Compression Syndromes, An Integrative Manual Therapy Approach
Consider Manual Therapy and Complementary and Alternative Medicine for Optimal Health.
Integrative Manual Therapy Compression Syndromes
Tissue in the body gets compressed, giving more stability to an area, decreasing fluid flow and swelling and containing pathogens and toxins. In Integrative Manual Therapy (IMT), an innovative hands-on approach to healing and recovery, Compression Syndromes are a therapeutic technique to permit the tissue to decompress allowing for healing of muscular tissue, ligaments, tendons and other tissues.
The theory is that the decompression techniques allow for tissue space, better fluid flow and decreases nerve entrapments. The functional changes clients see after the IMT practitioner treats with the Compression Syndrome techniques are decreases in pain, increases in range of motion, increased strength and a decrease in swelling.
Compartment syndromes and entrapment syndromes can occur due to a compression on tissues from the outside, from internal mechanical dysfunctions and tissue derangement.
“Compression Syndromes are a typical problem affecting health: an effect first, and a cause later. Many body problems occur which result from trauma, misuse and disuse. Repetitive trauma, and isolated traumatic occurrences can cause tissue damage. Often the damaged tissue will heal; sometimes the damaged tissue will not heal. Always the damaged tissue requires the body’s protection until it heals. Sometimes the body’s protection will last long after the damaged tissue is healed. When the body’s protection lasts after the tissue heals, this is the result of sustained neuroreflexogenic protective modes.”
―Giammatteo, S. W. (1998). Assessment, Integrative Diagnostics™, and Integrative Manual Therapy™ for diaphragm compression syndromes.
“The body has the inherent ability to provide protection. This ability is at least as profound as the body’s ability to self-correct and self-heal. The body’s innate mechanisms of self-protection are reflexogenic, autonomic and automatic. The body’s self-protection mode is initially a secondary problem. It is able to be transformed into a primary problem”
―Giammatteo, S. W. (1998). Assessment, Integrative Diagnostics™, and Integrative Manual Therapy™ for diaphragm compression syndromes.
Self-protection modes include: compression syndromes (multiple system contractions), and contractures. In typical compression syndromes, such as diaphragm compression syndromes, the muscles, ligaments, tendons, joints and connective tissue, both fibers and loose connective tissue compress the tissue.
Problems which commonly require protection are arterial perfusion, venous toxicity (CO2 toxicity), neural tissue tension, disruptions of membranes of visceral tissue and lymph derangement.
The underlying deep compression syndromes are closely associated with neural tissue tension and muscle spasm of the arterial, venous and lymphatic vessels.
Treatment recommendations include, Compression Syndrome Technique, Advanced Strain and Counterstrain for the Autonomic Nervous System (Giammatteo, 1998 and Wheeler, 2004) and Neural Tissue Tension Technique with Neurofascial Process. (Weiselfish, 2002).
―Giammatteo, T. and S. Weiselfish-Giammatteo (1997). Integrative manual therapy for the autonomic nervous system and related disorders : utilizing advanced strain and counterstrain technique. Berkeley, Calif., North Atlantic Books.
―Wheeler, L. (2004). “Advanced Strain Counterstrain.” Massage Therapy Journal 43 Winter(4).
―Weiselfish-Giammatteo, S. and T. Giammatteo (2002). Body wisdom: light touch for optimal health. Berkeley, Calif., North Atlantic Books.
“The Fulcrum Technique for Treatment of Compression Syndromes is an easy-to-learn approach for correction of compression syndromes. The concept includes, the less motion by the practitioner, the greater the release phenomenon attained for the client. Place both hands on the client. See anatomic placement unique for each compression syndrome. Direction of pressure is detail-oriented and specific. If the compression syndrome is mild, duration of technique may be 5 minutes total. If the compression syndrome is severe, duration of technique may be 20 minutes or more. Maintain the same directions of forces throughout the technique.”
