Yogi Jess on a Tightrope: From Mobility to Stability

Jessica

I remember one time when my fiance and I were hiking. We go hiking a ton in New Hampshire in the White Mountains. And so I’m wearing a hiking backpack and we’re climbing up a 5,000 foot mountain. And I remember for about two hours of the hike, I was feeling a weird sensation in my chest.

Robert Pease (co-host)

Jessica is young and athletic, a full time yoga instructor in Boston at a major university and private studio.

Valerie Wencis (co-host)

And this hike should be a walk in the park for Jessica, a day of pure pleasure and enjoyment. But for two years she’s been walking the tightrope of a serious condition with the potential for a life threatening episode out here in the mountains.

Jessica

I don’t know, something was weird in that collar bone area. And no matter what position I was putting my shoulder in or taking the pack off that area, it wouldn’t stop.

Robert Pease (co-host)

Despite that sensation, Jessica doesn’t say anything to her fiance and keeps on hiking, and this was on the way up the mountain.

Jessica

It’s on the right side of my body, which for some reason was more mentally comforting because I know my heart’s on the left side of my body.

Valerie Wencis (co-host)

As a yoga instructor, her instincts naturally turn towards the power of her own breath.

Jessica

I was like, just breathe, Jess, it’ll be okay. If it does start to get worse or you feel tingling in your arm, you’re gonna say something. But let’s just try not to freak out.

Robert Pease (co-host)

This My Body Odyssey, a podcast about the rewards and challenges of an active lifestyle. I’m Robert Pease.

Valerie Wencis (co-host)

I’m Valerie Wencis. And on that hike with her fiance, Jessica’s symptoms did subside eventually. She didn’t freak out. But this hiking episode is just one of several high risk moments in Jessica’s effort to return to normal life after receiving a diagnosis of thoracic outlet syndrome.

Robert Pease (co-host)

Thoracic outlet syndrome, or TOS, is a rare but serious condition. In Jessica’s TOS, a vein in her upper chest becomes pinched between two bones, the clavicle and the first rib. That restricts blood flow, thus causing clotting and all kinds of problems. Which was her fear on this hike.

Valerie Wencis (co-host)

TOS may occur more frequently in hypermobile athletes like baseball pitchers or swimmers or possibly yogis, which we’ll hear more about later in this episode.

Robert Pease (co-host)

As mentioned, Jessica is a yoga instructor by profession. Her livelihood depends on being able to demonstrate movement. So you can understand her surprise, and her deep concern, when she was diagnosed with TOS.

Jessica

I was floored, I was just like, what? And I was like, well, what could have caused this?

[Audio of a yoga class]

Valerie Wencis (co-host)

Let’s back up to before Jessica’s diagnosis. Before she even realized anything was wrong. At this point, Jessica is in her early 30s, extremely fit. She’s teaching yoga classes throughout the day, demonstrating hundreds of poses. Yet still makes time for her own yoga practice for 90 minutes every day.

Robert Pease (co-host)

As with so many conditions, TOS snuck up on Jessica with only the most subtle of warning signs.

Valerie Wencis (co-host)

But at first, these warnings were not frequent or lasting and never serious enough to suggest an underlying condition.

Jessica

Since I’m a yoga teacher, I had noticed when I would do certain positions where I would hold my arm overhead for a prolonged period of time, like headstand or shoulder stand or any type of these inversions that I would start to feel like my right arm would get very full and warm, almost like there was too much blood in it.

Robert Pease (co-host)

The frequency and severity of these feelings began to increase, but only gradually.

Jessica

What happened is I was actually doing an arm workout one day. And I noticed that after doing some rapid punching motions and that arm workout that my whole right arm was a lot redder than my left arm was. And it kind of subsided, but then the next night it didn’t go away, it came back.

Valerie Wencis (co-host)

Jess has two graduate degrees in anatomy and physiology. She helps yoga students with all kinds of medical issues, prehabbing and rehabbing injuries, improving breathing and movement patterns. Now she’s beginning to suspect she needs some help. She reaches out to her brother, who happens to be a doctor, for his advice.

Jessica

And so I texted my brother and he was like, let your primary care doctor know. And he said go to urgent care, get it checked out. And so then they did an ultrasound and I went into the waiting room and the doctor came back in. He’s like you do have a blood clot. And I was floored. I totally didn’t believe it.

