Nerve & Soma

You can't truly understand the inflammation of shoulders without knowing their innervation.

This is a surprise to many folks who learn about the nervous and immune systems as if they were fully separate -- but it turns out each system 'tunes' the other, both systemically and locally.

If a tissue is persistently inflamed -- but with no sign of infection or auto-immunity -- we need to ask ourselves if irritated nerves are partially to blame.

This question is crucial: Many 'neuro-informed' practitioners skip over the specific innervation and just say, 'your mysterious pain is just the brain/CNS perceiving threat!'

(Not so fast. Central sensitization may be present, but that only increases the usefulness of calming down peripheral signals.)

So in the shoulder, we are massively rewarded by attention to the Axillary and Suprascapular nerves* which not only pass signals to/from muscles/receptors, but also regulate local inflammatory behavior.

Here's a nice diagram from Bowens & Sripada, 2012.

(*Interestingly, this study excluded any mention of the Lateral Pectoral Nerve, which is often named as part of the capsule's anterior innervation.)

Integrating these nerves with more classical orthopedic maps and modern pain science gives us a flexible, robust framework for helping countless of our patients/clients.
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Hope some of your can join the online/in-person class on Saturday, June 13th's class, Neurofascial Approach to Frozen Shoulder.

Details: https://bit.ly/4uvzEYY


🐦Saturday, June 6th is the last day for early bird pricing--$75 USD, and there afterward it goes up to $85 USD 🐦

⚡ Neurofascial Approach to Frozen Shoulder ⚡

Open to all healthcare practitioners licensed in Manual/Massage Therapy, and meets the WA state CE requirements for physical therapy and massage therapy.

Saturday, June 13th from 10a-2p Pacific
4 CE hours • Cost: $75 USD

In person, online, or view in your own time

For more info & to sign up:
https://bit.ly/4uvzEYY

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Reference
"Regional Blockade of the Shoulder: Approaches and Outcomes" - Bowens, Jr. & Sripada - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3389656/

Have you ever seen a wound's edges tighten during the healing process? The stiffness that comes into the surrounding skin and fascia?

Normally, this contractile/thickening process resolves as the wound heals. But sometimes -- for reasons still being discovered -- this tightening and fibrous deposition feeds back on itself, amplifying into a painful and sustained disability.

Frozen shoulder (FS) is one such case, and if we can better understand its physiology, we can do much to improve function, ease mobility, and reduce pain.

"Most…studies indicate that FS involves both synovial inflammation and capsular fibrosis. Since characteristically pain precedes stiffness in FS, it is most likely that inflammation evolves to fibrosis…the initiator of synovitis, however, remains still unclear…based on the appearance of immune system cells, it is postulated that immunomodulated chronic inflammation may play some role in the pathogenesis of FS…there is no theory that explains why FS thaws spontaneously in most cases. (Tamai et al., 2014)"

This study identifies the primary elements that are typically involved in FS: stiffness of the joint capsule, rupture of supraspinatus tendon, and inflammatory/immunological processes.

Appreciating the neurofascial ecology of the glenohumeral joint is a good way to engage the local inflammatory behaviors that drive Frozen Shoulder, as well as a range of less-persistent inflammatory complaints in the shoulder.

Check out the linked article, and consider joining us for June 13th's class, Neurofascial Approach to Frozen Shoulder. (Full details below, and here: https://bit.ly/4uWPHyF)

🐦Saturday, June 6th is the last day for early bird pricing--$75 USD, and there afterward it goes up to $85 USD 🐦

⚡ Neurofascial Approach to Frozen Shoulder ⚡

Open to all healthcare practitioners licensed in Manual/Massage Therapy, and meets the WA state CE requirements for physical therapy and massage therapy.

Saturday, June 13th from 10a-2p Pacific
4 CE hours • Cost: $75 USD

In person, online, or view in your own time

For more info & to sign up:
https://bit.ly/4uWPHyF
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Reference:
Tamai, K., Akutsu, M., & Yano, Y. (2014). Primary frozen shoulder: brief review of pathology and imaging abnormalities. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association, 19(1), 1–5. https://doi.org/10.1007/s00776-013-0495-x
Arthroscopy from Cho et al 2019 ‘Treatment Strategy for Frozen Shoulder’.