―Giammatteo, S. W. (1998). Assessment, Integrative Diagnostics™, and Integrative Manual Therapy™ for diaphragm compression syndromes.
Cartilage Change, Force Response
Changes in the properties of articular cartilage are dependent on the kinds of forces on the tissue and the changes help the articular cartilage absorb or redistribute the forces in the safest way possible.
Researchers looking at the interplay between the fluid kinetics and fibril stiffening concluded that “this self-protective mechanism prevents cartilage from damage since the fibrils are strong in tension.” (Li, 2003). Li further explains, “the stiffness of articular cartilage is a nonlinear function of the strain amplitude and strain rate as well as the loading history, as a consequence of the flow of interstitial water and the stiffening of the collagen fibril network. The lower and upper elastic limits of the stress are uniquely established by the instantaneous and equilibrium stiffness. These limits could be used to determine safe loading protocols in order that the stress in each solid constituent remains within its own elastic limit. For a given compressive strain applied at a low rate, the loading is close to the lower limit and is mostly borne directly by the solid constituents (with little contribution from the fluid). In contrast, however in case of faster compression, the extra loading is predominantly transported to the fibrillar matrix via rising fluid pressure with little increase of stress in the nonfibrillar matrix. The fibrillar matrix absorbs the loading increment by self-stiffening: the quicker the loading the faster the fibril stiffening until the upper elastic loading limit is reached.”
―Li, L. P., Buschmann, M. D., & Shirazi-Adl, A. (2003). Strain-rate dependent stiffness of articular cartilage in unconfined compression. J Biomech Eng, 125(2), 161–168.
―Li, L. P., Buschmann, M. D., & Shirazi-Adl, A. (2003). Strain-rate dependent stiffness of articular cartilage in unconfined compression. J Biomech Eng, 125(2), 161–168.
Disease and Infection
Researchers are looking at the role of different pathogenetic mechanisms in the development of the disease, including “biochemical, autoimmune changes in the intravertebral discs, the state of the higher nervous activity, the vestibular apparatus, etc.”
Antonov, I. P. (1980). [Pathogenesis of spinal osteochondrosis and its neurologic manifestations at different ages]. Zh Nevropatol Psikhiatr Im S S Korsakova, 80(4), 490–494.
“Potential fascial spaces of the neck communicate inferiorly with the mediastinum and thus provide a route for spread of infections.”
―Shahzad, A. (2004). Mediastinal compression secondary to supraglottitis: a case report. Am J Otolaryngol, 25(2), 126–128.
Abdominal Compartment
“Abdominal compartment syndrome adversely affects many organ systems; the pathogenesis of renal dysfunction is probably multifactorial, from a combination of reduced cardiac output, reduced GFR mediated by secretion of renin and angiotensin, aldosterone-mediated water reabsorption, increased renal parenchymal pressure and direct compression of the renal vein.”
―Tal, R., Lask, D. M., Keslin, J., & Livne, P. M. (2004). Abdominal compartment syndrome: urological aspects. BJU Int, 93(4), 474–477.
“We report a rare case in which abdominal compartment syndrome resulting from venous hemorrhaging developed in a patient with stable pelvic fractures, resulting in a fatal outcome. An 84-year-old man with mild pelvic fractures developed hypovolemic shock and underwent transcatheter arterial embolization. This case suggests that brain death can sometimes occur due to abdominal compartment.”
―Hagiwara, A., Fukushima, H., Inoue, T., Murata, A., & Shimazaki, S. (2004). Brain death due to abdominal compartment syndrome caused by massive venous bleeding in a patient with a stable pelvic fracture: report of a case. Surg Today, 34(1), 82–85.
Neck and Upper Extremity
“The neurovascular bundle anatomy in the upper arm displays changing relationships of nerve and vascular structures along short segments. Fibrous tissues segregate these elements into enclosed compartments allowing for specific patterns of injury. Increased intracompartmental pressure may have led to nerve injury either thorough an ischemic mechanism or to focal compression. Recognition of this unusual pattern of nerve damage is important, since injury can be accurately localized to the midportion of the neurovascular compartment in the upper arm.”
