I have a new diabled client and have a few questions: She is paralyzed in the right arm, due to an injury to her briachial plexus about 8 years ago. She is also taking Neurontin, Lyrica, Percocet, and Kepra for the pain. I need to build a program for her that incorporates upper body, and would like to learn about some exercises and techniques in order to keep her interest high, yet keep her upper body balanced, as well as any side effect of this medication. Thanks Brian Morrissey, NASM-CPT Lakeshore Athletic Club, Chicago

There are many things that you can do for this client. The first thing I would do would be to fully assess your client. If you feel that assessing your client with these issues is out of your league, then refer out to a skilled PT, CNMT or CHEK Practitioner Level 3. You need to know exactly what it going on in order to design a rehab/corrective exercise program. Everyone has different reasons for a brachial plexus injury, etc, so no program will be the same.

A great book to learn more about the neurological system is Orthopedic Neurology by Hoppenfield. As well as for assessments, Orthopedic Physical Assessments by Maghee. These are two books that will assist you with understanding your client and will help you help others in the future.

The brachial plexus is a network of nerves that conducts signals from the spine to the shoulder, arm, and hand. Brachial plexus injuries are caused by damage to those nerves. Symptoms may include a limp or paralyzed arm, lack of muscle control in the arm, hand, or wrist, and lack of feeling or sensation in the arm or hand.

Although injuries can occur at any time, many brachial plexus injuries happen during birth: the baby's shoulders may become impacted during the birth process causing the brachial plexus nerves to stretch or tear (Erb’s Palsy). Erb-Duchenne (Erb's) palsy refers to paralysis of the upper brachial plexus. Dejerine-Klumpke (Klumpke's) palsy refers to paralysis of the lower brachial plexus. There are four types of brachial plexus injuries: avulsion, the most severe type, in which the nerve is torn from the spine; rupture, in which the nerve is torn but not at the spinal attachment; neuroma, in which the nerve has tried to heal itself but scar tissue has grown around the injury, putting pressure on the injured nerve and preventing the nerve from conducting signals to the muscles; and neuropraxia or stretch, in which the nerve has been damaged but not torn. Neuropraxia is the most common type of brachial plexus injury. So understanding what type is very important when designing a rehab program. This will determine what muscles and nerves are stretched and what exercises are chosen to strengthen the elongated muscles.
Knowing your anatomy in this situation is key. Forward head posture, Upper Cross Syndrome, Decreased 1dt rib angle, inverted breathing, tight Subclavius muscle, etc can all be causes for a brachial plexus injury.

I truly cannot just give you a program for two reasons:
1. I have not assessed your client and I would just be guessing
2. If I gave it all to you, what would you actually learn and get out of it.
My recommendation to you at this point as I have said would be to find a practitioner in your area to refer to and work with so you can help your client and learn at the same time.

As for the meds, wow! A lot of these will cause major gut and physiological symptoms to occur. I am sure she may have fungal/parasite infection, leaky gut, dysbiosis, and absorption problems. Taking all these meds is an extreme stress to the body. Not only will it cause some of the problems above, but it will increase her cortisol/insulin levels, making her catabolic most of the time. As well, she will be consistently in a state of sympathetic overload, facilitation inflammation and never giving her body a chance to repair and regenerate. She is beginning a vicious journey of “this for that” if she continues.

Know your role though! You can tell her to stop taking those meds. You can educate her and that is in your best interest. What I would do, would be do purchase Mosby’s Medical Drug Reference book and look there up. They sell a CD as well that has printer friendly documents on the side effects of those meds. You can hand them to her so she can learn more. Then from that point she can make the decision whether or not to go off them by asking her MD. Hopefully I have helped some and good luck!

Joshua Rubin