Tuesday, March 22, 2011

Right Shoulder Active Rehab part 2: phrenic nerve and the liver shoulder?

Welcome to Part 2 of my right shoulder rehab log.When my right shoulder started to hurt, it happened after doing a few ordinary kettlebell presses on the right side. I have no idea what i did to kick off this result - it didn't even feel like the usual uh oh the arm went too far back - something's pulled. It was just pain. This post is about the seemingly strange connections from the liver to the shoulder via the phrenic nerve - and how getting that connection may reduce pain and improve movement.

To cut to the chase after the first few days of nothing seeming to calm down what felt like an inflammatory response - that initial owie of restricted motion and soreness - i went looking for some ideas. Since the nervous system is the governor of the body, and the body responds quickly to threats to it (as in the arthrokinetic reflex), it seemed like an idea to look for any nerve responses about the shoulder.

Previously when i was working through the mystery of pain in my left shoulder, UK Osteopath Andrew Bellamy in the comments of that post suggested to keep in mind any mid neck issues (C5-C6) since this is an area where nerves running into the rotator cuff muscles can get squished. When neck nerves get squished they certainly can refer out to the shoulder.

To quote Andrew's Comment
The suprapsinatus nerve, ([C4] occ/5/6), which runs through the anterior and middle scalenes, close to the levator scapulae (vital for shoulder shrugging), into the supraspinatus fossa via the notch, under the periosteum (therefore tethered and liable to neural stretching) laterally. It divides in two innervate the supra and infraspinatus muscles. Typically it gives deltod, scapular, biceps and forearm radiating pain when irritated and is a regular mimic of shoulder pathology, especially cuff tear and subacromial impingement.
Indeed, here's a wee bit more on the neuropathy of this often troubling site of the suprascapular nerve and the rotator cuff muscles it innervates.

Cervical and Brachial Plexus. Quick aside about nerves: the spine is the origin point for nerves. Nerves send the signals to power anything in our bodies that moves or has signals moving through it. Veins, muscles, tendons, lungs, brain for instance, all have nerves. Most of these nerves are associated with what are known as spinal segments - areas around a given vertebrae.  Nerves come off these spinal segments quite often with thicker branches that split into finer strands.

These larger nets of nerves are referred to as Plexi. The nerves that connect with our neck, shoulders, arms  and hands are part of the Cervical (from C1 to C5) and Brachial Plexus, spinal segments from C5-T1 (T1 is the top of the thoracic spine). It's the shape of these plexi that give the nerve fibers, well, give for being able to stretch, compress, torque and move with the body. Amazing engineering.

From Suprascapular to Phrenic Nerve: the site of pain not the source of pain
It was thinking back to Andrew's comments that made me wonder about a nerve squish troubling my shoulder.  There are some good neurodynamic drills that can help release the suprascapular nerve if that's what the impingement is; there are lots of great mobilisations for the head and neck too. These weren't quite doing it for me.

Manual Therapy for the Peripheral NervesThere's a book by Barral and Croibier on the Peripheral Nerves. I pulled that one down to have a look to see what i might be missing in nerve world.  If you're interested in how the nerves work in our bodies, from how they're fed to how they can be manipulated for improving movement, this is a well illustrated and interesting text.

Starting with the area of the cervical plexus Andrew identified, Barral and Croibier after talking about the cervical plexus in general for treatment, zero in on the Phrenic Nerve. The phrenic nerve? Turns out, it, too comes off C4, is neighbours with the hugely important vagus nerve, and innervates the diaphragm. So what's that got to do with the shoulder?

Turns out as well that the phrenic nerve is really close to the liver - in particular the sensory (as opposed to motor) fibers of the phrenic nerve. Also Glisson's Capsule (fibrous stuff that wraps the liver) is innervated by the phrenic nerve. Indeed, something quite horrible can happen in liver surgery/transplants: the phrenic nerve right branch can get cut - which means half the diaphram can stop contracting, making breathing a challenge.

Enter the Liver Shoulder. So what's this got to do with the shoulder, interesting and all as this seems? Barral and Croibier call the right shoulder "the visceral shoulder."

The authors have a theory that based on the phrenic nerve's spinal segment, its location in the shoulder, and all the action along the pathway connected with viscera, trouble at one part of the nerve could superimpose or transfer sensation to other areas. This kind of effect isn't uncommon. Head's Zones are long standing maps of referred pain from viscera to other areas of the body. In Head's work, liver/gallbladder referred out to neck pain - more what looks like the upper traps area than the shoulder.