―Lazaro-Blazquez, D., & Soto, O. (2004). Combined median and medial antebrachial cutaneous neuropathies: an upper-arm neurovascular syndrome. Electromyogr Clin Neurophysiol, 44(3), 187–191.
“The suprascapular nerve may rarely be entrapped in the suprascapular notch. This causes weakness of the supra- and infraspinatus muscles and pain in the glenohumeral and acromioclavicular joints, which are innervated by this nerve. The entrapment syndrome may result from direct or indirect trauma, fracture of the neck of the scapula, kinking or traction on a sling affecting the nerve, from the shape of the notch, compression by a ganglion, or its cause may be idiopathic. Diagnosis of the syndrome is based upon deep unceasing pain reported at the postero-lateral shoulder, atrophy of the supra- and infraspinatus muscles, and impaired shoulder external rotation and a lidocaine test. The final proof is taken from polyphasic EMG potentials which are decreased in amplitude and increased in distal latency. Initially the entrapment neuropathy may be treated by immobilization, analgesics, and physiotherapy. A tear of the rotator cuff as well as a frozen shoulder have to be excluded by arthrography. In persistent cases of pain and pathologic EMG findings surgical decompression of the nerve should be done. The trapezius muscle is approached by a postero-superior incision. Via the suprascapular fossa the notch may be reached. Then the nerve is decompressed by removing the transverse scapular ligament.”
―Habermeyer, P., Rapaport, D., Wiedemann, E., & Wilhelm, K. (1990). [Incisura scapulae syndrome]. Handchir Mikrochir Plast Chir, 22(3), 120–124.
“Radial tunnel syndrome (RTS) is thought to result from intermittent and dynamic compression of the posterior interosseous nerve (PIN) in the proximal part of the forearm associated with repeated supination and pronation. The patients most often afflicted with RTS appear to be those who perform repetitive manual tasks involving rotation of the forearm and athletes involved in racket sports. The first case of RTS occurring in an elite power athlete and believe this case represents a direct compressive sensory neuropathy.”
Dickerman, R. D., Stevens, Q. E., Cohen, A. J., & Jaikumar, S. (2002). Radial tunnel syndrome in an elite power athlete: a case of direct compressive neuropathy. J Peripher Nerv Syst, 7(4), 229–232.
“At the second operation, the vertebral artery as well as the posterior inferior cerebellar artery were noted to be compressing the vagus nerve. “
Resnick, D. K., & Jannetta, P. J. (1999). Hyperactive rhizopathy of the vagus nerve and microvascular decompression. Case report. J Neurosurg, 90(3), 580–582.
“Some patients have vertigo that is more or less constant, associated with varying degrees of nausea, and only relieved by bedrest. This disorder, named disabling positional vertigo (DPV), was found to be caused by a blood vessel or vessels compressing the eighth cranial nerve in its intracranial portion, and it can be relieved by microvascular decompression (MVD) of the nerve.”
―Moller, M. B. (1991). Vascular compression of the eighth cranial nerve as a cause of vertigo. Keio J Med, 40(3), 146–150
“Brachial plexus irritation and other compression neuropathies can be diverse in their presentations and can cause a myriad of signs and symptoms.”
―Langley, P. (1997). Scapular instability associated with brachial plexus irritation: a proposed causative relationship with treatment implications. J Hand Ther, 10(1), 35–40.
