Showing posts with label quality of life. Show all posts
Showing posts with label quality of life. Show all posts

Wednesday, November 25, 2015

Quality of Life Considerations in Migraine and Chronic Daily Headache Treatment

This was originally published as a Blog for www.ThinkBetterLife.com and my Highland Park Illinois office that serves Highland Park, Lake Forest, Dererfield, The entire North Shore, Chicago, Lake County and Cook County. The office is conveniently located on the Metra line North at the Fort Sheridan stop.  The office is dedicated to treatment of Chronic pian, TMJ disorders and sleep disorders including migraines, trigeminal neuralgia, and chronic daily headaches.
Migraines, Chronic Daily Headaches, Tension Headaches and the Trigeminal Autonomic Cephalgias are all extremely invasive and disruptive to overall quality of life.
Medications to treat these disorders are often dangerous and have multiple side effects that range from minor to life threatening.
Medication Overuse Headaches and Rebound Headaches can actually be worse than the original problem the medications are used to treat. Even ubiquitous drugs like Ibuprofen are responsible for thousands of deaths on a yearly basis and a host of GI problems.
The two ways to approach headaches treatment is to prevent the onset or to treat the actual headache when it occurs.
Preventing the onset can be the avoidance of headache triggers and /or drug treatment.
I am not discussing drugs for treating migraines in this paper but rather alternative to stand drug therapies.
An excellent alternative that is more effective than most drugs for most people is the Sphenopalatine Ganglion Block. There are several methods of preforming SPG Blocks some of which require a visit to the doctor and others that can be preformed by the patient in the comfort of their own homes. The Sphenopalatine Ganglion is the largest parasympathetic ganglion in the head. The block turns off sympathetic overload often called the Fight or Flight reflex that can be a major headache/migraine trigger.
The best method is the intranasal approach by the patient to be reviewed later in this article.
There are multiple methods of injection. The injection thru the Greater Palatine foramen is an intraoral injection that is routinely used in dentistry. Oral Surgery procedures often require this block for removing wisdom teeth. Many patients who have maxillary wisdom teeth removed experience a respite from migraines often for an extended time. More often than not the migraine relief is from the block not the removal of the teeth. The block can be done just to turn off a severe headache or as a migraine preventive. It is often accompanied by temporary facial numbness and numbness of the palate.
Injection can also be done extraorally either from above the zygomatic arch or through the masseter muscle. I prefer the approach that avoids the muscle. It is a relatively easy injection and can be done in the office. It is also done by some doctors using video fluoroscopy but that gratly increases the cost. This method of injection is the most effective and fastest onset often relieving the headaches in a minute or two.
This is ideal SPG approach for headaches that would put patients in the ER, migraines or severe headaches of several days duration, and especially headaches related to anxiety, stress and worry.
There are also three devices that can deliver local anaesthetic to the nasal mucosa that overlies the Sphenopalatine Ganglion. The three devices are the TX360 nasal applicator using the MiRX protocol. Its is intended for use for Trigeminal Neuralgia, Migraines, Cluster Headaches and Tension Headaches. It is essentially a high tech double barreled squirt gun that is designed to deliver anesthetic solution over the area covering the Ganglion.
The Sphenocath and the Allevio devices are simpler to use and may deliver the anaesthetic solution in a slightly superior position. The Sphenocath is the original device and the Allevio is a copy made by the Sphenocath ‘s original manufacturer.
My preferrd method when nasal passages are large enough is to utilize hollow cotton tipped applicators that use a capillary action to continually deliver anaesthetic over a longer period of time.
The beauty of this approach is that patients can self apply the block in minutes at an extremely low cost. They can turn off the headache faster than any drugs take effect and Lidocaine or other anesthetic can be used.
Side effects are feeling relaxed, turning off fight or flight response, reduced anxiety, increased parasympathetic actiity such a digestion, feelings of warmth and comfort, increased sexual desire and responsiveness, lower blood pressure and other positive effects.
The most effective method of eliminating triggers is through a diagnostic neuromuscular orthotic that can be created to decrease noxious input to the trigeminal nervous system that causes headache. The diagnostic appliance allows evaluation of the effect in a safe and cost effective approach prior to comencine and dental, orthodontic or orthopedic interventions.
The combination or SPG Blocks and Neuromuscular Dentistry may be the closest we will ever come to curing migraines and other trigeminal type headaches.
Drug treatments are directed at changing neurotransmitter and neuropeptide levels by drug interaction. Neuromuscular Dentistry and SPG Blocks do it by restoring homeostasis and eliminating noxious input to the trigeminal nervous system.
The noxious input causes the ultimate release of neuropeptides by the TrigeminoVascular System like CGRP or Calcitonin gene Related Peptide in the meninges in the anter two thirds of the brain which cause vascular headaches,
It also corrects input to the trigeminal cervical complex that is responsible ofr occipital headaches, while at the same time postural corrections of the head reduce excess cervical muslce activity and makes the spine, especially C1 and C@ or the Atlas and Axis more stable. The mechanics have been well explained in the Quadrant Theorem of Guzay.