More Specific: Periarthritis. Moving into their chapter on the brachial plexus, the authors get into a discussion of right shoulder "periarthritis" in particular. A quick note that periarthritis is a chronic shoulder issue - also known as frozen shoulder. Now in my case i did not have a chronic right shoulder issue - far from it. My right shoulder has been my rock. But i was still interested. They say that of the hundreds (that's quite a bunch) of patients they've looked at with right shoulder periarthritis where the cause wasn't injury, they've found a connection with the liver and gallbladder also being touch sensitive.

A Test: does it hurt less / can you move more when you do this now? What struck me in their discussion is that pain in the right shoulder can come on seemingly from a simple typical movement and get attributed to that movement - when perhaps it's been a visceral issue just appearing. Oh my. They have a test. After checking the right shoulder - they assume a variety of diagnostics - check to see if the liver or gallbladder are touch sensitive.

Now as it turns out, in my case, that area was pretty sensitive - more so on the right than on the left - but heck i was also recovering from some intense DOMS for my first time using a power wheel for roll outs in awhile, so perhaps that was it? None the less, i thought ok, i'll check their evaluation. Starting seated with arm abducted and externally rotated, there are two touch tests for the liver area. I shan't describe them here, but in carrying them out, the question is, can the arm go past the previous range of motion, past the previous pain threshold. Mine went way past. As i told colleagues, i was not a little freaked out.

How Much Liver?  The challenge to consider: does this mean that there is some GI related issue screwing with my shoulder?

I don't know. I'm going to do some bloodwork with Bioletics soon just to check on how things are going - i like having a baseline - so will see. But i can say that just massaging the liver/gallbladder area in a way that Kevin Perone once showed me once to help me sleep seemed to have an ongoing, immediate effect in those first key days of getting the inflammation sense of really restricted/painful motion down and range of motion without pain, up. By painful i mean shampooing my head - that much pressure - hurt. Pulling the covers off me in bed hurt. That kind of thing.

What i do know, experientially from this: gentle visceral manipulation around the liver had a remarkable effect.

Update: here's another post courtesy of a find by Randy Hauer that shows a diaphram/shoulder connection - the more direct phrenic end (phrenic innervates diaphragm) to the shoulder.

Related: Barral Institute
Visceral Manipulation (Revised Edition)Kevin (shown here at 0.22 in doing some one arm pull ups) who demo'd that nice help sleep liver work had studied visceral manipulation with  the Barral Institute. I'd heard of this in z-health training; experienced kevin's ministrations, but had not put together that the author of this book was the same person as the eponymous institute. More than that, i had not had a direct experience of a test/reassess movement with visceral work and a demonstrable effect.

One of the things we learn in Z-Health is the value of test and reassess. Does the technique make a difference to performance right now (today it might; later today maybe not). For this period, there *seemed* to be a strong correlation between visceral work and shoulder pain reduction rom improvement. Whether the DOMS in my abs were another contributor to phrenic nerve irritation, i dunno, but even if it was, isn't that interesting?

In any case, i am interested to learn more about visceral work.

Back to the Shoulder: Next Part - Enter the Bands
While the visceral work certainly helped - amazingly so - it didn't eliminate the issue with my shoulder.

the micro mini band: excellent for exploratory band rehab

In the next part of this rehab log, we'll be looking at how bands - in particular light bands - for exploring, loading and testing range of motion work has been helping - a lot and quickly - to get my shoulder back to functioning without pain.

Caveat:
Just a note again, as i said in part one, these posts are just what i've been doing for myself, with myself. They're explorations grounded in practice and what i've learned formally and on my own, but i'm not generalising to say hey, if you want to fix your shoulder, this is what you should do.

As always, if in doubt about a painful experience, check with a qualified medical person - someone who knows athletes and athletic movement and won't tell someone "just don't lift heavy." Once you're cleared for rehab work, check with someone you trust to help formulate that action.

One phrase prior to the next episode that's been resonating with me is dan john's if it's worth doing, do it every day. I think there's a bit of the seminary about Mr John sometimes with expressions like that. Dunno why, but there it is. Taking that "every day" sentiment to heart, however, i have been working my shoulder every day - usually morning and evening. We'll look at how next time, but i'm convinced that lots of pain free movement, lots of the time, is a key healer.

Till next time.
mc

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2 comments:

B. Ramana said...

Visceral pain referred to the shoulder usually does not occur at the site of referral alone. It usually starts from the anatomical site of the organ and then shoots up to the shoulder. In medicine we never say never, so this would be the usual norm. Get well soon.
Rambodoc

David said...

Occam's Razor.

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