“Neck pain, headaches, upper thoracic pain, and dystonic scalene muscles are common findings in patients who have severe entrapment neuropathies of the upper extremities. This problem was taken to the laboratory in an attempt to discover the correlation between distal entrapment neuropathies, brachial plexus entrapments, and prominent scalenus muscles. When increased pressure (over 40 mmHg) was applied to the median and ulnar nerves in the forelimbs of eight goats, increased electromyographic activity was noted in the ipsilateral scalenus muscle. Pressures ranging from 100 to 150 mmHg caused increased electromyographic activity on the contralateral scalene muscle, and the authors postulate that it is mediated by the gamma afferent and efferent system. This relationship may explain the commonly found neck pain and muscle spasm in patients with peripheral neuropathies, and it represents a link between the somatic efferent nerves and the gamma motor neuron system. At present, the same phenomenon has been documented in 30 humans with the diagnosis of brachial plexus entrapment.”
―Monsivais, J. J., Sun, Y., & Rajashekhar, T. P. (1995). The scalene reflex: relationship between increased median or ulnar nerve pressure and scalene muscle activity. J Reconstr Microsurg, 11(4), 271–275.
Osteopathic Manipulation
“Osteopathic manipulative treatment is thought to affect microcirculation and anatomic positioning of structures, nerve compression syndromes appear ideal as models for studying how OMT accomplishes results. Techniques such as soft tissue, muscle energy, counterstrain, or myofascial release are appropriate for study in nerve compression syndromes.”
Luckenbill-Edds, L. and G. B. Bechill (1995). “Nerve compression syndromes as models for research on osteopathic manipulative treatment.” J Am Osteopath Assoc 95(5): 319–26.
Organ Compression
The cough reflex is an example of how the lungs are reflexly compressed in a protective mechanism based in the brainstem.
“The cough reflex is an important defense mechanism of the respiratory tract. It is a well-integrated reflex, which has afferent limb consisting of receptors and afferent nerves, the central cough center in the brainstem and the efferent limb consisting of motor nerves supplying the muscles of coughing. The cough process consists of inspiratory phase, compressive phase and expiratory phase. Stimuli that can initiate the cough process can be central or peripheral in the lungs or outside the lungs. The important function of the cough reflex is to maintain the airways and alveoli clear and healthy. The mechanisms by which it achieves this are (i) high velocity of expiratory gas flows produced in the expiratory phase (ii) the compression of the lungs and airways by high positive pleural pressure generated in the compressive phase.”
―Shah, M. D., & Shah, S. M. (2001). The applied physiology of cough. Indian J Pediatr, 68 Suppl 2, S3–10.
Median Arcuate Ligament Compression
“Compression by the median arcuate ligament might be a frequent cause of splanchnic aneurysm, which, on rupture of the aneurysm, could be life-threatening.”
―Sugiyama, K. and Y. Takehara (2007). “Analysis of five cases of splanchnic artery aneurysm associated with coeliac artery stenosis due to compression by the median arcuate ligament.” Clin Radiol 62(7): 688–93.
Lower Extremity
“A14-year-old boy sustained a heel injury while training for giant slalom. The skier had sophisticated equipment and used carving skies. We speculated that, when the skier tried to establish the lost balance during the fall, a violent contraction of triceps muscle occurred. Instead of an injury of a well-protected tuber or Achilles tendon, the strong pulling force of the Achilles tendon was transmitted more distally and anteriorly, generating axial compression force, which caused an intra-articular fracture of the calcaneus bone. Obviously, the existing ski boot did not sufficiently protect the calcaneus bone. We postulate that the calcaneal tuber and Achilles tendon were protected on the expense of the intra-articular calcaneal fracture.”
―Tudor, A., Sestan, B., Nemec, B., Prpic, T., & Rubinic, D. (2003). Intra-articular calcaneal fracture in a 14-year-old competing skier: case report. Croat Med J, 44(6), 764–766.
“Traumatic retroperitoneal hematoma in the iliacus muscle is an unusual but potentially serious cause of femoral compression neuropathy….The anatomical substrate for hematoma formation with subacute compression of the femoral nerve is emphasized. A subacute compartment syndrome with progressive edema, swelling and ischemia of iliacus compartment is suggested as the underlying cause. Early fasciotomy with or without hematoma evacuation should be considered in order to provide rapid decompression and to minimize the chance of permanent nerve injury.”