Sunday, August 9, 2015

Severe Exacerbation of Lifetime Headache Problem: Migraines, TMJ, TMD, MPD or other problem. All tests are negative but quality oof life is being destroyed and medications are no help.

Paul's Question for Dr Shapira
Tell us about your headaches...:    I remember my mother taking me to the doctors when I was a child for random tension headaches. I've always been an over-thinker, which can cause anxiety and stress, potentially leading to headaches. Throughout my childhood and adult life, I had headaches hear and there (more frequent than the average person, I'd say), but nothing that a an OTC and a little time couldn't handle. It was never chronic or debilitating. All that changed on October 25th, 2014...

On that day, after a stressful year and a half, I was knocked down by the worst headache/migraine I'd ever had. I didn't know what it was, but I feared for my life. It was as though something was going to explode in my head at any moment.

In the months that followed, it never went away, and I was plagued with off neurological symptoms (felt like someone was pouring cold water on my head at times, odd sensations in random parts of my body, my eyes would hurt at night) but the most difficult thing was the pressure. Every day it felt like my head was going to pop. I was living as though any second I could die.

Though the some of the strange symptoms have subsided, the pressure and fatigue remain. The emanate from the base of my skull where my spine meets my skull. That seems to be the centerpiece, but it moves to the sides of my head just above the ears, and sometimes the top. Different positions rarely help.

I've seen two neurologists. One said it was atypical migraines. She's wrong, though they can rarely turn into migraines, that's not what they are. She started me on magnesium, melatonin and riboflavin as well as topamax to no avail. I moved on to another neurologist who's DX was Chronic Daily Headaches, and does nothing but through pills at me. I'll admit that the only thing that relieves the pressure and makes me feel somewhat normal is Soma, but it's short-lived, tolerance builds fast, and I feel we are not getting to the root of the problem. Klonopin also seems to help, which makes me think it's a muscle tension, possible TMJ issue.

I had a decaying tooth, so I even saw the dentist, who wound up doing 2 root canals and I went through a round of amoxicillin just in case there was an infection. I can say my teeth are now the best is town (after a whole summer of treatments), but dental stuff doesn't seem to be the issue. She just gave me a referral to be evaluated for TMJ.

I also saw my optometrist, he said everything looked fine; however, my vision had improved, and I had been wearing contact lenses that were too strong for awhile. He said this isn't the cause of my headaches, but it certainly isn't helping.

I am now seeing a Chiropractor 3x/week who says I have an Atlas Sublaxation, and a bone in my neck/base of skull is out of place and could be pinching nerves. Over time, he plans to put that bone back in place. I'm skeptical.

I have had a CT and MRI of the brain, all unremarkable. Last week I went for a Lumbar Puncture to rule out other things. I go over the results with my neurologist on Tuesday.

I'm growing weary, and this is all making me depressed. The side-effects of the meds also make me depressed. I'd love some input.

I have a past history of substance abuse, and have kindled with benzo's and other GABAergics. In fact, right before this happened, I was taking a substance called phenibut for my anxiety, and coming off of a high dose of gabapentin (which i was put on after coming off of Klonopin). My abuse days are over, but I wonder if it plays a role.

