I have a client, a flight nurse, who lifted a 250 lb. man on a litter into a helicopter. She has seen a neurosurgeon and had an MRI with a C5-C6 compression diagnosis. She has had severe left shoulder pain extending from about C3 to her left wrist, including the scapula, and has weakness in her left triceps. She has had physical therapy for two months, and traction in a harness while sitting is relieving to her. She has permission from the neurosurgeon to see me. When she came in, her entire left shoulder was severely inflamed with tremendous heat and redness in the area. That was relieved in her first session. In the second session she reported that the shoulder was better until she worked again and was required to do repelling. She still has some mild discomfort, is continuing with home traction, and says that her triceps weakness remains the same. She has rotations all along the cervicals, and is afraid to see a chiropractor. She basically trusts me and thinks that I am her last resort before a myelogram and possibly a fusion. She and I both would like to get some results. I have not done any detailed spinal mechanics or de-rotation of the cervicals. I have worked generally to relieve the strain patterns in the soft tissue and there has been some general relief in the cervicals. My question is specific to the location of the spinal nerve to the weakness in the triceps. If the traction is working to relieve her discomfort, are there some assumptions that I can make? What is the possibility of reversing the weakness and what is the danger of making it worse? In general, I know the dangers; I am looking for the specifics. I am looking for a scenario of what might be happening to the nerve beyond the fact that there is a diagnosed compression. If I could look at this with my eye, what would I see?
I had exactly what you are describing last year, including the same weakness in the left triceps. Two Rolfers worked on me, it didn’t help, and one made it worse. I then went to an osteopath who helped a little. I took muscle relaxants for the first time in my life to help break the pain cycle. The chiropractor I went to worked on ribs 1 and 2, the shoulder, and a lot around the brachial plexus. That was the first thing that started it back on the road to proper function. Then a Rolfer started working on me and did not go directly to my neck until four sessions later, doing a lot of sacral and rib cage work. The initial Rolfers worked directly on the neck and it wasn’t good!
What is meant by “C5-C6 compression diagnosis.”? Do you mean a diagnosis of C5 nerve root compression or C5-6 disc? The triceps weakness tells you that the nerve is compressed, but doesn’t tell you by what. One possibility is disc, but the neurologist probably would not have referred her if it were. Second and more likely scenario is this: as the nerve root leaves the spinal cord it passes through the intervertebral foramen – a hole, basically, between the vertebrae. As you are visualizing the hole, notice that there are arteries, veins and a variety of connective tissues that share the hole. The injury to muscle tissue and/or the result of the vertebral fixation has caused an inflammatory reaction, which has led to swelling of the tissues in the hole. The tissue is binding on the axon – not a lot; the weight of a dime is sufficient to completely terminate transmission in the sciatic nerve. So there’s just enough pressure to impede transmission down the radial nerve to the triceps. If it were occluded she would have paralysis, not weakness. If you’re using non-force techniques, there should be no problem with relieving the fixation. She may have muscle strain contributing to the problem. The small muscles of the joint may have been torn. In re-reading your first post I noticed that this happened two months ago. This changes the inflammatory scenario somewhat, though it is still possible that the rotations are causing a sub-acute inflammation.
I am not clear on which of the above is the case. [Do you mean a diagnosis of C5 nerve root compression or C5-6 disc?] I have asked her several times specifically and what she has said is this: there is a C5-6 compression and possible herniation of the disc. I spoke yesterday with an Occupational Medicine M.D., and she said that the traction would increase the blood flow and relieve the cascading inflammatory response and that most likely working with the soft tissue and the rotations would improve the situation. She is a fan of Rolfing and felt that there was not an extremely high risk in working with her. She felt surgery was a much worse option.
If the M.D. considers surgery as an option at all, she must at least suspect disc involvement. Was there imaging done? See if you can get the report. You might want to keep the neck more into extension than flexion as you work. That decreases disc pressure should that be a concern. There shouldn’t be a problem with Muscle Energy release or similar technique, but if she’s in pain and spasmed, you’ve got a lot of work to untangle the compensations. If you’re familiar with the osteopathic energetic techniques, I often use those to quiet the angry tissue without having to manipulate the tissue directly. By the way, I keep a supply of traction devices that hang on the back of a door and have a plastic bag the client fills with water for counterbalance. They cost about twenty bucks. As an R.N., you may be able to use them under your license. They come in handy for clients with mild to moderate symptoms to use for relief between visits.
