Navigating The Complex Case Of Diaphragm Paralysis
This week on the Unreal Results podcast, you’ll hear all about my experience with treating multiple cases of diaphragm paralysis. While diaphragm paralysis is quite rare, I have had a few patients with hemiparalysis of the diaphragm and since one of my LTAP™ certified providers has a client with this issue right now, I thought it would be good to make a podcast episode about it. In this episode, you’ll hear about the causes of diaphragm paralysis and how I used the LTAP™ to help me guide treatment in these cases. You’ll also hear about specific treatments that I utilized with these cases as well as some of the other treatments my clients used from other healthcare providers to help them with their symptoms. This is one of those episodes you’ll want to hear because you’ll have some of this knowledge in your back pocket just in case you ever have a patient with diaphragm paralysis.
Resources Mentioned In This Episode
Episode 91: Diaphragm Details That Unlock Thoracic Mobility
Doctor on the East Coast: The Institue for Advanced Reconstruction
Vascular surgeon: Dr. Roy Fujitani, UC Irvine Head of Vascular Surgery
Red Cross Syndrome Articles
Learn the LTAP™ In-Person in one of my upcoming courses
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman, and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello. Hello. Welcome back to another episode of the Unreal Results podcast. Here we are, end of the day. I've been like trying to sit down and do this all day, but I'm still in recovery mode from this weekend. I was up in Tacoma, Washington for the first LTAP Level 1 course of the 2025 season of the year.
And, uh, yeah, so it went really well. I was, um, I was cold. It was, it snowed in Tacoma, which I hate the snow. If you're new here, maybe you don't know that, but most everybody else probably knows that. Um, but yeah, it was a really great course, great group of people. Um, pretty, I feel like pretty much everybody was from, Around the Pacific Northwest area there, um, one from Canada, a couple from Idaho, one from Montana, um, a couple came in from Phoenix, um, but then other than that everybody was like local to like Washington, um, Washington State or Oregon.
Then there was a, another couple of people from Bend, uh, another couple from Eugene. So, um, super excited to be, um, educating more and more practitioners and just, um, getting this work out there. It's so, so needed and it's so good and it's so practical. I mean, I feel like everyone at one point came up to me during the class and just like told me how much they were loving it.
And I already have heard from a couple, um, this week letting me know that they're practicing it with their patients and getting great results. So I love to hear that
Leading up to the course as maybe you know, I had the flu so my I've had a cough from the flu pretty much ever since usually when I have like a cold Excuse me or the flu The cough usually lingers for like a month, um, I mean, COVID was like that too, and that's so frustrating. Um, I don't know if it's because I had pretty bad asthma when I was a kid or what, but I really hate how that works.
So trying to knock this out, um, quicker, um, I might have to do some like intense cardio. Sometimes that really helps just like the breathing hard. Um, but anyways, because of all that, I just am like pulled to needing some extra rest. Yeah. But I got a lot to do. So and I got a busy couple of weeks coming up.
So I'm just pushing through. Um, one of the things when I was in Tacoma, I stayed at a hotel right on the water, right on the Puget Sound. Down across from Vashon Island, I was hoping to see some of the orca pods that are there in the Puget Sound, um, but I missed them. When I left Tacoma, they were probably like 10 miles north of the hotel.
There was a group of them. So I was like, oh, they're so close, but it's like still so far. Um, so maybe next time. Maybe next time I'm in, I'm in Seattle I'll see them again, but, um, it was a great hotel. Um. Yeah, just a great experience. So If you were there, thank you for being there. I appreciate you so much And if you've been on the fence about joining, what are you waiting for?
Come join our amazing group of professionals that like just building this community to like push the industry forward and change the paradigm It's just so fun So anyways That was my week last week. The flu and teaching. And, uh, this week I'm actually flying up to my hometown of Eureka, California.
Flying up there. Gonna see my uncles, my aunts, my aunt and my uncles. I haven't seen any of them. My uncle, who I'm staying with on Thursday, I haven't seen in, like, years. I'm pretty sure I haven't seen him since. before the pandemic, which is wild to me. But I think the last time I was in Eureka was when my dad, like right before my dad passed away and that was 2019.
