First aid for nerve damage

This is a rather nuanced treatment of this topic. For a practical summary, click here.

First aid for acute nerve damage is a difficult, complicated issue. I’ve read through quite a bit of research (some of which has contradictory findings, which I discuss below) and consulted a couple of kink-friendly MDs, and there is no clear consensus on some details.

A quick first aid summary:

  • Don’t stretch, compress, or massage the injured area (remember that stretch and compression likely contributed to getting the injury in the first place)
  • Mobilize early to prevent joint stiffness27
  • Consider splinting of the affected limb to prevent further injury (for example, a wrist splint for wrist drop)
  • Consider seeing an MD (a neurologist if possible) within a few days if symptoms persist.

“Conservative treatment is generally the rule for patients with a one-time compression injury to the radial nerve. Physical therapy, wrist splinting (to maintain function), and pain management are most important. Prognosis for full recovery is generally good.”26

That’s really what you need to know, but if you like to geek on on bondage safety and related medical studies — like I do! — a much more nuanced discussion of each of these recommendations is below.

This is what you should NOT do

There are a few very straightforward recommendations. The injured person should not compress the affected area (putting pressure on it, wrapping tightly with an ACE bandage, etc). Compression is likely a causative factor in getting the injury in the first place — further compression during the acute phase of the injury will not be helpful.

Additionally, the injured person should not stretch out the affected area. Stretch is often a contributing factor in causing the injury. “Mechanisms of nerve injury include direct pressure, repetitive microtrauma, and stretch- or compression-induced ischemia. The degree of injury is related to the severity and extent (time) of compression.”1

It’s important to remember is that the site of the damage may not be immediately clear or intuitive. For example, if the bottom has radial nerve damage (and subsequent wrist drop) from a box tie, the temptation is to think that their WRIST is injured, when the injury probably originates in the upper arm. Don’t rub, tightly wrap, or stretch out the injured area.

To immobilize or not to immobilize

Immobilization after nerve damage is a tricky issue. Many sources recommend immobilizing the limb (for example, wrist splints for radial nerve damage and wrist drop), and I think in the short term, that’s reasonable advice. Relative rest and protection of the area has to be balanced with early mobilization and therapy, which is also recommended. Your body has a well-evolved immune response to injuries, and increasing evidence shows that trying to short-circuit that by aggressively trying to bring down swelling is unhelpful at best. However, you don’t want to aggravate an injury in the acute stage and increase the swelling or traumatize already injured tissue further, therefore relative rest is important in the first few days after an injury.

In the weeks following the injury, you still want to strike a balance between mobilization and protection. Most bondage related nerve injuries are neurapraxial, which means your body repairs by remyelination of the axon sheath. You don’t want to disrupt this process, because anything that’s in the process of repairs is going to be weaker and more prone to injuries — there is lots of data showing very conclusively that nerve injuries are cumulative,11 and this is one of the reasons why.

Physical Therapy is your best bet, because balancing protection and mobilization is a job for the professionals! The injured person will want to use the muscles in the affected limb to prevent muscle wasting.2 Most experts in sports medicine recommend early mobilization and exercise for optimal recovery.23 “Experimental and clinical studies demonstrate that early, controlled mobilization is superior to immobilization… Early mobilization helped return the patients more quickly to physical activity, reduce persistent swelling, restore stability, restore range of motion, and improve patient satisfaction with the rehabilitation outcome.”24

As an example of the research available on this — patients with sciatica (damage to the sciatic nerve) were traditionally advised to be on bedrest while symptoms were acute. However a recent study that was published in the New England Journal of Medicine showed no difference in healing between patients who were randomly assigned to be on bedrest vs. those who were advised to continue their usual activities as tolerated.4

For something like wrist drop, the injured person may find it useful to use a velcro wrist splint to protect the wrist from injury (especially at night2) and help with ADLs (activities of daily living). “All patients require a wrist splint and hand therapy to prevent joint stiffness.”27

Some people suggest neural glides (also called neural flossing or nerve stretching) to either prevent or help rehabilitate after an injury – remember that there is zero data on using this for prevention or treatment of bondage-related nerve damage. If you want to try it, get advise from your physical therapist, and be sure to do so very gently and cautiously (never to the point of pain).

