Case Studies-Upper Limb

CASE STUDIES of Hand, Wrist & Elbow
What follows is as series of Case Studies describing the value of soft-tissue therapy.

Neuromuscular Contracture

On several occasions, this author has worked with Clients who had been diagnosed with contracture* or similar problems related to pain, dysfunction or weakness in, for example, their hand. Yet the CAUSE of their trouble was NOT in their hand, it was very often the muscles of the forearm, chest, shoulder or neck. Occasionally, even more distant.

* Contracture — though not uniformly defined, and described with several different manifestations — is a chronically held contraction of the muscles in a particular area. It is often thought of as being caused by processes other than the standard neuromuscular stimulation, such as metabolic anomalies, but that is not consistent nor well-defined, either. In fact, it is quite ambiguous.

One possible mechanism of contracture is a chronically contracted muscle moves water outside of the muscle cell due to osmosis. (The higher pressure inside the contracted muscle cell forces water to the extracellular space, or outside of the cell.) Chronically contracted muscle cells also reduce local blood flow, producing ischemia, in turn reducing nutrient delivery and detoxification. Reduced metabolic processes in turn reduce oxygen and nutrients necessary for reconstitution of ATP entry into the cell. ATP is necessary to release the myosin heads from the actin filaments, a necessary element of relaxation of muscle cells.

This contracted and ischemic state can, apparently, reduce metabolic and ability of muscle cells to relax and lengthen, such as occurs in rigor mortis.

Yet this ambiguity might, in some cases, also be an error in that the activity of the intrafusal muscle fibers was not detectable by EMG equipment of earlier decades when related neuro-muscular research was being performed. And although the intrafusal fibers have only a small fraction of the strength of the extrafusal fibers, they can certainly affect the muscle to be in a contracted state with sufficient influence on extrafusal fibers to modify posture and add to the compression of various tissues.

(Later in this publication, in an Appendix, a more “Radical” Hypothesis on the potential function and force of the intrafusal fibers shall be presented. It’s not really that radical, but it’s not well within the purview of the modern physiology that I know of.)

The Symptomologies:

Symptoms among the Clients in these case studies varied as such:

1.) A severely weak right thumb, preventing a concert musician from holding the bow of his string instrument long enough to get through a single concert, putting him on the verge of a forced ending to his very successful, many decades-long career.

2.) The hand of a restauranteur was chronically clenched (contracture into a partial claw) about 50%. He was told he was going to need months of physical therapy and possibly surgical intervention.

3.) Another musician had a “trigger finger”*1* symptom in the fourth digit of his left hand. After 3 cortisone shots in the same hand had worn off, surgery had been scheduled as, allegedly, the only remaining solution to the trigger finger, which was making it near impossible to play many pieces on his string instrument.

4.) A waitress who had severely cut her hand on broken glass received surgical repair to the cut tissues and tendons. Yet she retained a significantly clawed fourth and fifth digit. Surgery was recommended as the only solution. They wanted to break and pin the bones straight.

5.) A world class violinist perceived a burning sensation in the end of her left fourth finger when ever she touched something vibrating, including the strings of her violin. Going to medical hand specialists in five cities in North America and Europe produced no useful diagnosis or treatment. One therapist, labeling the affliction a neuroma, told her it was kind of like an “exploded nerve.”

6.) A twenty-four year old, up and coming professional violinist reported severe pain in her left elbow, to the point of often preventing her playing her instrument for any length of time at all. She also had a significant scoliosis, convex in the right lumbar, concave in the left. This Client was equally motivated to relieve her left elbow pain and straighten her scoliosis, although the scoliosis was somewhat more aesthetic in her priorities. Yet as a young woman and stage performer, her personal sense of her overall appearance and fit of her clothing was of significant importance to her.

The Soft-Tissue Solutions:

In all six cases, application of gentle, slow manual pressure to certain muscles of the forearm, upper arm, shoulder, chest and/or neck area — not at the location of symptomology in the hand and fingers — made significant or complete improvement in the conditions in the hand. The sixth case was an even more distant relationship:

1.) In the first case, the thumb strength was regained by relaxing the tensions in the abdominal and chest muscles. The formerly so-called “weak” thumb was able to play thirteen concerts in a row with very little to no weakness — and no treatment — and has not been a significant problem for more than two years after therapy.

