// Q&A: Nerve Damage in the Shoulder
by Lenny Parracino
Question:I have a client who severed a major nerve in his shoulder and, as a result, has no feeling in his hands. I talked with his physio, and she said he was only allowed to do exercises in the extension phase of the movement and movements that did not require much use of his pecs. Is there a way I can facilitate the strengthening of his rotators, shoulders, arms and forearms while also strengthening the hand?
Answer:Although there are no exact answers to your client’s situation, by providing a thought process, I hope to help you strategise what will work best for you.
Any time there is major nerve damage, there will be a form of structural change affecting your client’s function. The evaluation should attempt to identify how much of the structural damage is affecting function. Note: function is individually driven, not an arbitrary modality, program, exercise or muscle.
In other words, function is who your client is, what he needs and what he wants in his life. This definition is very important, as ‘functional fitness’ can take on different definitions. By defining his function, you can understand your client’s current threshold, and tackle the structural-function puzzle, i.e., how much of structure is hindering current function?
It is important to recall Hilton’s biomechanical law, which states that the nerve supplying a joint also supplies the muscles that move the joint and theskin covering the articular insertion of those muscles. This means the weakness you have properly identified is most likely a reaction of the injury and not the muscles’ fault. Therefore, attempts at strengthening individual muscles will most likely fail – in function. It can be confusing when a test is used to evaluate another test. In other words, a muscle could prove stronger with a given test, but still lack the ability to perform the needed function.
It seems the most important need at this point is to increase your client’s ability to grab or use his hand. If this is the primary function to restore, then test what he can do at the moment. Then ask, ‘What must he grasp throughout his day? Is there any strength associated with what he has to do? How does he compensate?’ Then build a process that closes the gap between what he can do and what he needs to do, and use this gap as your litmus test to ensure you’re on the right path.
Post assessment, use the following sequence:
• Global approach: Do not isolate muscles or movements. Instead, stay as close to the functional task (what he needs) as possible.
• Specific approach: Isolate-integrate as needed. There may be benefit to performing isolated tissue mobilisation, joint movement, modalities, etc. depending on outcome of function (global approach). Often, this is the job of the physio.
• Compensatory indirect: There are times where parts do not fully restore to the function demand. In these cases, we must teach strategies to compensate effectively for known structural deficits. As vertebrates, we ‘remodel’ as opposed to laying down ‘new parts’. Therefore, all injury stays with us to some degree.
Be careful not to waste time on muscles or isolate movements. Focus on what your client needs to do as this will form the basis of his assessment and program design. Personal training needs to be personal, which means no one should follow a protocol, but rather a thought process that is founded on universal principles. A great reference for improving the function in your client’s situation is Gary Gray’s Functional Video Digest Series: v1.12 - Lifting, in which Gary takes you through a chain reaction thought process that will help with the client’s dysfunction and therefore improve overall functional ability.
This article is reprinted from PTontheNET. Australian-based personal trainers now receive full access to PTontheNET.com as part of their Professional membership with Network. For more information on the combined Network and PTontheNET membership visit www.fitnessnetwork.com.au/pton or phone 02 8424 7200.
Lenny Parracino, BSc
Lenny has spent over 20 years serving the health industry as an international lecturer, soft tissue therapist and movement therapist. He currently serves as a faculty member of the Gray Institute of Applied Functional Science. As a full time therapist, he integrates an eclectic approach of soft tissue therapy and movement conditioning at Kinetic Conditioning Institute in Montrose, California.
NETWORK • SUMMER 2009 • PP28