CASE STUDIES of Hand, Wrist & Elbow
What follows is as a series describing the value of soft-tissue therapy in neuromuscular-myofascial case studies.
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.)
Symptoms among the Clients in these neuromuscular-myofascial 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 at the end of her left fourth finger whenever 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 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, 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 it 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 are 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, a 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, results were achieved not from working where the actually 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 positive results were achieved from working in other more-or-less distant yet very related areas.
Many Medical Specialists Miss the Diagnosis AND Treatment
The near tragedy here is that all the Clients in these neuromuscular-myofascial case studies were told they were being treated by the top medical specialists — licensed medical doctors — in their fields, specializing in the repair of the hand and arm, and in most cases, expert specialists in working with musicians. In all six cases, there was never any mention whatsoever of the possibility of chronic, excess muscular and nerve tension being the cause of the symptoms, especially when these tensions were located sometimes only inches away from the reported symptoms. Even when the actual source of the hand or finger trouble was in the muscles of the forearm — an obvious relationship since the comparatively large muscles and tendons of the forearm continue into the hand and fingers and are prime movers of the hand and fingers — this relationship was never even mentioned to any of these Clients, let alone treated. (Any basic anatomy book clearly reveals how the primary strong-force generators and controllers of the hand are located in the forearm.)
Yet, this author has worked with numerous Clients who were literally ridiculed or aggressively ignored by their so-called expert medical physicians for suggesting that such “alternative” viewpoints or strategies had any merit what-so-ever.
Finally, and possibly worse for future Client’s, is that when the Client reported their vast improvement, the physicians expressed NO interest whatsoever in learning about how the Client got better. This, correctly or not, adds ammunition to those who believe that many medical professionals are not truly all that scientific* in their thinking and understanding of medical issues; and that they really do not care if there is a better way than what they are already doing. This may very well only be true of a few physicians, but if these are supposed to be the top in their specialties, and if the best people are theoretically responsible for new advancements in their fields, what does that say for the possibilities and speed of progress in medicine if the Client’s issues are neuromuscular and myofascial in nature?
* Confessions of a Medical Heretic by Robert Mendelsohn describes how there is much less real science in medical science than one would readily believe. Dr. Mendelsohn was head of the AMAs Education Committee for four years and was in a position to see what was being taught in medical school. His assessments were far less than positive.
Conversely, most alternative practitioners seldom invest the time, intelligence or necessary energy to research and learn the concepts, data and sciences they could use to explain — in the doctors own terminology and paradigm — how and why these alternative practices work so “effecticiently.” For most physicians, using terms such as “energy,” “flow” and “chakras” in many cases only activates the roll-the-eyes factor with a sudden loss of credibility to the alternative practitioner. Whether they are true and valid concepts is not the issue. Gaining credibility and proof before going into certain areas of “questionable” explanation is.
For those who suggest not enough research has been done to validate such practices, many practitioners would more than welcome the opportunity to participate in well-designed studies supervised by impartial observers** who could, and would, advance the practice if it stood up to the claims. Yes, studies are being done, but they are seldom given the attention they deserve.
The biggest obstacle, of course, is funding.
** It is continually being proven that finding truly impartial observers for research purposes is far more difficult than it might seem. So much ego, money, and reputation ride on maintaining the Status Quo that impartiality among medical “authorities” is difficult if not impossible to achieve. Just one aspect of this is how many “studies” are performed on alternative remedies and nutrients with less than positive results, yet when the studies are examined, many flaws and misconstructions are discovered. But drugs that have been linked to many negative reactions or even deaths are later found to have studies that were substantially flawed in the opposite direction.
Clients Are Searching for the Alternatives
The success of the above, less than tiny sample of case studies provide examples of the great value of properly applied soft-tissue therapy, and show a great piece to the puzzle of why so many human beings in America and other countries are exploring so-called alternative medicine, and sometimes abandoning orthodoxy altogether. If these people were not getting better, most of them would return to orthodox medicine in a relatively short time; but many do not return or do so for only certain procedures. For many, their needs are well met by the alternative therapies, and many of them become life-long practitioners. The fact that they are often reticent to even mention an alternative health care provider or modality to their primary medical care physician is indicative of how open-minded the orthodox professionals are perceived to be by some of their patients. Yet to write these maverick patients off as “crazy” or “kooky” or “misguided,” as is often done, is only an avoidance mechanism revealing disinterest, arrogance, intimidation, or just plain having no ideas of what to do next. So it’s easier to blame the patient. More likely, it is fear of facing up to an all too hard to ignore the reality that means the orthodox practitioners have to relearn a few things … or maybe a lot of things.
As one successful alternative physician pointed out, “Patients are not stupid.” Yet many Clients or Patients feel as if they are being treated as stupid by many orthodox medical physicians. This is NOT reserved only for the orthodoxy. MANY alternative physicians, therapists, and practitioners are equally naive, arrogant or condescending, resistant to new information, if not worse, toward their clients or patients.
The Need for More Fully Trained Massage/Bodywork & Yoga Therapists
The necessity for massage and bodywork therapists to be more widely recruited, effecticiently trained and employed for these and similar cases, of which the number is very high, is paramount and urgent to the well-being and vitality of tens of thousands of current and future Clients nationwide. In somewhat different cases, Conscious Stretching Therapy (Yoga Therapy) would be the treatment of choice in a truly scientific environment.
There are certain critical aspects of performing therapeutic stretching, yoga and yoga therapy that, even within these professions, are commonly unnoticed, and thereby significantly reducing the ability of stretching or yoga to produce the results they could.
As opposed to the more Hindu or Indian based approaches to classical yoga, the idea of conscious stretching, or a more Western approach to Yoga, already has a foundation that is as scientific as can be hoped for given current limitations in accessibility to research. It already exists within modern medical literature and research, if one looks beneath the surface. Yet various factors prevent this knowledge from being recognized, explored, developed and implemented widely. These issues will be addressed later in this paper.
From the medical system’s perspective, the most obvious group to be performing these services is the Physical Therapy Profession: Physical Therapists as supervisors/evaluators and Physical Therapy Assistants to perform the actual manual work which can be very time consuming, yet does not require anywhere near as extensive an analytical skill or knowledge. However, very few P.T.s or P.T.A.’s know about, let alone perform, such services, and there is at this time little to no training in truly effecticient soft-tissue treatment nor structural strategies available in most physical therapy schools nation- or worldwide. Therefore the massage and bodywork community is, most probably, the inevitable First Choice providers in such cases. And the number of such cases is nearly astronomical.
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 healthcare 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.
*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 are 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