The results were derived primarily by decreasing irritation and pressure from pectoralis major and minor (surface and deep upper chest muscles) on the brachial plexus (a major nerve trunk emerging from the neck that controls the entire shoulder, arms and hands) where it travels between the clavicle (horizontal bone that positions the shoulder blade) and first costal arch (uppermost rib of the rib cage). Only minor work was done in the arm and forearm along the primary nerve pathways. Almost no work was done in the hand or thumb area.

NOTES on Pseudo-Weakness:
In regard to most general, chronic posture and pain problems, this author finds the assessment or diagnosis of “muscle weakness” one of the most near-mythical — and vastly counter-productive — conditions in modern times. While it is true that some people can “strengthen” their way out of such problems, seldom do posture or pain issues involve truly fundamental weakness. In many cases it is exhaustion of the muscle, or impingement (bone pressing on a nerve) or excess stimulation of the nerves feeding the muscle, that are causing the problem. The problem is actually a pseudo-weakness. Over-activated nerves can produce this pseudo-weakness as well as can under-active nerves.

It is quite possible that when strengthening works, it is NOT because they are getting stronger, but because they are activating certain nerve pathways and circuits in a rhythmical and controlled pattern of function. It is therefore not improving strength that is helping, but their nerve function and coordination that is improving, and producing the result that is incorrectly attributed to increased strength.

(They may indeed be getting stronger. However it is in my view probably not the strength itself that provides the therapeutic value.)

Excessive Overlap in Actin/Myosin:

As well, when muscle fibers have over-shortened (see C in illustration below), their actin/myosin fibers become too overlapped, and they are not able to shorten much, or any, further, and cannot generate much additional force regardless of how fundamentally “strong” one is.

Conversely, when over-lengthened (see A in illustration below), actin/myosin fibers are not overlapping each other much or at all, and cannot generate much or any pulling power. In either case, any perceived weakness — including that discovered by various forms of muscle testing — is not true fundamental weakness, but a pseudo-weakness that in many, if not most, chronic cases can be relieved in very short time with NO muscle strengthening exercise.

Treating these nerve or actin/myosin issues (insufficient or excessive overlap of cross-bridges) as if they were true, fundamental weakness usually leads to a wide range of so-called strengthening exercises which, in the long run, often cause far more troubles than they resolve. Even though short-term results are often good, or at least apparently so, this assumes the Client’s neuromuscular system has not reached certain degrees of over-shortening or over-lengthening of muscle fibers and/or compression. Worse, some people are told their nerves must be “degenerating,” and occasionally, nerve conductivity tests even appear to falsely prove this out. Yet though superficially paradoxical, restoration of nerve conductivity can often be restored merely by normalizing the tonus and sensitivity of the neuromuscular units in question.

Yet is should be noted that even many in the yoga profession are obsessively fixated on strength, and do not pay near as much attention to TRUE relaxation as is possible with appropriately performed yoga. Yet many so-called strength problems will just go away when the excess neuromuscular activity is reduced to a more normal state.

2. & 3.) In the next two cases, the treatment was applied primarily to the soft-tissues of the forearm, with little or no attention to the hand or fingers. The large muscles in the forearm, which deliver the primary contractile forces to the hands and fingers, were the culprits causing the problems. The restauranteur’s fingers and hand straightened out in 20 minutes and was so for many months after without treatment. The musician’s trigger finger had, after approximately four treatments, enough reduction in symptoms to cancel the surgery. Since treatment, the trigger finger has not been a significant problem and often non-existent. At the time of this writing, mild symptoms come and go, because other problems in other body parts have been the priority of treatment for the time being.

4.) In the fourth case, most of the initial change was generated by releasing the tensions in the forearm, but also due to the substantial trauma and laceration (actual tearing, cutting or damage to the tissue) to the tissues within the hand itself, those muscles needed much attention as well. The waitress had very noticeable improvement during the first treatment, with significant improvement over several one hour treatment sessions. She determined she did not require surgery to restore adequate, possibly full, function.

