De Oliveira 2019
De Oliveira 2019
De Oliveira 2019
Abstract
Background/Aims Brachial plexus injuries impair functionality, interfere with the
performance of activities and affect participation in social events, thus decreasing an
individual’s quality of life. In cases where there is a total loss of muscular strength,
complete rehabilitation is challenging. Motor irradiation is a basic proprioceptive
neuromuscular facilitation procedure that is used to activate weak muscles. It is a
promising procedure for rehabilitation following brachial plexus injuries, mainly in those
with total loss of muscle strength.
Methods The patient in this case study had suffered bilateral brachial plexus injuries
as a result of mechanical restraint during a psychiatric episode. He presented with
decreased muscle strength in the proximal segments of the upper limbs, no movement
of the wrists and fingers, tactile hypoesthesia and no pain sensation. Motor irradiation
was the main intervention used to improve motor function.
Findings At the end of treatment, complete and partial recovery of muscle strength
1Postgraduate Rehabilitation was observed in the proximal and distal segments, respectively.
Sciences Programme,
Augusto Motta University Conclusions The efficacy of motor irradiation in improving muscle strength following
Center and Physiotherapy brachial plexus injuries should be investigated in future clinical trials.
Course, Federal Institute
Key words: ■ Brachial plexus ■ Motor irradiation ■ Physiotherapy
of Rio de Janeiro, Rio de
■ Proprioceptive neuromuscular facilitation
Janeiro, Brazil
2Postgraduate Rehabilitation
Submitted: 18 January 2018; accepted following double blind peer review: 19 September 2018
Sciences Programme,
Augusto Motta University
Center, Rio de Janeiro, Brazil
3Federal INTRODUCTION
Institute of Rio
de Janeiro, Rio de Janeiro,
Brazil Brachial plexus injury leads to partial or total loss of motor, sensory and autonomic
4Postgraduate Rehabilitation function in the affected limb (Flores, 2006; Bonham and Greaves, 2011). Secondary
Sciences Programme, alterations, such as balance impairment, may also occur (Souza et al, 2016). When
Augusto Motta University experienced together, these impairments can affect functionality, work and activities
Center, Rio de Janeiro, Brazil of daily living, compromising social participation and quality of life (Jaquet et al,
5Deolindo Couto 2001). Epidemiological studies indicate that the majority (85–98%) of brachial
Neurological Institute, plexus injuries in Brazil occur in young males, and that a large proportion (60–79%)
Federal University of Rio de are caused by motorcycle crashes (Flores, 2006; Junior et al, 2011; Faglioni et al,
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Janeiro, Brazil 2014). Bilateral brachial plexus injuries are a rare condition that can be caused
Correspondence to:
Laura Alice Santos de Oliveira
How to cite this article: Oliveira LAS, Pedron CA, Andrade FG, Horsczaruk CHR, Martins JVP (2019)
Email: Motor recovery after bilateral brachial plexus injury using motor irradiation: a case report. Int J Ther
laura.oliveira@ifrj.edu.br Rehabil [online] 26(4):1–13. https://doi.org/10.12968.ijtr.2017.0170
CASE STUDY
Ethical approval
The institutional ethics committee approved this study before it was performed
(CAAE: 51657615.6.0000.5261). The individual provided written informed consent
to publish his case details.
his arms or hands. The patient had been addicted to alcohol from the age of 16 but
had overcome this; however, years later he had witnessed a murder, began using
psychotropic drugs prescribed by a doctor to deal with post-traumatic stress and
was only able to sleep if he drank alcohol. The concomitant use of these substances
culminated in a psychiatric episode in August 2013, which resulted in hospitalisation
(for 1 week) in a psychiatric centre, where a mechanical restraint was used across
his thoracic region. After regaining consciousness, the patient was unable to move
his upper limbs. He was discharged 3 months later.
An electromyography exam showed selective and generalised bilateral denervation
of the arm, forearm and hand muscles. The evaluating doctor decided that there was no
need for surgery. The patient was evaluated in a rehabilitation service 4 months after
the injury (in December 2013) by a physiotherapist not involved in the treatment. The
evaluation consisted of an anamnesis and complete clinical neurological examination
including assessment of range of motion, sensibility, tone, reflexes, balance and
strength. Strength was graded using the Kendall scale (Kendall and McCreary, 1995):
■ ■ Grade 0: no muscle contraction palpable can be felt in the gravity eliminated
position (arm supported by physiotherapist)
■ ■ Grade 1: muscle contraction palpable, but no movement occurs in the gravity
eliminated position
■ ■ Grade 2: patient has all or partial range of motion
■ ■ Grade 3: patient can tolerate no resistance but can perform movement through
the full range of movement
■ ■ Grade 4: patient can hold a position against strong or moderate resistance and has
full range of movement
■ ■ Grade 5: patient can hold a position against maximum resistance and through
complete range of motion.
There were bilateral large lesions in the axillary regions and the pectorals that were
healing (Figure 1). These lesions limited the range of motion of the shoulders. The
elbows, wrists and fingers had incomplete passive and active range of motion. The
Kendall scale scores for these joints are given in Table 1. In a sensitivity examination,
the patient had tactile hypoesthesia and anaesthesia in C5, C6, C7 and C8 dermatomes,
distal loss of vibratory sensitivity, and loss of arthrokinetic sensitivity in the proximal
and distal joints. He did not complain of pain.