Robert Pease (co-host)

And had you, I mean, you’ve studied an awful lot of anatomy and physiology, had you heard of TOS?

Jessica

I had heard of it before. Never in relation to what happened to me where I got a blood clot that resulted from it, which led them to discover it. Oftentimes, what I had heard is thoracic outlet syndrome was more of a neural response where when people would put their arm in certain positions, they would get an uncomfortable tingling sensation, which I actually never experienced.

Valerie Wencis (co-host)

With any life-threatening diagnosis comes the immediate need for stabilization – for Jess, that meant taking blood thinners to avoid the potential for a blood clot that could travel to her heart or lungs.

Jessica

There is a risk with blood thinners that have increased bleeding. Since I am young and healthy, that risk is a lot less than if I were older. But you know, I’m going to avoid activities where I might get blunt force to the head, like riding a bike around in the city or going water skiing or something like that.

Valerie Wencis (co-host)

But there was also the recommendation for a surgical consultation and a more permanent fix for the problem.

Jessica

He was like, if you’ve got thoracic outlet, let’s schedule you to have your first rib resected. And I said, is that my only option? And he’s like, well, I mean the rib and the collarbone are the sources of the compression. And so if we take the rib out, the compression goes away

Robert Pease (co-host)

The compression goes away. Then again so does the rib. And Jessica’s philosophy from her anatomy studies and yoga practice is that the body is a whole unit, fully interconnected and finely balanced.

Jessica

And I was like, well, don’t I have muscles that attach to that? Isn’t that kind of important? He was like, yeah, but they’ll be fine unless you need to take a really big, deep breath. I’m like, well, I’m a yoga teacher and I go on big hikes. So yes, that’s important to me.

Valerie Wencis (co-host)

We wanted to understand a bit more about TOS and that surgical intervention So we reached out to a respected thoracic surgeon Dr. John Wee of Brigham and Women’s Hospital in Boston

Dr. John Wee

Oh well, you know, I’m one of those kids that kind of always wanted to be a doctor. I’m one of those. I currently work at the Brigham in the division of thoracic surgery. As a director of robotics here, there’s a lot of intellectual stimulation, I guess, in terms of doing things that are new and innovative and trying to move the field.

Valerie Wencis (co-host)

Can you tell us about thoracic outlet syndrome? This isn’t something I think a lot of people know about. Could you give us an overview and how common it is or isn’t?

Dr. John Wee

You know, thoracic outlet syndrome is an interesting phenomenon. Thoracic outlet refers to the complex of structures that emanate from your neck down through your shoulder and down to your arm. And so there’s three different structures that run through that space: your artery, your vein, and your nerves. And as it progresses through your rib spaces, some of those structures can get compressed and have a variety of symptoms that result in pain or swelling or loss of function in the affected arm.

Robert Pease (co-host)

Again, that space Dr. Wee is talking about is located in the upper chest, just above the thoracic cavity; thus the name thoracic outlet syndrome.

Dr. John Wee

People who use their arm a lot, like baseball players and sports related injuries, you know, see those somewhat often in that setting.

Robert Pease (co-host)

Baseball pitchers work extremely hard to create hypermobility in their throwing arm and shoulder. And this reminded us of a conversation we had with Jessica about her own hypermobility, partly innate but also further developed from many years of yoga.

Valerie Wencis (co-host)

And before Jessica was a yogi, she was a competitive swimmer. She swam Division I backstroke in college. Through all the years of intense training, she never had any symptoms in her shoulder. But doctors thought all of that repetitive motion could have contributed to her problem.

Jessica

That was their thought. I also think that there was an instance that might’ve actually added a little bit of, kind of the final push, so to speak, where I was doing a handstand and I felt something in my outer right shoulder and that outer rotator cuff armpit, it felt like something kind of slipped or maybe tore.

Robert Pease (co-host)

It’s interesting how so many of us in hindsight realize, wait a second, there were some warning signs, but they didn’t strike us in the moment.

Jessica

But I came out of it and I was fine and because I am hyper mobile, so my ligaments and joints are quite loose, so to speak, compared to the average person, I think my body was very efficient and figuring out a compensation pattern around that, which resulted in me kind of over recruiting some of my chest muscles and my upper traps, which further contributed to that kind of narrowing of that space.

Valerie Wencis (co-host)

Isn’t it kind of ironic that really well-conditioned athletes may develop a whole different type of problem, almost like being a victim of success? You achieve hypermobility but that creates additional strain elsewhere in the body.