This is the best diagram I've ever seen for the sensory innervation of the shoulder — one that transforms how I approach shoulder pain/inflammation.

Laumonerie et al (2020)* beautifully mapped the concentrations of mechanoreceptors (green) and nociceptors (red), as well as the 3 nerves supplying the shoulder.

Imagine how this system moves when the body/arm moves. Imagine what kinds of protective behaviors might arise when 1 or more of these nerves is irritated.

Most importantly, given how often we use our shoulders and how much the humerus glides in its socket, imagine how acute inflammation/restriction might feed back on itself — turning into cyclical, chronic dysfunction.

The authors created this map for the purpose of nerve block injections, but it’s highly relevant for anyone hoping to defuse inflammatory drive to the shoulder.

3 nerves innervate the shoulder and (when cranky) prime it for inflammation — Axillary nerve, Suprascapular nerve, and (somewhat surprisingly given its path), the Lateral Pectoral nerve.

Finding and treating these is incredibly empowering for manual & movement therapists… and it’s a key part of June 13th's online/in-person class on Frozen Shoulder (https://bit.ly/4tsgKAB).

We'll be learning to assess and treat patterns of persistent irritation in these nerves, and hopefully thereby easing/shortening the long arc of this condition.

You can take live *or* watch on your own time, both of 4 CEs. I hope you can join us!



🐦Saturday, June 6th is the last day for early bird pricing--$75 USD, and there afterward it goes up to $85 USD 🐦

⚡ Neurofascial Approach to Frozen Shoulder ⚡

Open to all healthcare practitioners licensed in Manual/Massage Therapy, and meets the WA state CE requirements for physical therapy and massage therapy.

Saturday, June 13th from 10a-2p Pacific
4 CE hours • Cost: $75 USD
In person, online, or view in your own time

For more info & to sign up:
https://bit.ly/4tsgKAB
—-
* 'Sensory innervation of the human shoulder joint: the three bridges to break' https://www.sciencedirect.com/.../abs/pii/S1058274620306108

Suppose your voice has gotten weak, tight, even painful -- what we sometimes call 'muscle tension' dysphonia. Is skilled massage around the larynx a good option? Does it help to do physical/manual treatments on the larger vocal column?

According to a recent systematic review by Cardoso et al (2017), the answer to both questions is a provisional 'yes'. Even higher-quality studies were limited in their sample size, but the results were encouraging. Several forms of massage and manual therapy for the neck, larynx, and breathing column were assessed for their impact on vocal function, and most methods showed at least moderate benefit.

Full text: https://pubmed.ncbi.nlm.nih.gov/28484700/

The big question I have is: how can we extend the relief beyond a few days? What are the cofactors that turn a meaningful session into a robust recovery? My guess is that within sessions, we must simultaneously seek to create near-term relief and also teach our patients a practice of self-inquiry.

Unless a person can build tools around breath, vocal posture, and emotional self-regulation, their voice will engage in protective contraction and the sordid feedback loop begins again. Let us instead use our vocal massage to initiate a virtuous cycle of relief, curiosity, and resilience.

We'll be learning some ways of doing this in next Saturday's online/in-person class -- Neurofascial Approach to the Diaphragm, Breath & Vocal Column.

⚡ For more info & to sign up: https://bit.ly/422gSf6

The class blends hands-on manual therapy, compelling breath/voice practice, and of course, a solid neurofascial anatomy of the diaphragm, pericardium, and larynx.

We hope you can make it.

⚡ Neurofascial Approach to the Diaphragm, Breath, & Vocal Column

Open to all healthcare practitioners licensed in Manual/Massage Therapy, and meets the WA state CE requirements for physical therapy and massage therapy.

Saturday, May 2nd from 10a-2p Pacific
4 CE hours • Cost: $85 USD

For more info & to sign up: https://bit.ly/422gSf6

In-person, online, or view in your own time.



References

IMAGE: Bourgery and Jacob, 1862

Cardoso R, Meneses RF, Lumini-Oliveira J. The Effectiveness of Physiotherapy and Complementary Therapies on Voice Disorders: A Systematic Review of Randomized Controlled Trials. Front Med (Lausanne). 2017 Apr 24;4:45. doi: 10.3389/fmed.2017.00045. PMID: 28484700; PMCID: PMC5401878.

