First aid for nerve damage
First aid for acute nerve damage is a difficult, complicated issue. I’ve read through quite a bit of research (some of which have contradictory findings, which I discuss below) and consulted several kink-friendly MDs, and there is no clear consensus on some details.
A quick first-aid summary:
Avoid stretching, compressing, or massaging the injured area (remember that stretching and compression likely contributed to getting the injury in the first place)
Mobilize early to prevent joint stiffness [27]
Consider splinting the affected limb to prevent further damage (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 what you need to know, but if you like to geek on bondage safety and related medical studies—as 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 straightforward recommendations. Generally, the injured person should avoid compression on the affected area. Compression is often a causative factor in getting the injury in the first place—further compression during the acute phase of the injury will not be helpful. Compression includes: wrapping with an ACE bandage, massage, or even sleeping on the affected limb. There is a lot of evidence that nerve damage is cumulative, and a damaged nerve is especially vulnerable—even something like sleeping on it wrong could worsen the injury.
Generally, the injured person should avoid stretching 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.”[1] Some folks believe “facial stretch” or “nerve flossing” may aid recovery—I’d recommend only doing this with professional guidance.
It’s important to remember that the site of the damage may not be immediately apparent or intuitive. For example, if you have radial nerve damage (and subsequent wrist drop) from a box tie, the temptation is to think that the 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 good advice. Relative rest and protection of the area must be balanced with early mobilization and therapy, which is also recommended.
Your body has a well-evolved immune response to injuries. Increasing evidence shows that trying to short-circuit that by aggressively bringing 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 essential in the first few days after an injury.
In the weeks following the injury, you 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 in the process of repairs will be weaker and more prone to injuries—there is lots of data showing 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 professional job! 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 bed rest while symptoms were acute. However, a study published in the New England Journal of Medicine showed no difference in healing between patients randomly assigned to be on bedrest vs. those who were advised to continue their usual activities as tolerated. [4]
For something like a wrist drop, the injured person may find it helpful to use a velcro wrist splint to protect the wrist from injury (especially at night [2]) and help with ADLs (activities of daily living). [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 the prevention or treatment of bondage-related nerve damage. If you want to try it, get advice from your physical therapist, and be sure to do so very gently and cautiously (never to the point of pain).
Ice Ice Baby
The 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 delays healing.” [28]
RICE was poorly studied in the first place: “[there is] insufficient evidence available from randomized controlled trials to determine the relative effectiveness of RICE therapy.” [21] Studies on the use of ice after an acute injury are scarce and poor-quality (for one thing, it is impossible to do a double-blind study where the patient does not know whether they are receiving ice therapy or not) and mainly focus on relief of acute pain rather than enhancing recovery. Most studies conclude that ice may temporarily decrease pain but don’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 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 also suggests that cold is unlikely to help heal such an injury.
Remember that almost all the studies on this subject (including the ones cited above) look 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 potentially help an injury of more vascular tissue (muscle) and more potentially 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 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 a large bruise (hematoma) forms, where swelling reduction becomes important and ice may be indicated. Injuries of this sort are unlikely in a bondage context and should prompt an 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 should ever use ice after a bondage nerve injury.” I wouldn’t do it if it were my nerves, but you should make your judgment. If you 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 could not find research specific to heat as a treatment for acute nerve damage. If you want to try heat, consider waiting 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 medications [26] (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 your doctor OK’s it, could help with healing. [12]
We need an MD, STAT!
Beyond first aid, it’s essential 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 undoubtedly 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 limb and the slower it resolves, the more urgent the need to visit the local ER. So, if someone has 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 better—rush to the ER immediately. Remember: Tell the ER doctors the truth. 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, or a few months…or they could end up with permanent nerve damage, for which there is little medical treatment (there are some surgeries, and 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 a 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 what they could do (such as communicating!) to help prevent injury. A person cannot give risk-aware consent if they are not risk-aware! I also believe bottoms are responsible for being proactive about risk education, but that’s getting off-topic.
Sometimes, despite everyone’s best efforts and intentions, an injury happens. 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, 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 a notable improvement over the hours following the injury, generally, recovery will occur within a few days, perhaps a week. If it takes days to see progress, it will likely take weeks to recover—a longer time to initial improvement = a longer time to full recovery.
Cumulative nerve damage
One final note is that there is emerging evidence, both in scientific journals and 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 nerve. [7] Studies of baseball players have shown that cumulative microtrauma from repetitive overuse places them a risk for peripheral nerve injury of the upper extremities. [8] This means that a person who has been in a box tie the 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 unique, different, or “wrong” that 51st time.
Wow, that’s a downer, huh? Let’s try to end on an up note—bondage is fun; focus on education and prevention!
