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102 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 6 technique MYOSKELETAL ALIGNMENT TECHNIQUES Double Crush Nerve Damage Addressing Neurogenic Thoracic Outlet Syndrome By Erik Dalton, PhD The term double crush syndrome (DCS) was coined by Harvard University plastic surgeons Albert Upton and Alan McComas, who wrote, "Neural function is impaired when compressed axons at one site cause the nerve to become especially susceptible to damage at another site" (Image 1). Their double crush research began after observing that many carpal, cubital, and radial tunnel patients also complained of unilateral shoulder, chest, and upper back pain. 1 While the DCS mechanism is not completely understood, it likely involves nerve sensitization and neuroplastic changes in the pain-modulating systems of the brain and spinal cord. Neural compression of the brachial plexus is suitably called neurogenic thoracic outlet syndrome (NTOS). These clients present with a variety of symptoms, including painless atrophy of intrinsic hand muscles and nighttime paresthesia. Athletes may have diffi culty grasping a racquet or ball, and some report pain. However, I've found that rather than being a main pain event, NTOS is more of an enhancer of symptoms at a distal site, such as the carpal tunnel. Put simply, the brain pays more attention to double crush nerve insults and is more likely to respond with pain or spasm. Although most clinicians feel that NTOS is an underestimated cause of DCS, assessment is often diffi cult due to vague, fl uctuating symptoms. Instead of chasing the pain, I've achieved superior outcomes by palpating and releasing all fi brous connective tissue sites that may be kinking, stretching, or infl aming the brachial plexus. In the January/February 2016 ("An Alternate Approach to Tennis Elbow," page 102) and May/June 2016 ("Carpal Tunnel Syndrome Revisited," page 102) issues of Massage & Bodywork, I addressed carpal and radial tunnel compression sites. Now, we'll palpate and release NTOS contractures at the interscalene triangle, costoclavicular canal, and retropectoralis minor spaces (Image 2). INTERSCALENE IMPINGEMENT Nerve fi bers originating at the spinal cord travel from the neck, through the thoracic outlet, and into the hand, providing sensation and movement during daily tasks. Certain postures or sleeping positions may increase tension and pressure on entrapped nerves. Further complicating the nerve's journey through the thoracic outlet, researcher David B. Roos, MD, FACS, discovered irregular fi brous bands that increased brachial plexus stiffness and decreased movement. 2 Roos classifi ed 10 types of contractures that can stiffen the already unforgiving boundaries of the thoracic outlet container. Despite all the neural roadblocks, it has been my experience that many DCS clients respond well to massage, movement, and any type of cognitive training that lowers the brain's threat level during Double crush syndrome. 1 2 Interscalene, costoclavicular, and retropectoralis compression sites. Carpal tunnel compression Neurogenic thoracic outlet syndrome injury subclavius pectoralis minor scalenes

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