That's probably the last time I saw him. I'm looking forward to seeing him. And then my aunt and I are I'm driving to Sacramento so she can see my sister and my nieces. Um, it's been a while since she's seen everyone and the drive from Eureka to Sacramento is like six hours, you know, windy, coastal highways, Northern California, like rural two lane highways.
And um, She doesn't feel super comfortable driving by herself anymore, so I volunteered to fly up there and drive her and then drive her back and, uh, also it's just, I'm looking forward to being in Eureka. I haven't seen Eureka, like I said, I haven't seen Eureka in a really long time. Got some like, very like, special food items that I'm looking forward to get and to bring some to my sister and bring some home.
Um, there's this restaurant in Trinidad, California called Larapin's and they have these sauces that they sell, Larapin's sauce. There's two of them. There's a Larapin's red barbecue sauce, which is so good. It's like this rich. molasses based barbecue sauce, and then there is the, the, the better of the two, like the one that like, I miss the most, is um, this honey mustard dill sauce, and it's so good, and uh, so whenever we go home, we try to stock up on that kind of thing.
Even though they do ship it, it's just, I don't know. It seems more fun when either somebody sends it to me or if I get it on my own. So looking for that. Actually, my sister just told me that Trader Joe's now has like a sweet honey mustard dill sauce and she was looking at the ingredients and she's like, and it's like the same thing, which it would be completely wild if Trader Joe's ripped off Larapin's sauce.
For two reasons. One, because like, it's so good. But then two, because that makes me feel bad. Uh, anyways, so looking forward to that. Uh, my favorite bagel shop of all time is in Eureka called Los Bagels. Uh, so I'm gonna stop and get some bagels. Um, I like to do a bagel with cream cheese and then carrots, shredded carrots and larapin sauce on it.
So good. So, I'm gonna do that and then, um. I shouted this out on my Instagram the other day when I was making a steak, but there is this, um, meat seasoning, uh, that was sold at the old Eureka Meat Company from, uh, the butchers there who were named Ted and Barney. It's called Ted and Barney's Meat Seasoning.
Um, Eureka Meat Company no longer exists, and I think either one or both of those butchers have passed away. Maybe? I know, I mean they definitely retired but I think at least one of them passed away even. But, but their product Ted and Barney's meat seasoning still exists and it's still amazing. So I would definitely pick some of that up because I'm almost out.
And it's, the funny thing about that meat seasoning is it's not even like some special mix of like herbs and spices or something. Like it's so simple. It's salt. pepper, garlic powder, and chili powder. That's it. Like, when I use all those separate and put it on the meat. Um, it's good, but somehow when I do it as Ted and Barney's meat seasoning, it's so much better.
And I just has to be in the ratios. And I wish I could know what ratios they use or like in like the grain size. I don't, I don't know what makes it so much better, but it was so much better. So those are like the half to gets, and then there's some like. Jam I like from there and then, um, a candy shop, uh, with really good candy, like a seized candy, but like better called Partricks candy.
So I don't know if I'll make it to Partricks. My sister and I just had it over Christmas, um, but Los Bagels. And Larapin sauce and Ted and Barney seasoning, definitely getting all those things. So, would love to have some time to see some of my high school friends while I'm there, but I'm not sure I'm gonna have time.
We'll see, I might see if anybody wants to like, meet me for drinks or something on Thursday night, but I don't know. But anyways, not looking forward to like, the drive. But, looking forward to the trip. So. Ooooooh. Excuse my yawn. I told you I'm tired. Anyways, I asked recently. Well, if you've been listening in the last few episodes, I've been talking all about the foot and ankle because I have a foot and ankle self paced online course coming up.
Having the flu last week pushed it back again. Um, but with that said, like, I feel like I was at a. point with the, um, podcast about the foot and ankle where I'm like, okay, I've talked about it enough. Like let's move on. Maybe as I continue to finish that course, I might have some other topics about the foot and ankle that I want to share.
But we'll hold off on that for now. I have some new ideas for some episodes. I did ask on Instagram for some ideas or requests. And, um, so that's what this episode is actually going to be. Um, one of my certified providers, actually, shout out Beth Drayer. She has a patient right now who has a lot going on.
One of the things that they have going on is they have a, um, hemi, hemi paralysis of their diaphragm. And so she was asking about an episode related to that and I was like, you know what, let's talk about this solely for the reason of, it is pretty rare, but I've had a couple of patients with it and, um, because it's pretty rare, there's not a lot of information out there on like.