Robert Pease (co-host)

TOS presents different levels of risk depending on the patient. And generally speaking, Dr. Wee, like many surgeons, feels surgery should be the last resort, if time permits other approaches.

Dr. John Wee

I think you should always try conservative management before committing to surgery. You should try to see what you can do without changing your anatomy.

Robert Pease (co-host)

But in cases like Jessica’s, the clock could be ticking. That’s because her constriction involves a vein and thus blood flow. Which is why Dr. Wee emphasizes that putting off surgery to manage this form of TOS through physical therapy and medication – that does come with real risk.

Dr. John Wee

I often think that if you have anatomic issues, if you have vascular issues that require anticoagulation, I think you’d be better off ultimately having surgery to relieve that compression. So you don’t have to be on lifelong anticoagulation.

Robert Pease (co-host)

Jess didn’t want to be on blood thinners forever. She also didn’t want to jump into surgery. You could say she was experiencing some emotional constriction during these many months, as in: what to do about her TOS?

Valerie Wencis (co-host)

Fortunately, her own surgeon realized this was a special case with a unique patient.

Jessica

So with my thoracic surgeon, he was really great actually. He was not your stereotypical surgeon that says surgery is the answer to everything. He heard me out about, you know, I find that I’m very mobile and I kind of demonstrated a few things. And I said, worst case scenario, what happens if I don’t get surgery? He said, well, worst case scenario is that you clot again, but given that you have this education and this background and this awareness, I’m okay with you trying to figure things out.

Valerie Wencis (co-host)

Two years pass. Two tough years of COVID and all that angst added to the stress Jess is feeling from TOS. And all this time we’re wondering, how’s she doing?

Robert Pease (co-host)

Had she been able to, in her words, figure things out? Had she had another issue like her hiking episode and possibly decided on surgery?

Valerie Wencis (co-host)

And, one way or another, was Jessica getting any closer to her normal life of hiking on the weekends and cycling around the city to yoga classes during the week?

Robert Pease (co-host)

So Jessica, I guess the general question is, are you behaving yourself and doing what you set out as your plan?

Jessica

So, no, I definitely am using my bike to commute around. With that being said, I am on a much lower dose of blood thinners now. And as regards to the lifting of the arms overhead, I’ve definitely made some progress in how I’m able to manage my shoulder and my movement, both from an awareness perspective as well as a biomechanical perspective of how the tissues are moving.

Valerie Wencis (co-host)

But it’s important to note how much thoughtful work has gone into making that progress.

Jessica

I kind of started, you know, basically from the name. Thoracic outlet syndrome means that this one area in my chest between my collarbone and my rib is very small and compressed. And so then I started thinking about that area and the muscles and the bones and what can I do muscularly to get the collarbone to lift off the rib?

Robert Pease (co-host)

Jess started working on her shoulder to stabilize the rotator cuff. But her knowledge and philosophy of anatomy leads her to see this as more than a local issue.

Jessica

Granted, no two shoulders are built the same, but I could tell that something was off. And so then my lens had to start to come a bit bigger and I was kind of looking at my ribs and my pelvis and how I was holding those. And I found a lot of blind spots, I guess I could call them, and how my glutes were firing or my abdominals were firing. And the gist of the story is that my pelvis and my ribs were kind of rotated and creating a little bit of a compression system on that right side.

Robert Pease (co-host)

I know at one point you were trying to do yoga. I think you said 90 minutes every day, even before this challenge came along. So have you been devoting that same amount of time to this problem? Has it replaced your yoga practice in a way?

Jessica

I think they’ve kind of become each other in a way And so my yoga practice, as well as – I’ve been doing a lot more strength training, and it is a lot more of like, I guess a way you could say is like suctioning the bones into the joints a bit more, finding that deep stability and trying to limit the range of motion I go into and finding strength and stability in a single range of motion.

Robert Pease (co-host)

Ironically, then, after years developing an exceptional range of motion, Jessica is now working to reign in some of that mobility.

Jessica

And so I think, you know, for the people that are more on the bendy flexible side, which are the people that tend to be drawn to yoga naturally, right? Because they feel like they can, you know, do yoga well because they can hit these big ranges of motion. They’re actually the people that probably don’t need so much yoga or they need to approach their yoga practice from a different lens of stability, strength, not flexibility

Valerie Wencis (co-host)

And isn’t that surprising but also understandable? We often gravitate toward our natural strengths, and not toward what we really need. As a result, our bodies do tend to get out of balance, one way or another.