―Pirouzmand, F., & Midha, R. (2001). Subacute femoral compressive neuropathy from iliacus compartment hematoma. Can J Neurol Sci, 28(2), 155–158.
“Piriformis syndrome (PS) is defined by a loose cluster of symptoms arising from entrapment of one or both divisions of the sciatic nerve as they pass the sciatic notch……. Physical therapy aimed at reducing mechanical impingement was successful in 11 of 12 patients on followup at three to nine.”
―Fishman, L. M., & Zybert, P. A. (1992). Electrophysiologic evidence of piriformis syndrome. Arch Phys Med Rehabil, 73(4), 359–364.
“A 66-year-old man underwent emergency surgery for a ruptured abdominal aortic aneurysm associated with right common and internal iliac aneurysm. Postoperatively, his right buttock was distended and tender to compression……. To our knowledge this is the first documented case of gluteal compartment syndrome after the repair of an abdominal aortic aneurysm.”
―Ishibashi, H., Ohta, T., Hosaka, M., Sugimoto, I., Kawanishi, J., & Yamada, T. (2004). Gluteal compartment syndrome after abdominal aortic aneurysm repair. Vasa, 33(2), 89–91.
Pain
“Implicated in primary fibromyalgia syndrome, the “trigeminocervical reflex is a brainstem reflex that is evoked by stimulating the sensory branches of the trigeminal nerve and can be recorded from the neck muscles. Electric stimulation of the supraorbital nerve evokes a reflex response and early reflex response.”
Yuruten, B., & Ozerbil, O. M. (2003). Trigeminocervical reflex in fibromyalgia patients. Arch Phys Med Rehabil, 84(7), 1087–1089.
Reflex Sympathetic Dystrophy
“The sympathetic nervous system is hierarchically organized. At the bottom of this organization are the sympathetic pre-post-ganglionic channels which supply the autonomic target organs, at the top the hypothalamus and cortical structures.
According to this hierarchy the reactions to noxious, tissue-damaging events, which are organized by the hypothalamus and suprahypothalamic brain structures, are of a more general character than those organized by the spinal cord, these being of a more specific character. The spinal cord is probably much more important than hitherto believed for integration and in determining the characteristic discharge patterns of the sympathetic pre- and post-ganglionic neurones. The defence reaction is described as a general reaction to noxious stimuli.
Its sympathetic components consist of the patterns of discharge in sympathetic neurones supplying skin, skeletal muscle, viscera and adrenal medulla. It is organized in the hypothalamus and upper brain stem. The spinal cord integrates more specific somato-sympathetic, viscero-sympathetic and viscero-visceral reactions to noxious stimuli which are of a protective character. Visceral thoraco-lumbar afferents in ‘sympathetic’ nerves innervate visceral organs in the pelvic abdominal and thoracic cavities. Some innervate deep somatic structures of the ventral compartment of the vertebral column.
It may well be that visceral noxious events are encoded by the intensity of the discharges in these neurones. No conclusive experimental evidence exists to show that peripheral nociceptors are controlled by activity in sympathetic post-ganglionic neurones. In certain pathophysiological situations, however, it may happen that activity in sympathetic post-ganglionic neurones, which supply an extremity, leads to excitation of afferent axons, thus establishing a vicious circle between primary afferent neurones, spinal cord and sympathetic outflow. This situation may occur after partial lesions of peripheral nerves in a ‘reflex sympathetic dystrophy’.”
―Janig, W. (1985). Systemic and specific autonomic reactions in pain: efferent, afferent and endocrine components. Eur J Anaesthesiol, 2(4), 319–346.
This literature review shows the many ways the body can get compressed in an effort to protect the organs, muscles and tissues from damage. Manual therapy approaches have shown improvements by decreasing pain and increasing movement and function.