What do you do? Like where to start, especially from a standpoint of like, I'm going to, I'm assuming that most manual therapy or movement practitioners are kind of like, where would I even start? Because like, can I even help and is it worth doing and, um, or is this, this something that a doctor needs to address and like what, what to do?
So Um, Yeah. I wanted to share my insight around that, um, so yeah, without further ado, let's dive into that. So diaphragm paralysis, you can have unilateral or bilateral diaphragm paralysis. Obviously bilateral is a little bit more of an emergency, uh, since your diaphragm is the main muscle to, uh, create
respiration. Um, though you can technically have a paralyzed diaphragm and still breathe with your accessory muscles. Um, but most of the time, if you have a bilateral paralysis, you might be on a ventilator or needing some sort of surgery to have like a pacemaker put in. So you. can have some function of the diaphragm.
When you have unilateral, like, um, paralysis or hemiparalysis of the diaphragm, um, it's less of a emergency situation, um, and you don't necessarily have to get surgery. However, there are surgeries that you can do. Any of the surgeries that you can do or any of the solutions that you do happen to be based upon, like, what happened in order to create the paralysis.
The paralysis can happen from infections, it can happen from, like, crush injuries to the phrenic nerve, so it can be an injury to the neck, it can be an injury to the mediastinum, it can be an injury to, um, lower down in the thorax, basically anywhere the phrenic nerve is, you could potentially injure it Um, oftentimes it is a itrogenic injury, meaning like an accident, like an accident, it gets, you know, the nerve gets nicked in a vascular surgery or a thoracic surgery, um, or an orthopedic surgery of the neck and, um, but it can also be injured in traumatic accidents, um, like I said, um, illness, infection.
Different medicines people take. These are all things that could cause it too. And then there's obviously diseases that it would be, um, common in like ALS um, multiple dystrophy I think is one, like just those kind of, um, neuro degenerative type of illnesses. So. I think it can also be affected in a like diabetic neuropathy scenario as well.
So all possibilities and obviously if someone comes to you with this, you're helping them figure out along with the doctors, like what happened? And that is sort of where my knowledge of it comes from is because A man, um, who was a friend of my old boss slash colleague, Mark Verstagen, um, he spontaneously, without incident He had a diaphragm paralysis and no one could figure out how to help him and also like what was going on.
Like even the doctors were like really unsure because he didn't have a traumatic accident. He didn't have any medical procedures where it would have gotten injured and he had been sick, but it didn't. necessarily coincide with his illness
So, um, they were a little bit stumped on what was happening in the first place. And so Mark basically told him, they're like, if anybody, Mark said, if anybody can figure it out and help you, it's Anna. And so he referred him to me and he came from out of town to see me and, uh, I was like, wow, this is. Yeah.
Yeah. Yeah. It's really challenging, my guaranteeing results in one to three visits, because I was like, wow, I don't know, but just like I would approach any case, the most complex case or the least complex case, everybody, it's the same. I start with my general listening. I start with the Locator Test Assessment Protocol, the LTAP, because I want to actually not be distracted by the story.
I don't want to be distracted by the fact that they have a paralyzed diaphragm. I want to evaluate their body in a, the most non biased way so the body can help direct me where to apply treatment, to have the best chance of Um, helping them out and this is where the practice of like how it was so important that I had so much practice practicing letting the body's wisdom guide me.
And um, the first time I saw him, um, his listening, his, his test took me to like liver. right lung and that it was his right side that was paralyzed and I mean I did kind of the basic my basic treatments on him and I did a liver lift and liver visceral mobilization and like I cupped around the area and I did like a bronchial tube stretch and I did a little work on the phrenic nerve at the area Debussy's point, which is the area down by the 10th rib where the diaphragm, or where the phrenic nerve sort of interacts with the diaphragm down there.
And um, Um, I was like, I don't know, like, I don't even know what to expect with the treatment and, and actually within one treat, within that session, his pulse ox improved and his respiratory rate decreased and, um, because he was in like a hyperventilation state, um, his coloring of his face changed, um, definitely looked better.
And then he reported to me afterwards, like driving back home, it was like the best his breathing had felt. And then that night he slept better than normal. And so I was like, whoa, that was really interesting. And then I saw him a couple more times and it was similar, similar. Um, treatment similar direction from the LTAP.