Jessica

So I think it really comes down to noticing what’s happening in your body and doing what’s best for you. Which sounds a little cliche, but that’s really the gist of it.

Valerie Wencis (co-host)

We wondered at this point in time, having made progress in mobility with stability and having reduced the blood thinners, what was she feeling about that surgical option?

Jessica

Given my background and my, you know, yoga philosophy, I was definitely not keen on having that first rib removed. So I was diagnosed at the end of January and I was supposed to have the surgery in May of 2020, but then the pandemic hit. So it kind of, you know, in my mind, maybe I would’ve just gone ahead and done it because there is that very scary feeling of a time bomb inside me. Is there a blood clot that’s gonna dislodge in my chest and go into my lungs and my heart? But the pandemic kind of forced me to not have that. And in that extra time I was able to kind of realize that this isn’t my only option. Now I’m so grateful because surgery, no matter how advanced and minimally invasive it is, still leaves scar tissue. In my case, I was gonna have a total rib removed and so my scalene muscles wouldn’t have anything to attach to. They would just be hanging out in there.

Robert Pease (co-host)

But Dr. Wee, a surgeon who performs this procedure frequently, has a different view.

Dr. John Wee

She really shouldn’t have any concerns. Again, the only muscles that attach the first of the scalene muscles, which are muscles that are attached down and up to the neck, you know, lower skull area, but you have other muscles that take over that function quite easily and they’re very small muscles, you know? So you actually don’t require every muscle you have in your body. You can lose quite a bit and the other muscles take over the function without you really realizing it.

Robert Pease (co-host)

Which, in nutshell, is more less the historical tension between holistic or traditional eastern medicine, which emphasizes interconnection, and western or modern medicine that focuses on the separate parts or systems of the body and their function. Not surprisingly, Jessica’s brother also expressed the view that Jess should have her rib removed.

Robert Pease (co-host)

Well, what about your brother, Jessica? Is he not a doctor and what was his thinking about the surgery and your progress?

Jessica

Yes, he is a surgeon as well. He’s a urologist, so different area of the body. His initial inclination, I think out of maybe it’s two parts: it’s protection, like he wants his sister to be okay and safe and take that risk away. But part of it also is his MD training. He thinks you should just get the surgery. And we had a disagreement over it and you know, agreed to disagree. And I think that I might have shifted his perspective a little bit now after he’s heard my story.

Robert Pease (co-host)

And were there any, I don’t know, periods where you weren’t making progress or you’re having more symptoms where you were in the least bit tempted to just take the easier path?

Jessica

I think in the back of my mind, the one thing that was like, well, if I clot again, then I’ll definitely get the surgery. And if I do go off the blood thinners, seeing how that progresses, since I won’t have that layer of protection anymore.

Robert Pease (co-host)

That’s Jessica, a yogi on a tightrope. But slowly moving forward on that journey, so far at least. Let’s hope that progress continues.

Valerie Wencis (co-host)

Special thanks to Jessica for sharing this really challenging body odyssey. We’ll be checking back to see how things go as she tapers off blood thinners, continues self guided therapy, but hopefully also heads to the nearest hospital if she develops symptoms on a hiking trip – especially on her way up the mountain.

Robert Pease (co-host)

Next up on My Body Odyssey, another tough challenge in the form of multiple sclerosis, an autoimmune condition affecting the nervous system. Nearly 2.5 million cases worldwide and one million in the US. Including Josie, a former special ed teacher who refuses to take her MS sitting down – unless it’s on her customized tandem bike with her husband Joe.

Joe

What it allows is independent pedaling, so she can stop pedaling, I can keep pedaling, I can stop pedaling. She can keep pedaling. So it’s great. It just really works out.

Josie

I just wanna tell people with MS or anything that if they can’t do something, if something’s holding back, there is a way to get it done.

Robert Pease (co-host)

That’s next up on My Body Odyssey. We hope you’ll join us for that episode and turn a friend or two onto the show. And if you or someone wants to share a story of staying active despite or because of a major challenge, please let us know via our website, mybodyodyssey.com, or social media. Thanks for listening from the whole team here at Fluent Knowledge. Original music by Ryan Adair Rooney.