I am currently on the following medications:
Vyvanse (70mg/daily) - a mild amphetamine for ADD and unresponsive major depression
Klonopin .5mg 3-4x/daily PRN
Baclofen 10mg 4x/daily PRN
Soma 350mg 4x/daily PRN

I also take melatonin, magnesium, a B-complex, Fish oil/omega-3's and a multivitamin.

Any help, direction, or input would be greatly appreciated, as this leads to such a poor quality of life that living seems useless at this point and I think about death far too often.

Tell us about your headaches...:    I remember my mother taking me to the doctors when I was a child for random tension headaches. I've always been an over-thinker, which can cause anxiety and stress, potentially leading to headaches. Throughout my childhood and adult life, I had headaches hear and there (more frequent than the average person, I'd say), but nothing that a an OTC and a little time couldn't handle. It was never chronic or debilitating. All that changed on October 25th, 2014...

On that day, after a stressful year and a half, I was knocked down by the worst headache/migraine I'd ever had. I didn't know what it was, but I feared for my life. It was as though something was going to explode in my head at any moment.

In the months that followed, it never went away, and I was plagued with off neurological symptoms (felt like someone was pouring cold water on my head at times, odd sensations in random parts of my body, my eyes would hurt at night) but the most difficult thing was the pressure. Every day it felt like my head was going to pop. I was living as though any second I could die.

Though the some of the strange symptoms have subsided, the pressure and fatigue remain. The emanate from the base of my skull where my spine meets my skull. That seems to be the centerpiece, but it moves to the sides of my head just above the ears, and sometimes the top. Different positions rarely help.

I've seen two neurologists. One said it was atypical migraines. She's wrong, though they can rarely turn into migraines, that's not what they are. She started me on magnesium, melatonin and riboflavin as well as topamax to no avail. I moved on to another neurologist who's DX was Chronic Daily Headaches, and does nothing but through pills at me. I'll admit that the only thing that relieves the pressure and makes me feel somewhat normal is Soma, but it's short-lived, tolerance builds fast, and I feel we are not getting to the root of the problem. Klonopin also seems to help, which makes me think it's a muscle tension, possible TMJ issue.

I had a decaying tooth, so I even saw the dentist, who wound up doing 2 root canals and I went through a round of amoxicillin just in case there was an infection. I can say my teeth are now the best is town (after a whole summer of treatments), but dental stuff doesn't seem to be the issue. She just gave me a referral to be evaluated for TMJ.

I also saw my optometrist, he said everything looked fine; however, my vision had improved, and I had been wearing contact lenses that were too strong for awhile. He said this isn't the cause of my headaches, but it certainly isn't helping.

I am now seeing a Chiropractor 3x/week who says I have an Atlas Sublaxation, and a bone in my neck/base of skull is out of place and could be pinching nerves. Over time, he plans to put that bone back in place. I'm skeptical.

I have had a CT and MRI of the brain, all unremarkable. Last week I went for a Lumbar Puncture to rule out other things. I go over the results with my neurologist on Tuesday.

I'm growing weary, and this is all making me depressed. The side-effects of the meds also make me depressed. I'd love some input.

I have a past history of substance abuse, and have kindled with benzo's and other GABAergics. In fact, right before this happened, I was taking a substance called phenibut for my anxiety, and coming off of a high dose of gabapentin (which i was put on after coming off of Klonopin). My abuse days are over, but I wonder if it plays a role.

I am currently on the following medications:
Vyvanse (70mg/daily) - a mild amphetamine for ADD and unresponsive major depression
Klonopin .5mg 3-4x/daily PRN
Baclofen 10mg 4x/daily PRN
Soma 350mg 4x/daily PRN

I also take melatonin, magnesium, a B-complex, Fish oil/omega-3's and a multivitamin.

Any help, direction, or input would be greatly appreciated, as this leads to such a poor quality of life that living seems useless at this point and I think about death far too often.

Dr Shapira's Response:


DEAR PAUL,

You have been through a lot and even though non-diagnostic MRI and CT scans can be disappointing they are actually very good news.

Most chronic pain is from causes that are not visibile in those tests.  The number one source of pain is MPD or Myofascial Pain and Dysfunction which is always a major portion of all Temporomandibular Dysfunctions.  