There was one day it like took me to his legs and we did some nerve glides and that seemed to like, everything we did always seemed to like help a little bit, um, but it definitely led him, well, it definitely encouraged him to keep
moving and doing things that help. And, um, my thought process too, so this is, I guess, what I want to share is not just this case, but kind of my thought process of how to approach something like this. So the first step is, where does the LTAP lead you? The orthopedic tests around something like this are going to be obviously evaluating rib mobility and breathing pattern, reevaluating trunk mobility, especially with a chest lift.
So lifting our head and chest up, um, requires the diaphragm to function optimally. That's actually, when we look at development of a baby, as a baby gains control of their head and neck, it's because the diaphragm starts to drop down in the chest. And so this is the same, my thought process with this, using this as an orthopedic test, and then also a, one of his exercises to work on, When you have diaphragm paralysis, what happens is the diaphragm goes into a exhaled position, a shortened position, and it domes up and elevates in your chest.
So that's actually how they can see on x ray what's going on, is how high the diaphragm is in your chest. And so, um, We use that as an orthopedic test and like a, um, milestone to be aware of. So, um, head and neck control via chest lift. And then, um, The other treatment strategies were to address cervical mobility, cervical, like, neck fascia mobility, retroclavicular space or thoracic inlet, um, mobility space, uh, treatment, and then also.
to facilitate, um, the, the phrenic nerve through the phrenic nerve sensory pieces. And the, the phrenic nerve is a sensory nerve to the, The organs of the mediastinum, the organs of the thorax, and then the abdominal organs within the thorax as well. So the peritoneum around the liver, uh, the stomach, the up, like upper part of the peritoneum, basically.
Um, the parietal peritoneum. And so doing just general focused visceral mobility work in those areas was also a key part of his rehab plan.
And, um, after, I think after our second or third visit, every time he saw me he did feel like it helped. Though, It wasn't like, all of a sudden, it wasn't paralyzed anymore. And my theory was to, like, if all we do is support all of his accessory breathing things, then, like, worst case scenario was we're helping him anyways.
And at the same time, we were going into COVID, and we were, like, also very worried about him getting COVID. And so, it was And my goal to really show him as many tools and exercises that I could around breathing thoracic mobility, like keeping health of the lung and the diaphragm function that he had on the left.
So, at one point, he saw a doctor and the doctor found that he had a sort of, uh, a hidden infection between his liver and his diaphragm. And so the doctor put him on some antibiotics and some other sort of, maybe even like an antifungal or something like that, um, to knock that out, hoping that maybe that was what had created this paralysis was an infection on the phrenic nerve and, um, at first Um, after that treatment, he did feel like he regained a little bit of his breath function.
But then when he went back to get an x ray, it really hadn't changed the position of his lung much. So he was a little bit defeated. And then he came and saw me again. And then, um, that day I was led from the LTAP and my general listening to the area of the phrenic nerve in his neck. And when I was setting him up for treatment in his neck and doing the, like, the actual neural manipulation to the, the phrenic nerve at the neck.
I noticed that there was, I would position him in a way and then like do a certain treatment and I would see his breathing reflexively turn on and then I would take him back out of that position and it turned back off and I was like, Oh my gosh, like, I think, I was like, I think you're having. A thoracic, positional thoracic outlet type of scenario on the phrenic nerve, like a, like a positional entrapment of the phrenic nerve causing this.
And I was very encouraged and I called the doctor that I work with, Dr. Schaefer, and I was like, Hey, have you ever heard of this? And he was like, nah, I've never necessarily heard of it specifically to the phrenic nerve. He's like, but. It would make sense that it's possible and like the hard thing is, is to diagnosis, especially when it's positional thoracic outlet like that.
And he referred me to this doctor in Texas that works with baseball players specifically on positional thoracic outlet syndrome. And so we were working on getting that referral and in the meantime, I decided to go to PubMed and do a search on. compression of the phrenic nerve, like at the thoracic inlet.