Vocal expression is a nuanced action. Shaped by linguistic & social patterns while reliant on the underlying rhythms of breath, it comprises both conscious (cortical) and unconscious (autonomic) aspects of bodily expression. In practice, how might we work with the voice as a place of embodiment & integration between these interwoven systems?

We would love to have you join us in our upcoming workshop and diver deeper into the discussion:

⚡ Neurofascial Approach to the Diaphragm, Breath, & Vocal Column.
For more info & to sign up: https://bit.ly/4cB1UCT

Related research excerpt:

"This review of the central nervous control systems for voice and swallowing suggests that the traditional concepts of a separation between cortical and limbic and brain stem control should be refined and more integrative. Recent human studies of emotionally based vocalizations and human volitional voice production has shown more integration between these two systems than previously proposed...Central nervous system control for both systems include both relatively autonomic behaviors present from birth and volitional control acquired with development."
from Central Nervous System Control of Voice and Swallowing - https://bit.ly/3RvbNEg

This article investigates the role of the central nervous system in the organization of vocal production. The author considers the role of brain structures responsible for involuntary functions related to the voice - particularly, the midbrain & brain stem, which control breathing rhythm and the emotive expressions of crying, laughter, & pain - and their connection with cortical brain structures involved in voluntary use of speech & language. As we engage our clients, how do we stay curious about both aspects of vocal expression, listening for the volitional meaning of speech as well as the embodied rhythms & involuntary affect that underlie its expression?

⚡ Neurofascial Approach to the Diaphragm, Breath, & Vocal Column

Open to all healthcare practitioners licensed in Manual/Massage Therapy, and meets the WA state CE requirements for physical therapy and massage therapy.

Saturday, May 2nd from 10a-2p Pacific
4 CE hours • Cost: $85 USD

For more info & to sign up: https://bit.ly/4cB1UCT

In-person, online, or view in your own time



References

Ludlow C. L. (2015). Central Nervous System Control of Voice and Swallowing. Journal of clinical neurophysiology : official publication of the American Electroencephalographic Society, 32(4), 294–303. https://doi.org/10.1097/WNP.0000000000000186

What do you visualize when you hold someone's shoulder complex? For me, it depends on what's going on with the patient -- but the brachial plexus nerves often take center stage.

Especially if I suspect irritation/entrapment of nerves in the shoulder/arm, or a neurogenic driver to some other condition (hello tennis elbow! hello dequervain's!)... I'm really going to take my time assessing along the path of these nerves.

The first thing to 'unlearn' from dissective anatomy: Nerves don't live in isolation.

They corkscrew through tunnels, splay across membranes, rake across bone, entwine with blood vessels, and perforate through muscles, fascia viscera. Despite these traversals their intense metabolic needs, they remain remarkably robust and adaptable.

They can (usually) self-regulate their bloodflow and permeability. They can activate their own protections via muscle tension, inflammatory cascade, and behavioral modification.

But sometimes a mistuned pattern of protection can entrap us, or even injure us. Sound familiar? So it goes with nerve entrapment, like TOS or carpal tunnel -- these are best understood as feedback loops where stress causes cascades of protection, causing further stress.

In this class, which I've taught in some form now for almost 20 years -- we'll learn to defuse the stressors and unwind the overbearing protectors of the upper limb nerves. We'll learn

• Nerve palpation skills,
• Neurodynamic assessment, and
• A strategic treatment framework
.. All grounded in a contemporary understanding of how nerves actually regulate and heal over time.

We already have a wonderful group of practitioners signed up for this one. We look forward to seeing you there.

(REMINDER: ALL attendees receive a FULL recording of the course, regardless of ticket type.)

🖥️ Online & In-Person | 4 CEs 👉 More info & sign up: https://bit.ly/41LbI6P

⚡ Neurofascial Approach to TOS & Carpal Tunnel

Open to all healthcare practitioners licensed in Manual/Massage Therapy, and meets the WA state CE requirements for physical therapy and massage therapy.

Saturday, April 4th from 10a-2p Pacific
4 CE hours • Cost: $85 USD

In-person, online, or view in your own time