These conditions were well described by Dr Janet Travell in her landmark text 
"Myofascial Pain and Dysfuntion:   A Trigger Point Manual"

You did not mention having SPG blocks which may help butare not the ultimate answer.  Atlas /Axis problems with the first two vertebrae can give a host of strange symptoms.
The SpenoPalatine Ganglion is the largest parasympathetic ganglia of the head and neck and is implicated in a wide variety of wierd and inexplicable cases of chronic pain and dysfunction.  It was made famous in the best selling book "Miracles on Park Avenue" which is a worthwhile read.

The Trigeminal Nerve is responsible for over 50% of input to the Central Nervous System after amplification in Reticular activating System.  It is an oversimplification to call it a TMJ problem but more accurate to call it a musculoskeletal/ trigemino-vacular and trigeminal nervous system dilemma.

I frequently hear stories that are similar yet different.  I assume the lumbar puncture will be negative but it is good to rule out all organic problems.

I am located in the Chicago ara but I frequently see long distance patients.

Visit my website www.ThinkBetterLife.com to learn more.

I will put some links to patients testimonials for you.  Each and every case is unique and different, but you have already ruled out all the worst alternative causes and probably are dealing with a functional issue.

Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO

Chair, Alliance of TMD Organizations




Sunday, April 10, 2011

Quality of Life Destroyed By Chronic Daily Headache according to Cephalgia article. Neuromuscular Dentistry can improve Quality of Life

A total of 34 studies were reviewed in this paper. Chronic Daily Headache (CDH) and Chronic Daily Headache with Medication Overuse (MOH) consistently created a lower quality of life. The Cephagia Article "Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: A systematic review." include 25 studies of patients and 9 studies of the general population.

I strongly recommend Neuromuscular Intervention as soon as possible when chronic headaches begin. These studies clarify the importance of utilizing a diagnostic neuromuscular orthotic early in the course of the problem. Almost every study done on headache treatment with a neuromuscular diagnostic orthotic shows at least a 50-80% improvement with NMD and frequently far superior results than medication.

Chronic Daily Headache frequently responds extremely well to Neuromuscular Dentistry but unfortunately a diagnostic orthotic is rarely offered to patients in pain centers and neurology offices. The biggest complaint about Neuromuscular Dentistry is that it can be expensive and time consuming when compared to writing a perscription. Long term savings and improvement in quality of life are essential considerations that must be taken into consideration. Insurance companies frquently are uncooperative using sneaky contract language to deny medically necessary treatment. One of the most common and unquetionably fraudulant techniques is to call all headaches and migraines treated by a dentist TMJ or TMD and then place an artificially low coverage maximum on that treatment. The article clearly states "Chronic Daily Headache was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than Episodic Headache, it is essential."

The principal conclusions of this review were"the findings of this review underline the detriment to Quality of Life and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache."

Reducing medication use and overuse is one of the real advantages of Neuromuscular Dental treatment of Chronic Migaine and Chronic Daily Headache. The side effects of massive drug use in headache and migraine often worsen the problem.

Prior to treating migraines, Tension -type headaches sinus headaches, and chronic daily headaches with dangerous medications it is logical to utilize a Dignostic Neuromuscular Orthotic, if relief is obtained the Medication Overuse is diminished. Medication Overuse Headaches are one of the worst headache types in destroying quality of Life.

The Neuromuscular Dental Institute (Institute for the Study of Neuromuscular Dentistry) is my answer to this disaster. Dr Barry Cooper, a leading Neuromuscular Dentistry Educator will teach his introduction to Neuromuscular Dentistry course to small groups of 4-6 dentists. We hope large numbers of these students will continue their Neuromuscular Dental Education at ICCMO (International College of CranioMandibular Orthopedics) meetings and at the Las Vegas Institue (LVI)

This wll be in addition to the current course I give on Sleep Apnea Treatment with oral appliance (Dental Sleep Medicine) as well as coverage of nerve blocks including the SPG block. The SPG or Sphenopalatine Ganglion Block can be incredibly effective in preventing and eliminating migraines. Ideally patients can learn to utilze and self administer SPG blocks to prevent or Amelliorate migraine headaches early in their course. It is simple, inexpensive and frequently incredibly effective.

