle (dentatorubral tract), the dentate nucleus, or the central tegmental tract. (2,4)

The triangle is defined by dentate efferents ascending through the superior cerebellar peduncle and crossing in the decussation of the brachium conjunctivum inferior to the red nucleus, to finaliy reach the inferior olivary nucleus (ION) via the central tegmental tract. The triangle is completed by ION decussating efferents terminating on the original dentate nucleus via the inferior cerebellar peduncle.

The central tegmental tract has several connections to the nucleus ambiguous, which gives rise to efferent motor fibers of the vagus nerve that innervates the muscles that control palatal movement. (2,5)

The clinical manifestations of hypertrophic olivary degeneration probably reflect a loss of inhibitory control as a result of disruption of the dentato-rubroolivary pathway. (1-3)

Below from this site:

http://www.hindawi.com/journals/criot/2013/934386/

The red nucleus receives most of its fibres from the dentate, but there are also contributions from the emboliform and globose nuclei. Efferents from the dentate nucleus ascend through the superior cerebellar peduncle or brachium conjunctivum and decussate in the caudal midbrain to finally reach the contralateral red nucleus. The rostral third of the red nucleus (parvicellular part) is the end point of the dentatorubral pathway where they have asymmetrical synapses. Fibers from the parvicellular part of the red nucleus descend ipsilaterally via the central tegmental tract to reach the dorsal lamella of the principal inferior olivary nucleus. The triangle is completed by decussating fibers originating from the inferior olivary nucleus, forming the largest component of the inferior cerebellar peduncle (corpus restiform) and terminating on the original dentate nucleus [3]. M. Goyal, E. Versnick, P. Tuite et al., “Hypertrophic olivary degeneration: metaanalysis of the temporal evolution of MR findings,” American Journal of Neuroradiology, vol. 21, no. 6, pp. 1073–1077, 2000.

This is a bidirectional pathway, a coupled system likely to be of a feedback function, because there are also projections from the dentate nuclei to the contralateral caudal inferior olivary nucleus. The inferior olive has an intrinsic slow, rhythmic, and spontaneous activity [6]. M. Goyal, E. Versnick, P. Tuite et al., “Hypertrophic olivary degeneration: metaanalysis of the temporal evolution of MR findings,” American Journal of Neuroradiology, vol. 21, no. 6, pp. 1073–1077, 2000.

it is olivary deafferentation that is thought to trigger the hypertrophic degenerative changes [3].

A midline lesion at the level of the brachium conjunctivum will result in bilateral HOD as the ducassating fibers of the right and left dentate olivary tracts are likely to be involved.

Many collaterals from the reticular formation and from the pyramids enter the inferior olivary nucleus.

Removal of one cerebellar hemisphere is followed by atrophy of the opposite olivary nucleus. Wikiapedia

The majority of red nucleus axons do not project to the spinal cord, but instead (via its parvocellular part) relay information from the motor cortex to the cerebellum through the inferior olivary complex, an important relay center in the medulla.

Inferior Olive Function[edit]

It is closely associated with the cerebellum, meaning that it is involved in control and coordination of movements,[1] sensory processing and cognitive tasks likely by encoding the timing of sensory input independently of attention or awareness .[2][3] [4] Lesions to the inferior olive have been associated with a decreased ability to perfect highly specialized motor tasks, such as improving one’s accuracy in hitting a target with a ball.[5]

Funct Nuero

Alternatively, the downward smooth pursuit pathway could pass through the dentate nuclei.

Pierrot-Deseilligny C, Gaymard B
Service de Neurologie, Unité INSERM 289, Hôpital de la Salpêtrière, Paris, France.
Bailliere’s Clinical Neurology [1992, 1(2):435-454]

Strategies which activate reflexogenic pathways such as optokinetic stimulations along with voluntary planned movements such as “no no” and “yes yes” head movement ( I usually do this with a head tilt ipsilateral to the weaker cerebellum and opposite to the weaker prefrontal cortex) which may effect activation / afferentation to the inferior olivary nucleus through projections from the reticular formation (possibly some through the cortiobulbar pathways). There are several other tricks I’ve used that have worked with these cases as well. There may be some aspect of dentate activation with smooth pursuits downward which the reflexogenic aspect of a downward optokinetic would create. Generally the OPK that augments the myoclonus has been in a oblique direction. Something that can be done using an app on an iPhone or iPad (OPTOK).