Ice Ice Baby

Use of ice to treat acute injuries is controversial and current thinking (especially in sports medicine) is moving away from it. Many experts recommend MEAT (Movement, Exercise, Analgesia, and Therapy) rather than the old stand-by RICE (Rest, Ice, Compress, Elevate) for optimal recovery after an injury.19 In fact, even the doctor who coined the acronym RICE now recommends against routine icing: “applying ice to reduce swelling actually delays healing.”28

RICE was poorly studied in the first place: “[there is] insufficient evidence is available from randomized controlled trials to determine the relative effectiveness of RICE therapy.”21 Studies on use of ice after an acute injury are scarce and poor-quality (for one thing, it is basically impossible to do a double-blind study where the patient does not know whether they are receiving ice therapy or not), and mostly focus on relief of acute pain rather than enhancing recovery. Most studies conclude the same thing — ice may temporarily decrease pain, but doesn’t have much (if any) effect on healing: “Application of ice appears to be effective in reducing pain, but there is no credible evidence that it accelerates healing.”20 “There is insufficient evidence to suggest that cryotherapy improves clinical outcome in the management of soft tissue injuries.”22 “Cryotherapy or icing… could actually delay recovery and increase muscle scarring following significant muscle damage.”25 It’s worth noting that there is solid evidence that a cold environment increases the likelihood of acute nerve compression injuries,11 which strongly suggests that cold is unlikely to be helpful in healing such an injury.

Keep in mind that almost all the studies on this subject (including the ones cited above) are looking at injuries like sprained ankles. I could not find any studies on acute compression nerve injuries, which is most directly relevant to bondage injuries. However, multiple articles suggested that ice would have more potential to help an injury of more vascular tissue (muscle), and more potential to be harmful to an injury of less well-vascularized tissue (ligaments or nerves). As these tissues have minimal perfusion to begin with, and perfusion is crucial to healing, further decreasing perfusion by applying ice is unlikely to be helpful and may even be harmful.19 All of that is IF the cooling effect from ice even penetrates down to the muscles/nerves, which studies suggest it probably doesn’t.25

There are a few outlier cases, for example if there is a large bruise (hematoma) forming, where reduction of swelling becomes important and ice may be indicated. Injuries of this sort are quite unlikely in a bondage context, and should prompt immediate visit to the closest ER.

Ice may reduce pain, and likely doesn’t have much effect on healing, therefore I wouldn’t be one to say “no one ever should use ice after a bondage nerve injury.” If it was my nerves, I wouldn’t do it, but you should make your own judgements. If you DO choose to apply ice after a bondage-related nerve injury, do so conservatively (applying a padded ice pack for 10 minutes every hour, only for the first day). Remember that the location of the injury may not be immediately intuitive or apparent. If there is a radial nerve injury from a box tie, mostly likely the origin is the upper arm (wherever the rope was compressing) rather than the wrist (the main place symptoms manifest). If ice was to be used in this case, it should be applied to the upper arm, not the wrist.

Heat me up!

I was unable to find research specific to the use of heat at a treatment for acute nerve damage. If you wanted to try heat, certainly wait until after the acute phase of the injury — at least 48 hours. “Heat therapy can be used during the repair stage of an injury when new tissue is being formed. This is usually 48 to 72 hours after the initial injury (once the risk of internal bleeding is minimal)… Heat in any form should not be applied to an acute injury or where discoloration or swelling is present.”11

Pop some pills

Are there any meds you can take for this? The best recommendation would probably be anti-inflammatory medications26 (ibuprofen, aleve, advil, etc): “Anti-inflammatory medications are often added [for initial management of most nerve injuries], although it is unknown if they aid healing.”2  However, some experts suggest that anti-inflammatory medications may delay or impair healing. Carpal tunnel syndrome is somewhat different from bondage related nerve damage, however there are parallels — a summary of evidenced based treatment for carpal tunnel suggests: “… short-term benefit from local corticosteroid injection, splinting, oral corticosteroids, ultrasound, yoga, and carpal bone mobilization.”9

Nerve damage can be exacerbated by vitamin B-12 deficiency. Taking B-12 supplements, if it’s OK’d by your doctor, could help with healing.12

We need an MD, STAT!