The Alliance of TMD organizations (I am the ICCMO representative to the TMD Alliance) is working to prevent patients from being denied care that will mprove their overall quality of life and subsequently result in enormous long term savings in costs and expenses associates with chronic headaches and migraines.

The way TMJ, TMD and Neuromuscular Dentistry is dealt with by insurance companies is an example of Discrimination against women since the vast majority of patients with headaches, migraines and TM Joint disorders are female.

I will continue to treat patients at my Gurnee Dental practice, Delany Dental Care Ltd in our current locatin and in our new location that has a better layout for giving continuing educational courses to dentists, physicians and allied medical practitioners. Contact my office at 847-623-5530 for information on becoming a patient.

We do make special arrangements for long distance patients to make treatment requre less time and travel.

Ira L Shapira DDS, D,ABDSM, D, AAPM, FICCMO


Pub Med Abstract follows:

Cephalalgia. 2011 Apr 4. [Epub ahead of print]
Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: A systematic review.
Lantéri-Minet M, Duru G, Mudge M, Cottrell S.

CHU de Nice - Hôpital Pasteur, France.
Abstract
Objective : To evaluate the evidence for quality of life (QoL) impairment, disability, healthcare resource use and economic burden associated with chronic daily headache (CDH), focusing on chronic migraine (CM) with or without medication overuse. Methods : A systematic review and qualitative synthesis of studies of patients/subjects with CDH that included CM, occurring on at least 15 days per month. Main findings: Thirty-four studies were included for review (25 studies of patients and nine of subjects from the general population). CDH and CDH with medication overuse headache (MOH) were consistently associated with a lower QoL compared to control or episodic headache (EH) and CDH without MOH. CDH was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than EH. Data were not amenable to statistical pooling. Principal conclusions : The findings of this review underline the detriment to QoL and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache.

PMID: 21464078 [PubMed - as supplied by publisher]

Wednesday, March 31, 2010

IMPROVING THE QUALITY OF LIFE WITH TMD TREATMENT. NEW ARTICLE IN ACTA ODONTOL SCAND.

IMPROVEMENT IN QUALITY OF LIFE WITH TMD TREATMENT HAS RECENTLY BEEN PUBLISHED. THIS STUDY USED EVIDENCED BASED ARTICLES FROM Medline and Cochrane Library databases. This severely limited the number of studies considered and eliminates publications of exciting clinical work and case reports. This type of search tends toward bias toward drug therapy.

The study showed almost universal improvement in the quality of life with TMD treatment. The twelve papers reviewed showed that the more symptoms and the worse the condition was to begin with the greater the improvement in the quality of life. These results are unmatched in most of medicine where even a 50% improverment is touted. Men and women appeared to improve equally.

The study concluded that: "The reviewed studies convincingly demonstrated that OHRQoL (quality of life) was negatively affected among TMD patients. this coincides with other known materials including Shimshak et al who published in Cranio Journal a 300% increase in medical spending in all medical fields.

An excellent article on how TMD affects the quality of life can be fond in Sleep and Health Journal at:
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor Neuromuscular dentistry has begun to exhibit exponential growth as measured facts are replacing opinions.


AN EXCITING NEW ARTICLE ON IMActa Odontol Scand. 2010 Mar;68(2):80-5.
Temporomandibular disorders and oral health-related quality of life. A systematic review.
Dahlström L, Carlsson GE.

Research Center, Public Dental Service, Clinic of Odontology, Göteborg, Sweden. lars.dahlstrom@vgregion.se
OBJECTIVE: Oral health-related quality of life (OHRQoL) is considered an important aspect of different oral conditions. It has also gained increased attention in temporomandibular disorders (TMDs) in recent years. The purpose of this study was to systematically review the literature on OHRQoL and TMDs. MATERIAL AND METHODS: A systematic search of the dental literature was performed using the Medline and Cochrane Library databases, supplemented by a hand search. Various combinations of search terms related to OHRQoL and TMDs were used. Among numerous titles found in Medline, abstracts and eventually full papers of potential interest were reviewed. Twelve papers fulfilled the inclusion criteria and were included in the review. RESULTS: Most studies used the Oral Health Impact Profile, an instrument with good psychometric properties, for evaluation. All articles described a substantial impact on OHRQoL in TMD patients. Only a small proportion of all patients, a few percent, reported no impact at all. The difference between men and women was small and not significant. The impact appeared to be more pronounced in patients with more signs and symptoms. The perceived impact of pain on OHRQoL seems to be substantial. Two studies found that the impact increased with age among TMD patients. CONCLUSIONS: The reviewed studies convincingly demonstrated that OHRQoL was negatively affected among TMD patients.

