Signs of a bondage injury

On My Nerves, Part 1: Signs of a bondage injury

Question: What are the warning signs re: potential nerve damage (for subs and doms both) to look for when using rope/suspensions/etc?

This is a great question! First off, a disclaimer: There are no controlled scientific studies on bondage and how to predict bad outcomes (anyone want to give me grant money?). Most of what I’m going to talk about is based on anecdotal stories from the bondage community and a basis of medical/anatomical knowledge, including reviewing medical articles on other types of nerve damage (from sports, intraoperative positioning, etc). I’m also going to address a couple of common myths about bondage related nerve injury.

The fact that you’re asking about nerve damage (rather than reduced circulation, which many people seem to think is a comparable if not greater problem) indicates that you have a good idea of the risks involved in bondage. For the record, signs of decreased circulation to a limb include cold, color change, and numbness. These signs and symptoms generally occur SLOWLY. In isolation, circulation can be decreased for a long time before serious tissue damage begins (in some surgeries, they cut off circulation to an entire limb for over two hours). NOT that it’s a good idea to do that in a bondage context (don’t try this at home, stop planning that operating room limb ischemia scene!!), but I think too great a focus on circulation misses bigger issues.

Nerve damage is a greater concern than decreased circulation. Danger signs for nerve damage include pain (generally described as sharp/shooting), weakness, tightness, stress, tingling, and numbness. These generally occur QUICKLY, sometimes instantly, and should be acted on immediately. Nerve damage can occur either by stretching of the nerve (for instance by over-extending the arms over the head for extended periods of time) or by compression (for instance rope pressing up against the armpit). As a guideline: The more force and the longer the time, the greater the damage will be. Nerve irritation that is immediately resolved leads only to temporary nerve damage (“numbness” that goes away quickly). Any prolonged irritation can lead to semi-permanent damage (nerves need weeks or even months to heal!) or to permanent loss of function.

Careful negotiation before tying someone up should include asking about conditions that might predispose the bottom to nerve damage. Those include pre-existing peripheral neuropathy (nerve damage) from diabetes, peripheral vascular disease, and previous traumatic nerve injury. This isn’t to say, for example, that you can’t tie up a diabetic- but it’s certainly something you need to be aware of for lots of reasons (are they going to drop their sugar mid-scene?), not the least of which being a need for more cautious bondage with more careful monitoring. Diabetes and play, and health negotiation for bondage, could fill a whole separate article, so for now I’m going to leave those specific subjects at that…

Generally, the type of bondage pain that is going to cause long term damage is a type of pain that will set off alarm bells in the bottom’s head. It will not feel erotic, it will just hurt! Bondage bottoms must be alert to numbness and tingling (which also doesn’t feel erotic to most people), not just to sharp shooting pain. If you’ve ever hit your “funny bone” then you know where your ulnar nerve is and how it feels to have trauma to it- not sexy for anyone I know. Note that sometimes nerve damage is focused on a particular area rather than the entire limb. For example, the ulnar nerve covers, among other areas, your pinky and half of your ring finger. Several very experienced bondage bottoms have told me that the first sign of an issue with their radial nerve is that the top of their thumb goes numb. They therefore monitor for this during a scene by rubbing their index finger on the top of their thumb periodically to make sure they can feel it.

The bad news about nerve damage is that the top really has no way to know when it is happening, other than communicating with their bottom! This means that rope tops have a serious responsibility to educate their bottoms to communicate when they have bad pain/sensations so that the top can adjust or release the bondage. I’ve heard all sorts of misconceptions- I recently had a rope bottom tell me that she was taught that as long as she could move her fingers she was OK. Therefore, when her arm went numb in a strenuous suspension (but she could still move her fingers), she didn’t say anything to the top, and suffered a serious injury to her radial nerve (causing her to not be able to write for over a month) as a result.

IMG_5571While communicating with the bottom and checking in frequently is of paramount importance, there are a few other things tops can do during the scene to help decrease risk of nerve injury. This includes watching for signs of trouble (like the bottom wiggling fingers or self-adjusting ropes) and paying attention to body language. Another thing that may help is to multiply the points of tension to spread the pressure over a wider area (in rope-speak: use more wrapping turns!). Often, hands are the first area where the bottom experiences problems. If possible, arrange the bondage so the hands can be easily released without having to undo everything else first. Avoid gags unless you know each other well and have another way to communicate (non-verbal safe signal, drop ball, etc), and always have a method of quick release readily available. Making frequent shifts in the rope- just a slight re-position adjusting the tension, or temporarily releasing the pressure to allow the underlying tissues to readjust- can make all the difference. This may be as simple as running fingers under the rope or as complicated as rearranging a suspension so the bottom is in an entirely different position.