The most interesting aspect of my success has involved the use of endo-nasal balloon manipulations. These are done specifically based on testing done with the patient standing. There are various anatomical area’s challenged by pushing lightly and looking for an unstable reaction. These findings correlate to body positions and specific balloon placements within the nasal passages. The patient is then placed in that position usually using pelvic blocks, head flexed or extended and the head turned to one side. An assistant will hold one of the legs in a slightly flexed position with the foot with inversion and dorsiflexion. The balloon is inflated so that it travels through the nasal passage until just before it begins to enter the throat when it is then deflated and removed. Generally either one side or both will be inflated per day. There are 6 positions that can be used (lower, middle and upper) and I generally will only inflate one area per side. I will do this along with the specific brain activation that seems to decrease the PM symptoms for 4 days straight. Every patient has been a bit different and there has been such a diverse presentation and reaction to treatment. Some seem to be improved more with the balloons and others with the activation / exercise strategies described above. I’m still working on improving my care with these cases as they continue to fly in from around the world to seek care at my office.

Incidentally I have been working with using endo-nasal ballon manipulations for almost 20 years on a variety of conditions including many neurological with much success. I teach these methods as a technique called Functional Cranial Release. You can see more on my web site www.FuncationalCranialRelease.com

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What do the balloon adjustments (FCR) do for Palatal Myoclonus?

Dr. John Lieurance can you explain what the balloons do? I have tried many of the “conventional” methods for treating this. Next is botox, if that doesn’t work I am interested in trying FCR.

Thanks for asking.  I’m still not 100% sure what the primary action the balloons is having for PM or that its multiple. My theory’s are that it could be mechanical see picture below as the manipulation the balloon makes is so close to the action of the the soft palate (also known as velum or muscular palate).

unnamed

The following are the muscles that can be involved in Palatal Myoclonus.

  1. Tensor veli palatini, which is involved in swallowing
  2. Palatoglossus, involved in swallowing
  3. Palatopharyngeus, involved in breathing
  4. Levator veli palatini, involved in swallowing
  5. Musculus uvulae, which moves the uvula

Notice above the proximity of the nasal cavity to the muscles of the palate/velum. Next look below and see the cranial bones such as the palatine bone, vomer and sphenoid. The vomer is midline nd is not depicted in the second picture but is very important and is manipulated with FCR.Gray174Palatine-Bone-Image

 

 

 

 

 

 

 

 

 

 

 

 

 

The second theory is that it’s neurological through the trigeminal nucleus and that the inflation is somehow interrupting the windup in the inferior olivary nucleus. Since the sinus’ are innervated through the trigeminal nucleus. The soft palate muscles are innervated by the vagus nerve, with the exception of the tensor veli palatini. The tensor veli palatini is innervated by the mandibular division of the trigeminal nerve. Somatosensory Trigeminal Projections to the Inferior Olive, Cerebellum and other Precerebellar Nuclei. This then corrects the dentato-rubro-olivary pathway that is dysfunctional in Palatal Myoclonus.

To date I have treated 26 cases of palatal myoclonus and have seen more success with these cases than failure. Most cases also have head pressure along with the “clicking” from the myoclonus pulling on the eustachian tube to the inner ear. I have found the head pressure almost always goes away with endo-nasal balloon adjusting (FCR) and the myoclonus has been relieved by the endo-nasal balloons on some cases but generally these cases also require specific activation of the brain described as functional neurological exercises. These exercises are based on a detailed neurological evaluation and also sacciometry testing. I also use Glutathione nebulized (GlutaGenisis) and PEMF of the brain to support the brain with it’s neuroplasticity (healing). Many cases have had the 4 day series and had complete resolution of PM. It should be important to note that some cases required follow up treatment. I generally see these cases for a 4 day course of care.   Some cases require follow series. I have seen some cases receive incremental improvements in the symptoms of palatal myoclonus. I

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How to cure Palatal Myoclonus or PM using Functional Neurology.

I just wanted to announce to the group I have begun writing a paper for publication in the medical journals. It’s interesting to embark on such a task as it gets one to really delve into the literature to better explain whats happening in the brain with various forms of brain activation in which seem to help create neuroplasticity that re-afferentates the inferior olivary nucleus which is the primary area that is an issue with PM. There are several aspects of my work that could have various effects to correct the myoclonus and in this paper I need to explain all possibilities. I’ll keep you in the loop as my work progresses. Please keep in mind that there will NEVER be a drug or injection or herb that will cure PM!!! All of these do not specifically effect certain pathways. Drugs and such can only increase or decrease brain activity and it is a global effect. What needs to happen with PM is you need to have very specific pathways activated in order to “rewire” the brain. Specifically the dentato-rubro and rubro-olivary (central segmental) pathways. But also there maybe be ways to activate the olivary nucleus to stabilize through presynaptic and postsynaptic pathways. As my work evolves I may be able to better treat the large variety of presentations that PM folks present to me. Sorry for rambling on but it’s exciting to be able to help such a horrible condition!