And I was like, there's gotta be something written on this because I, like the doctor said, like knowing the anatomy, it's very possible. And as I said, in my evaluation, like I like witnessed it. And so, um, I came across this article called It was a case report and it was an article referring to a thing called Red Cross syndrome and Red Cross syndrome is basically the transverse cervical artery, which is one of the branches of the arteries that come off of the I believe it comes off of the carotid artery The transverse cervical artery, it crosses over the phrenic nerve, and it can actually be a crush point or a compression point of the phrenic nerve, and in at least these three cases that the doctor had written up.
Cause unilateral paralysis of the diaphragm. And I was like, Oh my gosh, this, the location that the transverse cervical artery was at when I looked it up, I was like, that's exactly where my hand was when I was working on the phrenic nerve. Like that's the spot. So I sent it to him and I was like, I think this is what's going on with you.
So, and he took it to a, He's a vascular surgeon in the Orange County area and um, the vascular surgeon said, I've never heard of this, doesn't exist, but I'd be willing to do an exploratory surgery to help you out because this has been going on for so long and nobody knows. He's like, so I'm down with doing an exploratory vascular thoracic surgery basically to see.
So, the patient was like, I'm in and so he, they did the surgery and I get a text message from him later that day and he was like, you were right. He's like, the doctor went in there and he found that I had double red cross syndrome, which was two arteries. Both going transverse, so like two, basically two transverse cervical arteries causing a compression on his phrenic nerve.
And so they ablated those arteries and then stented the phrenic nerve right there in the hopes that maintaining the space around it, it will sort of rebound and he will regain function. He had a noticeable change in function within the first, you know, few weeks of surgery, but then the vascular and then it kind of like calmed down and the vascular surgeon like assured him that it might take a little bit more time.
Um, and that we wouldn't really know how successful it was until about six months after surgery, because when a nerve has been compressed for that long, sometimes it doesn't regain its function. So, um, But either way, it was like, so validating for me to be like, that is like, I like figured it out. And I figured it out by I mean, it wasn't me.
I mean, it was kind of me figuring out, but it was mostly me figuring out because the body directed me there. And so that was a really cool scenario. And then we, he, from a rehab standpoint, he continued to focus on all those things that we've been doing, right. Um, keeping the liver happy, mobilizing the anterior.
Um, upper organs of the peritoneum, doing breathing exercises, doing chest lift type stuff, doing like neck mobility, things like that. So the, a limitation I had with this patient was that he didn't live where I lived. And so I didn't get to be super active in his rehab. He basically rehabbed on his own. Um, Um, you know, and he, he had tried working with some other practitioners that did like stim and things and it didn't, nothing really, really nothing helped.
So then year, a couple of years later, I got a phone call from a random guy who's referred to me from a physical therapist out in the New England area that I'd taken my mentorship and had heard this story about my patient with a the hemiparalysis and he, she referred him to me because she's like, this sounds exactly like the case that Anna had.
So go talk to Anna. So this guy talked to me and it did. He had sounded exactly like it. Like just one day, woke up in. Diaphragm didn't work anymore. Nobody could figure it out. This guy though was like very much like I'm like he was like I mean both the patients were very much like I'm figuring this out and I want to get better.
They were both very motivated to improve They're both like military backgrounds like high level military backgrounds And this is just like their mindset to that just like push and work as hard as they need to and figure it out and this And then so I put them in contact with each other and then this guy just so happened to find a doctor on the east coast that did reconstruction surgery for the phrenic nerve.
He, the doctor on the East Coast, takes like the sural nerve out of the lower leg and uses it as a graft and reconstructions, reconstructs the phrenic nerve from the root of the spinal cord down to the diaphragm. And which is just fascinating to me. And um, so he went ahead with that surgery and I think, I believe it was successful.
I never really heard from that patient again, but he communicated with my old patient and sure enough, after six months or more from the vascular surgery, he never really regained function of the diaphragm. And so he became a good candidate for this reconstruction too and decided to go get a reconstruction using his sural nerve.
And when he and the interesting thing too is whenever I worked on this patient's neck, it was like his neck was really stiff and I didn't really ever feel like I was making real gains in anything in his neck. And also the MRIs would never really show. anything of significance in the cervical spine that would lead us to believe there was some sort of like stenosis um, causing a nerve impingement in that area.
But, when the doctor went in for this reconstruction, there was significant damage around the neural foramen of the cervical spine at the level of C4 to which That tells me that this patient had like multiple areas of compression to the phrenic nerve causing this paralysis. So the Red Cross Syndrome area, perhaps why his improvement after that was minimal, was because there was another area of compression going on.
