PT on the Net Research

Nerve Damage in Shoulder


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. I was wondering if there was a way I could strengthen his rotators, shoulders, arms and forearms while also strengthening the hand.

Answer:

Thank you for your question. Although there are no exact answers to your client’s situation, by providing a thought process, I hope to give you a place to strategize what will work best for you. I will start by breaking down what you have posted in regards to your client’s current state. We will start with the “major nerve damage” you mentioned. 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. In other words, function is who your client is, what he needs and what he wants in his life. This definition is very important seeing as function in fitness seems to take on different definitions. Again, function is your client, not an arbitrary modality, program, exercise or muscle – these can be a part of function. Therefore, we can “anchor” to the definition of function as a means to understand your client’s current threshold, allowing us to accomplish the structural-function puzzle (how much of structure is hindering current function?). One important fact to note is Hilton’s biomechanical law, which states that the nerve supplying a joint also supplies the muscles that move the joint and the skin covering the articular insertion of those muscles. In application, 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. What is confusing is when one uses a test to test a test. In other words, a muscle could prove stronger with a given test but still lack the ability to perform the needed function.

Based on what you have stated, it seems the most important need at this point is to increase the 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?”

My suggestion is to follow the below process:

  1. Assess current threshold - What does he need to do, and what can he do?
    • Build a process that closes this gap, and use this gap as your litmus test to ensure you’re on the right path.
  2. Post assessment, use the following sequence:
    • Global approach – Do not isolate muscles or movements. Instead, stay as close to the functional task as possible (what he needs).
    • Specific approach – Isolate-integrate as needed. There may be benefit to perform isolated tissue mobilization, joint movement, modalities, etc. depending on outcome of function (global approach). Often, this is the job of the physio.
    • Compensatory indirect – There are times in function where parts do not fully restore to the function(s) demand. Therefore, because we still need to function, we must teach strategies on how to compensate effectively with our known structural deficits. As vertebrates, we remodel as opposed to laying down new “parts.” Therefore, all injury stays with us to some level. The level at which the injury lurks is per individual.

In conclusion, 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 on Lifting. (Click here for more info.) Gary will take you through chain reaction thought process that will help with your client’s dysfunction and therefore improve overall functional ability.