During the scene a bondage top can check CSM (circulation, sensation, and movement) in all sorts of fancy medical ways (capillary refill, point differentiation, etc)- however, the main predictor of bad outcomes seems to be the bottom’s subjective experience in the bondage. Pay attention to body language and check in frequently. In addition to testing for sensation, there are several motor “tests” the top can do:

  • If the bottom is in a position to do so, have them make their wrist and fingers a straight line with their forearm. Put your hand on top of theirs. Have them push up (towards your hand, away from the direction of their palm- this is called “wrist extension“). Inability to do this generally indicates a problem with the radial nerve (often from a box/TK tie).
  • Ask the bottom to spread out (“extend“) their fingers, by themselves and against resistance. Inability to do this indicates a problem with the radial nerve, or specifically with the thumb, the median nerve
  • Ask the bottom to squeeze your fingers and *maintain* a grip. Inability to do this can indicate damage to the medial nerve.

If the bottom “fails” any of these tests, that is an indication that they have some nerve impairment and should be untied. However “passing” any of these tests is NOT an “all-clear” that would indicate everything is definitely OK.

Some tops have told me that they think it’s valuable to check circulation if the bottom complains about numbness because if circulation is decreased, they feel they can chalk up the numbness to decreased circulation, which is not dangerous by itself. The trouble with this is that reduced circulation and nerve damage are not mutually exclusive, and in fact often happen together. The main predictor of bad outcomes seems to be the bottom’s subjective experience in the bondage. Bondage tops should empower their bottoms to say something if they need the bondage modified/removed. I always tell my bondage bottoms that I will not be disappointed if they tell me their arm is going numb and I have to untie them. I WILL be disappointed (to say the least!) if they decide to tough it out and I end up having to take them to the ER for a severe injury.

Other than educating their bottoms and taking the step outlined above, tops can help prevent these injuries by knowing basic nerve anatomy. Anecdotally, it seems that most problems with bondage are caused by damage to the radial nerve, in most cases due to tight ties across the upper arms. The radial nerve wraps around the upper arm and is close to the surface around the bottom of the deltoid, where people love to put rope (especially in box ties and the like). Other forearm nerves include the medial and ulnar nerves. Note that the exact location of these nerves varies from person to person, and both location and degree of exposure will vary based on position. When possible, it is best practice to avoid wrapping any rope that will bear load or be under more than a minor amount of tension around the bottom’s knees, elbows, groin, and armpits– these are places that major arteries, veins, and nerves are near the surface. Medical articles have documented nerve damage to both the radial and medial nerves caused by blood pressure cuffs positioned too distally on the arm (meaning the cuffs were not high enough on the arm, instead ending up over the elbow)- the recommendation of these articles was to be sure blood pressure cuffs are placed proximally (close to the center of the body), to avoid overlap with the bend of the arm.

Now, we have all had a limb “fall asleep,” and we all recovered, I imagine? That sensation is caused by a combination of reduced circulation and nerve injury (they are inseparable to some extent- reduced circulation reduces circulation to everything, including the nerves, which causes them to go a bit haywire). Despite the fact that most of the time your body will recover when you experience these symptoms, the damage that can be done by bondage is a bit different than the type caused by crossing your legs for too long (it’s more focal, for one thing). Also, people can do nerve damage to themselves by crossing their legs too long or too often!

So, as a top, what should you do if your bottom reports numbness, tingling, tightness, or pain? You need to immediately take steps to address it. For experienced bondage tops, this may sometimes be done by removing or redirecting tension, shifting ropes, or changing position, and then checking back in with the bottom to be sure the problem has resolved. When in doubt, and for beginning rope tops, my advice would be to untie the affected limb completely. I’ve heard bondage tops say that they don’t worry about rapidly untying a bottom with symptoms of nerve damage, because “once it’s done, it’s done.” This is a gross misunderstanding of the physiology of nerve damage. While it’s true that you can’t un-do an injury that has already occurred, nerve damage is not an all-or-nothing thing– it happens on a continuum, and immediately taking steps to address it may keep a minor injury from turning into permanent damage.

After the scene, if the bottom experiences numbness lasting more than an hour or so, at least some nerves have been damaged. Other signs of nerve damage include weakness (often focal depending on the affected nerve), difficulty with fine motor control, and specific signs like “wrist drop” (which generally indicates radial nerve damage). Prevention is KEY because if the bottom has these symptoms after the scene, there is no quick fix. The symptoms may resolve in a matter of hours… or it might take months.

First aid for nerve damage is a complicated issue… which I will address in detail in another column! It is possible for nerve damage to occur without any warning signs at all, and even with an experienced bondage top who does “everything right.” Thus, even though prevention is really my focus, knowing what to do immediately after the fact is also very important.

 

Stef and Shay bounce houseStefanos & Shay (StefanosandShay.com) are a vivacious, unconventional D/s couple with over 8 years of experience educating, hosting, performing, and advocating together within the BDSM community. Issues they are passionate about include risk awareness and healing/recovery from abuse. Shay is a nurse by day and education director for the SF Citadel by night; Stefanos is all kink all the time in his professional life as the Producer/Steward of Kink.com’s The Upper Floor and CEO of Bondage-a-Go-Go. They’re compulsive volunteers within the leather community, and identify as pansexual polyamorist playsluts (and probably a few other P’s they haven’t thought of yet).

Note: This article originally appeared in Kink-E-Zine, in a column called “Private Duty” that had an ask-the-kinky-nurse format. These articles were edited by a kinky MD, Dr. Who.

Re-Posted with permission for Shay & Stefanos

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