PMID: 20141363 [PubMed - in process]

Sunday, February 28, 2010

Neuromuscular Dentistry treats Migraines, Tension-Type Headaches, Chronic Daily Headaches and Sinus Pain related to Trigeminal Nerve and TMJ Disorders

Chronic pain is frequently multifactorial in nature. Neuromuscular dentistry has been very successful in treating TMD, Migrines, Tension Type headaches and other disorders. Frequently it is not a total cure but 50-80% reduction in pain is usually attained within several visits. There are many disorders and symptoms associated with TMD including:
Ear Aches or Otalgia
Sinus Pain
TM Joint Clicking and Popping
Ear Stuffiness or Eustacian Tube Dysfunction
Dizziness
Vertigo
Temporal Pain
Occipital Headaches
Morning Headaches
Sleep Apnea
Snoring
Sore Throats
Neck pain or stiffness
Feelings of a foriegn object in the throat
Pain in or behind the eyes
Scalp pain or feeling like your hair hurts

Most of these symptoms are mediated by the Trigeminal nerve and the Trigeminovaqscular system. These Nerves also connect to facial nerves, occipital nerves, glossopharyngeal nerves and to the autonomic nervous system. What happens in these nerves cause biochemical changes in the brain. Recent stuies shown the neural plasticity can create permanent changes in the brain. If chronic pain is the stimulus it can lead to central sensitization.

Changes inthe brain can be reversed over time but the exact amount of recovery will vary with individual patients genotypes, how long the pain has been present , other comorbidities that the patient carries. Some patients experience immediate3 and almost miraculous pain relief while others have a slower longer version of recovery. I always tell my patients to work for 50 - 80% improvement in pain. That is then our new starting point and we again seek 50 - *0 % reduction in pain.

There is "no cure" for long term chronic pain because lives have been changed due to living with pain. A cure would require a do-over of the years you had pain. There are no do-overs therefore we look to improve your future quality of life to the maximum. Some patients still have to do exercises or watch diet or even continue different medications. Other patients have remarkably and incredible improvements as described by Dr Barry Cooper in Cranio where he talked about "overwhelming success". This is why we use a diagnostic orthotic as the first step of treatment. We try to avoid permanent changes until the patient feels substantially improved. This is not a judgement that any doctor can make for the patient. It is a subjective evaluation by the patient themselves. Only the patient knows how well or poorly they are doing. We may have objective data showing physical improvement but the final test is have we improved or dramatically improved the patients quality of life. If the answer is yes we can talk about long term stabilization. The diagnostic orthotic is the first phase of treatment for those patients.

If the patient has improvement, whether it is only 25-30% or if they are at 80-90% the decision that the diagnostic orthotic treatment is successful remains the patient's. If they do not feel sufficiently improved they should not feel pressured into continuing treatment or making permanent changes. You should treat the diagnostic orthotic like a CAT SCAN or MRI but instead of images we have improvement in the quality of life. If improvement is not sufficient then a diagnostic approach should continue.

While NEUROMUSCULAR DENTISTRY IS REMARKABLY EFFECTIVE AT TREATING MANY CONDITIONS THERE ARE OTHER CONDITIONS THAT ARE NOT RELATED TO THE TRIGEMINAL NERVOUS SYSTEM, MYOFASCIAL PAIN OR JAW JOINTS.

TMJ disorders are frequently called The Great Imposter ("SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" IS A MUST READ FOR ANY PATIENTS WITH MIGRAINES OR TMD http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor) but we must remember that other disorders can also masquerade or more frequently coexist with these problems. Many times a diagnostic orthotic relieves many of the symptoms but the remaining symptoms have a different cause. The expression that "you can't see the forest for the trees" applies. When the majority of symptoms are relieved you now find that you can identify a particular problem that was lost in a long and winding maze of symptoms. As NMD unravels the maze a specific problem can now be identified and treated.