Beyond first aid, it’s important to consider when to get ye to a doctor. Generally, I wouldn’t think that nerve injuries resulting in mild symptoms in isolation would require a trip to the emergency room right this second, but if there are any concerns that there may be further or more severe injury (ongoing circulation compromise, severe deficits, ongoing pain, deformity of the limb, hematoma (large bruise) which could compress the nerve, etc) then a trip to the ER would certainly be appropriate.

Any “funny feelings” or numbness in a limb can be due to a bunch of different causes: direct trauma by compression of the nerve, swelling of other tissue (or even internal bleeding) that compresses the nerve, and impaired blood transport into the limb caused by traumatic occlusion of a blood vessel are a few options. As a guideline: The “deader” the bottom’s limb and the slower it resolves, the more urgently they should visit the local ER. So, if they have a bit of tingling in their pinky from hitting their funny bone, they can easily wait. If their whole arm is numb, pale and doesn’t get ANY better in 10-20 minutes – RUSH to the ER IMMEDIATELY. Remember: Tell the ER docs the truth. They won’t judge you, and they need to know exactly what happened. The more authentic the story you’re telling is, the less likely they will suspect any abuse.

A person with nerve damage may recover in a few minutes, a few hours, a few days, a few months… or they could end up with permanent nerve damage, for which there is little medical treatment (there are some surgeries, they have varied success rates). “Recovery of nerve function is more likely with a mild injury and a shorter duration of compression.”2 If there is serious impairment of nerve function and no improvement in 3 months, surgery might be indicated.27

Beyond basic first aid — handling a bondage injury

From a top’s perspective, what should you do if your bondage bottom has these symptoms after you untie them? Hopefully the possibility of this happening was discussed beforehand, and the bottom was educated about the risks and also the things they could do (such as communicating!) to help prevent injury. A bottom cannot give risk aware consent (the hallmark of the RACK model) if they are not risk aware! I also believe bottoms have a responsibility to be proactive about risk education, by the way, but that’s getting off topic.

So, sometimes, despite everyone’s best efforts and intentions, an injury results. This is an important (and often overlooked) point to cover in negotiation — hey, it’s possible you could get an injury. Do you have health insurance? Who will be financially responsible if something goes wrong? (Note that injuries don’t just happen to bottoms, but that’s also getting beyond the scope of this article.) IMHO the top *always* needs to take responsibility for what happened (not *sole* responsibility, but responsibility) and at the least needs to listen to (and not minimize) the bottom’s symptoms and concerns, provide emotional support and aftercare, start basic first aid as outlined above, and follow up with the bottom over the days and weeks after the injury to see how they are doing and if further support is needed.

An indication that experienced bottoms report regarding recovery time is that if there is notable improvement over the hours following the injury, generally recovery will take place within a few days, perhaps a week. If it takes days to see improvement, it will likely take weeks to recover. Longer time to initial improvement = longer time to full recovery.

Cumulative nerve damage

One final note is that there is emerging evidence, both in scientific journals and also anecdotally in the bondage community, that nerve injuries can be cumulative. For example, studies have shown that having existing sub-clinical damage to the ulnar nerve before surgery makes it more likely that a patient will come out of surgery with an intraoperative positioning injury to the ulnar nerve7.  Studies of baseball players have shown that cumulative microtrauma from repetitive overuse places them a risk for peripheral nerve injury of the upper extremities8. This means that a bottom who has been put in a box tie the exact same way 50 times and never had symptoms of nerve damage, might the 51st time suffer from a symptomatic nerve injury, even though there was nothing special, different, or “wrong” that 51st time.

Wow, that’s a downer, huh? Let’s try to end on an up note — bondage is fun, puppies are cute, education and prevention, people!

 

About the author:

This article was written by me (Shay) — I’m an ER nurse and ACLS (Advanced Cardiac Life Support) instructor who has spent WAYYY too much time geeking out over bondage safety. I also got input on the ideas in this post from a kinky MD (Dr. Who). I would, however, note that nurses (and doctors!) can and do say idiotic/incorrect things, so using your own judgement no matter how “qualified” the source is always a good thing. Thanks for reading, and please feel free to email me (shay.sfblondie AT gmail) with any feedback or suggestions on how this article could be improved!

References can be found here!