Memphis man finds relief of Palatal Myoclonus (throat Clicking) through unusual treatment with balloons.

This is an amazing story from Fox News in Memphis of a man with Palatal Myoclonus who was treated by Dr. Allen Goode who is a certified FCR doctor trained by Dr. John Lieurance, DC the developer of FCR. Functional Cranial Release or FCR is a method which has successfully treated many difficult neurological diseases through the use of specific endo-nasal balloon adjusting along with Chiropractic Functional Neurology. Dr. John Lieurance has successfully treated more Palatal myoclonus patients than any other single physician on the planet which makes him the worlds expert on the disease. He has many of these cases posted on his web site www.palatalmyoclonushelp.com where dozens of real patients share there struggles with PM and the successful results through the FCR treatment. Dr. Lieurance personally coached Dr. Goode with Joel in his treatment and hopes that eventually with the right combination of care Joel can live completely free of PM.

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Palatal Myoclonus successfully treated without drugs or surgery-naturally. Fast results!!

This was a young man who traveled from California to Florida to receive FCR. His condition was treated using endo-nasal balloon adjustments, PEMF, Glutathione nebulizer, and Functional Chiropractic Neurology. Dr. John Lieurance is leading the way in the treatment of Palatal Myoclonus and has treated more of these cases world wide than any other hospital, clinic, or single physician.

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Palatal Myoclonus can be successfully treated without drugs or surgery-naturally, see proof

This was a young man who traveled from Ireland to Florida to receive FCR. His condition was treated using endo-nasal balloon adjustments, PEMF, Glutathione nebulizer, and Functional Chiropractic Neurology. Dr. John Lieurance is leading the way in the treatment of Palatal Myoclonus and has treated more of these cases world wide than any other hospital, clinic, or single physician.

The below is this patient!

Essential palatal myoclonus following dental surgery: a case report.

Authors

Lam JH, et al. Show all

Journal

J Med Case Rep. 2013 Oct 14;7(1):241. doi: 10.1186/1752-1947-7-241.

Affiliation

College of Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK. H.P.J.Lam@sms.ed.ac.uk.

Abstract

INTRODUCTION: Various presentations of essential palatal myoclonus, a condition characterized by clicking noises and palatal muscle spasm, have been reported in the literature. We are reporting the first case of essential palatal myoclonus following dental treatment.

CASE PRESENTATION: A 31-year-old Caucasian man presented to our Ear, Nose and Throat department complaining of objective clicking tinnitus occurring immediately after he had undergone root canal treatment on his right lower third molar 3 months ago. Magnetic resonance imaging of his head revealed no abnormalities in the cerebrum, cerebellum or brainstem making the diagnosis essential palatal myoclonus. He returned a week later, and 20 units of botulinum toxin A (Allergan) were injected into his left tensor veli palatine muscle. He reported an immediate improvement; however, symptoms recurred 6 months later.

CONCLUSIONS: Dental treatment can be a trigger of essential palatal myoclonus. Botulinum toxin injections are an effective treatment for short-term relief of symptoms.

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After 8 months of relief from Palatal Myoclonus he is back for a 2nd FCR treatment.

Screen Shot 2013-11-10 at 2.26.38 PMAfter he had 8 months of relief from Palatal myoclonus from his first series of PEMF, Glutathione nebulizer, functional chiropractic neurology, and endonasal balloon adjusting which is called functional cranial release or FCR. This was done in Sarasota Florida by Dr. John Lieurance, who has successfully treated many cases of palatal myoclonus using these methods. To date he has treated more PM cases than any other single doctor world wide!

He can be reached at (941) 330-8553.

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Olivary Hypertrophy and Palatal Myoclonus

A 64-year-old woman had sudden onset of clouded consciousness, left hemiparesis, and dysarthria. She was found to have pontine hemorrhage on cranial computed tomography at the local hospital. Medical treatment was begun immediately, with subsequent gradual clearing of consciousness. She was admitted to our hospital 2 months later for the purpose of rehabilitation. Neurologic examination showed that she was alert and not demented. Although mild spastic dysarthria was noted, palatal myoclonus was not detected. Tendon reflexes were moderately exaggerated on the left side, with depressed superficial sensation on the same side. She showed intention tremor in the left arm. Ten months later, cranial magnetic resonance images disclosed an olivary prominence of the medulla on the right side on T1-weighted imaging (Figure, A) and a hyperintense ovoid area of the right inferior olive on T2-weighted imaging (Figure, B). This prompted us to reexamine the palate, and we found a palatal myoclonus with a frequency of 60 to 80 times per minute. The woman continues to have mild left hemiparesis, but lives independently.