Hello Faye, It sounds like you have put a lot of time and resources towards helping this person, you should feel very good about your efforts. It sounds like you have been coming at this problem from a biochemistry perspective, attempting to regulate local cellular activity and responses as well as trying to reduce sympathetic neurological activity in order to support optimal activation and reduce fatigue related to phrenic nerve activation and diaphragm recruitment. While I am sure that there may be some biochemical approach that may be helpful, I would suggest looking towards a mechanical intervention as well. There in lies my expertise. I am a Chiropractor, and although I understand that this profession tends to bring a sense of anxiety to certain individuals especially when related to cervical spine manipulation, I do believe it to be a very effective treatment method for these types of issues. I have dealt with this particular issue in my own practice with some success. I am also a scientist and I certainly appreciate the work that you have done and your approach I believe that in light of the original issue of a HNP causing the initial problem I would turn your attention to the source of the phrenic nerve disturbance. Typically in these situations the nerve dysfunction is the result of a combination of the local cellular and inter-cellular biochemical changes as well as the altered mms activity associated with these changes. The neuro feedback, or afferent information being sent to the thalamus and cortex via local mechanoreceptors is altered both by the damage and subsequent loss of these very receptors combined with local stimulation of C fibers carrying pain signals as well as the build up of TNF (tumor necrosis factor) in the inter-cellular matrix which inhibits the local Nitric Oxide pathway.

These changes create an altered pattern of motor recruitment and biomechanical stress responses, that make it impossible for the tissue in the area damaged to maintain normal function. This combination significantly alters local blood flow/exchange via micro-capillary beds in the tissue and this subsequent stasis in exchange of nutrients/waste and vital gas exchange further disrupts local metabolism and that tends to affect function of any nerve fibers in the area, to a greater degree than any supposed direct mechanical stress, especially when the herniation is small. It is often assumed that in the presence of a HNP that any local nerve dysfunction/palsy is related only to mechanical compression, this however is usually not the case and in surgical cases and in several MR based studies this has been a very poor correlation to nerve palsy and direct mechanical compression.

This being the case, I have found it effective to use a combination of cervical manipulation, postural neuro-muscular re-education and cervico-thoracic stabilization exercises to restore normal afferentation and subsequent efferent motor recruitment/coordination. This process has shown great benefit in restoring local tissue health, thereby allowing for normalization of local cellular/tissue metabolism. This will have a positive impact on phrenic nerve function in your situation.

Thank you for your intelligent response,Gabriel. Let me clarify that the MRI and initial presentation was seven years ago, and there was such significant improvement after implementation of the iron lung for a couple years and given the natural hx of disc absorption, the hx was consistent with this problem being resollved and ongoing and recurring problems due to iatrogenic damage from pressure from the turtle shell cuirass- the only system available or utilizable for several different reasons patient related and system related, and due to the newer onset brachial neuritis. I am not sure therefore that it is the same picture of an acute HNP like your patients present with. The big issue now is the enormous sensitivity to sound and conversation and the unfortunate increase in both in her milieu because of recent death of elder parentleading to the spouse moving in who is unable to control or limit her speech or use sign languate for communication. Also I am going to review the initial MRI to check if it was a hermiation or bulge but what I do recall is that the reading of impingement of the cord at c5-c6 was consistent clinically with exam and presentation. So given this, and given the patient's sensitivity to sound and breathing under duress, influenced by other medical disorders, there is need to miniimze travel and procedures and such interactions, so I am not sure I would recommend a repeat MRI at this time.

I thnk the take home message from your comments might be that the patient needs a firmer mattress or a better bed wedge and to consider sleeping with a good cervical collar and gentle neck stretches.If you have sources that sell good wedges you recommed from an allergen free environment I would apprecuate it as she recently bought a new collar and cant use it because it was scented from the pharmacy counter softeners etc to which she is severely allergic. I will look into TNF and similar biochemical alterations that you comment upon and see if that generates any addtional practical modalities for treatment. I would be interested if you can be more detailed or specific in the cervical-thoracic stabilization exercises, since the a fib is aborted by mechanical expansion of the opposite lung which requires leaning to left which then puts presssure on left shoulder to trigger the same rsi.

Please, in addition, let me know if you have seen this sound sensitivity among patients with phrenic nerve palsies of any degree and where i can get documentation of this to perhaps help her family members understand the need for respecting avoidance of sound as much as possible. I am most grateful for your thoughtful considered assistance and your kind words on a case that can be exhausting re looking for treatments but we have come so far and i wish to provide hope and not to have the injury progress after all these years.