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technique CLINICAL APPS Massage and the Indirect Approach to Nerve Injury By Whitney Lowe Nerve injuries can be intimidating for massage therapists. However, they don't have to be if a few key evaluation and treatment concepts are applied. In this installment, we examine a complex case involving a client with neurological symptoms in her hand. Monica is an aerial silk artist. These performers do complex acrobatic maneuvers while hanging from large silk ribbons. It is an elegant sport that takes a great deal of strength, flexibility, and grace. Three weeks ago, Monica had an accident during practice in which she lost her grip and had to catch herself from falling. The incident had her horizontal and grabbing the silk with her right hand as she fell; her head was thrust in the opposite direction. About a week after the injury, Monica began experiencing pain— along with pins-and-needle sensations (paresthesia)— in her right hand. She sought massage therapy, hoping it would resolve the symptoms and prevent further problems. Clearly, Monica was having neurological symptoms, and although one might be tempted to immediately refer a client with neurological involvement, it is not always necessary. Initial assessment indicated Monica's injuries might be primarily soft-tissue related, and so it was determined that massage may be appropriate. Further assessment is crucial for effective treatment in a condition like Monica's. PHYSICAL EXAM/EVALUATION Monica reported delayed upper extremity neurological sensations several days after the accident. The paresthesia symptoms were predominantly on the ulnar side of her hand, but not in her arm. The location of symptoms is one of the most important clues as to where a predominant nerve injury is located. To fully understand how to use this information effectively, let's first review some key principles of nerve anatomy and physiology. There are two basic types of mechanical nerve injury that can result from the type of accident Monica experienced: radiculopathy or a peripheral neuropathy. A radiculopathy is an injury to the nerve root. A common example is a disc herniation or spinal tumor pressing on the nerve root. A peripheral neuropathy is a nerve injury that impacts the nerve farther along its path, distal to the nerve root. These conditions produce distinct symptom patterns, but it is not always easy to distinguish between them. You can have both problems simultaneously: nerve root and peripheral nerve impairment. However, for determining the tissues involved and making good treatment decisions, it is important to be able to make distinctions between the symptom patterns of these conditions. There are two important concepts related to symptom patterns in radiculopathy and peripheral neuropathy: dermatomes and cutaneous innervation. Understanding these concepts is essential to the evaluation process of nerve injuries. A dermatome is an area of skin innervated by fibers originating from a single nerve root. For example, Earn CE credit for this article! www.academyofclinical massage.com F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 91 When watching aerial silk artists in action, it's not hard to envision the multitude of injuries they might sustain as a result of their craft. Image courtesy Kendall Knowles, Central Oregon Aerial Arts.