So like a double crush syndrome. Um. Yeah, and last I heard, um, about this patient, last I touched base with him, um, I think he has been doing pretty good. I need, this podcast episode, I'm like, I definitely need to see how he's doing, um. He said the recovery, last I heard was like right after surgery and he's like, recovery's slow, but improving and, and like doing well.
So, um, I hope he's still continuing to do well and I hope he has like full function of the diaphragm again, but it was like such an interesting case and yeah, I just felt like. When Beth asked me to talk about this, I was like, yeah, I guess I probably should share this on the podcast. I've talked about it before but um, I present it in the mentorship because I show the pictures of this actually the surgical pictures from when the doctor did the ablation of the artery.
I don't have surgical pictures of the reconstruction that was a different doctor, but um It's just a great story in terms of really listening to the body, let the body guide you, and then understanding the anatomy. And when you understand the anatomy you understand, it opens up so many options of locations or areas for treatment, both from a manual therapy and a treatment standpoint, like a manual therapy and an exercise standpoint, as well as different areas to consider to like help.
figure out what doctor is going to help us diagnose it, right? Like,
all the different areas, all the different doctors, right? There was like an infectious disease piece of it. There was a peripheral nerve entrapment piece of it, which was a vascular piece. So thoracic surgeon. And then there was an orthopedic and neurological piece at the neck and then there was a neurological piece with the graft from the sural nerve to the to the neck.
So it's like wow so many different opportunities and I think in cases like these So many patients give up, so many practitioners give up because they're like, just don't know what to do. And both of these patients were unique in the fact that they were not giving up. They were very motivated in their care, taking care of themselves, and then they were very motivated in finding practitioners to help them, both from a surgical and physician standpoint Rehab professional standpoint, and that's, I mean, that is a huge key characteristic of someone who has a successful outcome.
Um, I always tell people that, like, not every athlete is the right athlete for me to work with. Because I know it takes an active participant in their care to sometimes really figure things out and to fully get the result that the patient, that the person wants. And, You can only want it so much for your patients as the clinician because they have, there's so much other stuff that goes into helping them out and they have to want it too.
So so my thought, my like wrap up on that, you know, besides like I talked about at the beginning is like consider all the areas, the neck, the cervical fascia, the thoracic inlet, the thoracic cavity in mediastinum, the thoracic cavity in the parietal peritoneum, like all of those spots are going to affect the phrenic nerve.
The role the diaphragm plays in movement. Not just from breathing, but from head and neck control and chest lift, upper thoracic flexion. So the understanding all of this, which I did an episode not too long ago, all about the diagram. So that, that podcast episode is a great resource and I'll have Joe link that in the show notes too.
But like understanding all of that paired with an assessment like the LTAP that's going to help. Direct you where to go and how to unravel things. In addition to this knowledge about all the possible reasons why someone could have this paralysis and what doctors are out there to potentially help it, like this creates a big picture.
But at the end of the day, if the patient, the clinician and the, and the physician team are not willing to do all this work to figure out what it is, like. You can only do so much, but the so much is also important because let's say worst case scenario These patients didn't find that doctor to do the reconstruction and we're left with a paralyzed Diaphragm The other options, right?
There's a couple other surgical options for them. One surgical option that's common is a placation of the diaphragm, which basically takes the diaphragm and pins it down into a lower position to allow for space for more lung volume and not impede upon the space for so the accessory muscles can work better.
It's not ideal, but it is an option. Um, And then there's also an option for a pacemaker of the phrenic nerve to create diaphragm function. The downside of that is if the nerve itself is affected, you put a pacemaker to it, but it's not going to actually fire the diaphragm. So that is limited as well.
But also just knowing that these doctors exist, right? Like, so, and I'll, I'll make sure I have Joe link these doctors in the show notes, too. Just, if you ever find yourself in these positions, like, these are guys that, like, have seen it at least once, and clearly think, Out of the box a little bit differently.
So hopefully this was a helpful episode. I know it's like very niche, but um, also very interesting. So wow, yeah, diaphragm paralysis doesn't sound fun. Um, and uh, hopefully this gives you a little bit more insight into be able to help your patients if it does come up. So. Thanks for being here. See you next time.