Has your client taken any antiinflammatories? Even though it has been a while since the original injury, in my experience in my own body, you can get into an inflammation “circle” where it never really dies down enough for the tissues to heal. Taking Celebrex for a month or two worked wonders for me. I started on it about two months after the original injury.
Celebrex ate a hole in the stomach (ulcer) of one of my clients, so proceed with caution.
Some thoughts on the cervical compression syndrome discussion. I agree with the addition of traction devices as an adjunct to decompression, as well as the Osteopathic Muscle Energy technique if you know and can use it. The strategy from a strictly Rolfing perspective must hold the support and preparatory/ adaptive principles in the foreground. Fundamentally we must create avenues of discharge in the extremities, while working directly with the acute area for decompression and to establish normal motion.
With any acute neck problem, assume that there are lumbo-sacral adaptations as well. Ask how the legs are doing in relation to that. I think we need to continuously circle through the lower extremities (with particular attention to the interosseous membranes), and the ilio-sacral region, to create local support and adaptability. This is also critical in providing more generalized support for a system-wide higher level of order (geometric palintonic). Also, any neck problem is overlaid and adapted through the arms. Decompression of the interosseous membranes of the forearm allows the stressed eye-hand coordination to discharge, and hopefully will allow the neck to follow with more successful adaptation.
Finally, the thing that has been missing in the discussion so far is the issue of strength. Inability to recover from the acute situation may lead to loss of tone through shock, or accumulated smaller traumas. The victim is simply unable to carry the structure in a way that supports decompression. It seems to me, and this is borne out by hard experience, that without the balance of reciprocal tone between tonic function and phasic function, you can’t stay out of trouble.
Ida used to say that the flexors are fighting the extensors, and the flexors always win. Lots of Rolfing technique works on the dorsal extensors, from the cervicals to the gastrocs. I wonder if we are sometimes letting the extensors get longer, and not correspondingly releasing the flexors enough. Think of loosening the back of the neck when the client has a lot of ventral “drag,” including the prevertebral membranes of the thorax. They lose order; their support is undermined. Witness Valerie Berg’s story about her neck. In studying this, I began to give my chronic pain clients, some with acute discs (both lumbar and cervical), strengthening exercises. These look primarily like a form of isometrics. The intention is to build strength and tone at the LIMIT of range of motion. I do this with respect to pathological barriers, but still take the joint to the motion (or pain) barrier, and then have the client flex and hold isometrically. In order to radiate this isometric flex, I then ask them to take a half breath, hold it, and then spread the isometric contraction into the abs, lumbar erectors, and the gluteals. Sometimes this will include the arms and legs if it fits the situation we are working with. When they exhale and relax, they often demonstrate immediate increase of pain-free ROM, and over time, less disc pain. I notice improved head carriage in these clients, with improved function. I use some familiar yoga and chi kung root postures, and add this isometric at the ROM limits to address the specifics of the client’s problems.
Of course they have to do it in between sessions with some focus, but if they are desperate, they might. I did it with my own “neck from hell,” and I have resolved neuralgia and chronic pain, and serious motion deficits over time. In fact it was my own desperation, much as several of you have described, that led me to try something different. I actually could not be “fixed” from the outside, God knows I tried, but had to dig into resources to find a way to heal myself. There were corresponding unfinished emotional stressors that had to be processed as part of getting well.
I see this process then as a function of improved tone, greater circulation of blood and lymph, and a re-patterning of system wide tonus problems that are part of the inability to resolve the acute neck syndrome. Allowing for the feeling functions, and resting on well-executed Rolfing, as stated above, these isokinetic exercises are a great addition to the resource you can offer to the client. They don’t share the dangers of the currently vogue, repetitive motion “strengthening exercises” common to PT and sports medicine. Slow stretching coupled with isometric tonification will not usually make the situation worse, and you can adapt the intensity of position and tensioning for the client’s particular situation.