5.) In this case, a nerve pathway referral to the fourth fingertip from the subscapularis (a muscle on the front surface of the shoulder blade) was discovered in the first treatment and was fully resolved after approximately eight treatments. The violinist has been playing all over the world for more than two years since completion of treatment with no symptoms.

6.) Finally, beginning the very first session with the intent to straighten the foundation of her scoliosis, it was decided to start in the abductor muscles of her right hip, as they were contributing to (in relative terms to the left hip) a depressed right hip and (along with the left lateral lumbar flexor muscles) raised left hip. Within minutes of beginning the treatment of the RIGHT hip abductors*2*, the Client reported a direct neuromuscular referral pattern into her LEFT elbow! Although many other areas of her torso and arms required treatment, it required approximately 12 sessions of 3 hour duration to resolve the elbow pain sufficiently to perform in concert, making significant improvement in her scoliosis.

What’s The Mechanism?

In all fairness, the exact mechanisms that are at work in any one case is difficult — maybe impossible — to determine with any certainty. There are many potential relationships at work: local trauma and stress, structurally transmitted strains, neurologically transmitted stress and antalgic* movements. And each of these has a wide range of possible factors.

* Antalgic: etymologically, to move away from pain.*3*

Because of the very wide range of potential variables, the practitioner must not get too hung up in trying to figure out exactly what is happening before proceeding with treatment. To be successful, they must learn and become confident of the fundamental principles of how the body works, and stick to them unless some new information appears to indicate a different etiology*4* for the pain, pathology or dysfunction in question. Sometimes, full certainty of what caused and resolved the problem will never be achieved. However, most of medicine suffers from this deficiency in one way or another.
An important fact to note is that in ALL six cases, much, if not most, of the results were achieved not from working where the actual reported symptoms were located. In fact, doing so prematurely could very easily have exacerbated the problems, or at best had no long-term positive effect. A significant portion of the positive results were achieved from working in other more-or-less distant yet very related areas.

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If this author’s experience is of any validity at all, all of the above points to a vast need for more research and training in the principles, sciences and practices of conscious stretching (physical/mental yoga), clinical massage and structural bodywork therapeutics, and related bodymind integration techniques that have, as a prime or central focus, the reduction and management of Chronic, Excess Muscle & Nerve Tension.
All this will prepare practitioners to provide more education, value and results for their existing Clientele, while educating and persuading increasing numbers of health care consumers to try the soft-tissue approach described herein.
If more physicians want to join in this endeavor and become more familiar with how to utilize or refer to such practices, and work with the providers, all the better, and they are more than welcome.

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*1* A so-called Trigger Finger occurs when the joint of a finger becomes “locked” in a fully flexed (bent) or extended (straightened) position.
*2*The contributions and relationships between the abductor/adductors and lateral (side) lumbar flexors is outside the scope of this publication, yet is addressed elsewhere.
*3*While certain chiropractors use the term antalgic in this way, orthodox medicine does not.

Thank You for Reading,
David Scott Lynn (DSL)
DSL: Your Hi-Touch Up-Link to the Inner-Net
Inner-Net: Your Psycho-Neuro-Musculo-Fascial System

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David Scott Lynn (DSL)

DSL the Yogi at Whole Life Perspectives
Beginning at 13 years of age, DSL's been involved with alternative philosophies & practices most of his life. Becoming a yoga teacher in 1976, then a hands-on bodyworker in 1981, he developed a unique & highly effective form of Yoga / Bodywork / Whole Health Fitness & Therapeutics. … David wrote the chapters on a wholistic philosophy & physiology of bodywork & stretching for the textbook Structural Balancing, published by McGraw-Hill, Inc. in 2010. … He is the author of Simple Steps to Let-Go Yoga, available at: www.letgoyoga.com/simple-steps/ … Several other e-books and e-courses are soon forthcoming at www.letgoyoga.com/dsl-publications/ … David consults with Kyle C. Wright on massage school development at the Schools of Advanced Bodywork at http://kylecwright.com/structural-balancing-a-clinical-approach/co-author-dsl/ .
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