The patient was able to perform transfers from a bed to a chair, walk and use the
stairs independently, but required help for activities of daily living that were related
to self-care, such as feeding and drinking. The patient had separated from his wife
and gone to live with his mother, who helped him with all of the activities he needed
assistance with. He had stopped working and was in receipt of disability benefits.
Figure 1. The patient 1 week after mechanical restraint. Note the scars over
the pectoral region
Table 1. Kendall scores for muscular strength before and after treatment
Shoulder
Extension 4 4 5 5
Flexion 4 4 5 5
Abduction 2 4 5 5
Elbow
Flexion 1 1 5 5
Extension 2 2 5 5
Wrist
Flexion 0 0 5 5
Extension 0 0 5 5
Fingers
Metacarpophalangeal 0 0 4 4
interphalangeal flexion/extension
Proximal 0 0 3 3
Distal 0 0 3 3
Abduction 0 0 0 0
Adduction 0 0 0 0
Opposition 0 0 0 0
Intervention
Treatment was implemented by two physiotherapists over approximately 28 months.
The patient initially undertook three sessions a week. Over the treatment period,
this was reduced to two and finally to one session a week. The treatment goals and
approaches used varied according to the degree of muscular strength presented
throughout the treatment. All exercises displayed in the following figures were
demonstrated by a healthy volunteer and not the patient.
extensors. In the lateral decubitus position, the patient performed a scapular posterior
depression against resistance (Figure 2). He performed a pelvic posterior tilt against
resistance from the physiotherapist (Figure 3).
For shoulder and elbow extensors, the patient lay on his back with his knees
bent and feet flat on the floor (supine hook lying position). One of his arms was
positioned over the treatment table he was lying on with the hand in the prone position.
The other arm was positioned over the trunk. Resistance was applied against the hip
elevation (physiotherapist’s hands over the patient’s pelvis) (Figure 4).
For shoulder abductors and elbow, wrist and finger extensor the patient remained in
the supine hook lying position, the upper limb being treated was in a slight shoulder
abduction and elbow extension, the forearm was in a neutral position against a wall,
and the opposite upper limb was positioned over the patient’s trunk. Resistance was
applied in the medial part of one knee and the lateral part of the other, while the
patient moved the lower limbs towards the treatment table in the opposite direction
of the supported upper limb (Figure 5). For shoulder external rotators and wrist
and finger extensors, a supine hook lying position was used. The upper limb was in
horizontal abduction with the elbow flexed to 90 degrees, the shoulder externally
rotated, and the forearm, wrist and fingers resting on a pillow. The opposite upper
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limb was over the trunk. Resistance was applied in the medial part of one knee and
the lateral part of the other while the patient moved the lower limbs towards the
treatment table and away from the abducted upper limb (Figure 6).
The supine hook lying position was used to activate the wrist and finger flexors. The
shoulder was gently held, the elbow extended, the forearm pronated and the fingers
Figure 5. Hook lying position with the arm touching the wall. The physiotherapist
is applying resistance for lower trunk rotation. The goal is motor irradiation
to the right shoulder abductors and elbow, wrist and finger extensors
resting on the edge of the treatment table when the upper limb was being treated.
The opposite upper limb was positioned over the trunk. Resistance was applied to
the medial part of one knee and the lateral part of the other while the patient moved
his lower limbs in the direction of the abducted upper limb (Figure 7).
with trunk flexion, rotation and lateral flexion to the side that the upper limb was in
contact with the treatment table. The patient performed trunk extension, rotation and
lateral flexion to the opposite side against the physiotherapist’s resistance (Figure 8).
The lateral decubitus position was used for elbow and finger flexors. The lower
limbs were flexed to 90 degrees at the hips and knees. The upper limb undergoing
Figure 8. The initial position is trunk flexion, rotation and lateral flexion to left
with the left hand in contact with the treatment table. The patient performs
trunk extension, rotation and lateral flexion to the right. The physiotherapist
is applying resistance against the movement of trunk extension
treatment was flexed at 90 degrees, with the fingers resting on the edge of the
treatment table. The opposite upper limb was positioned as the patient preferred. The
patient performed a triple flexion against resistance from the ipsilateral lower limb
by performing dorsiflexion of the ankle and bending the knee and hip (Figure 9).
Figure 9. Side lying position with the fingers holding on the edge of the
treatment table. The goal is motor irradiation to the left elbow and finger
flexors. The patient performs dorsiflexion of the ankle and bends the knee
and hip against manual resistance
Figure 10. In prone on elbow position Figure 11. Flexion, abduction and
with fingers holding the edge of external rotation of the upper limb,
the treatment table. Resistance with elbow flexion against resistance
is applied to the shoulders in the
direction of the right foot. The goal
is motor irradiation for finger flexion
RESULTS
The patient was collaborative and adhered well to treatment. He gradually recovered,
with proximal movement occurring first followed by distal movement. When the
patient was able to flex his elbows against gravity (moving his upturned palm
towards his shoulder), an occupational therapist taught him how to use a cuff brace
so he could use cutlery. After 9 months of treatment, many aspects of the patient’s
muscular strength had improved; he had Kendall scores of 5 for shoulder, wrist and
elbow movements; 4 for metacarpophalangeal flexion; 3 for proximal and distal
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interphalangeal flexion and extension; and 0 for other flexion, extension, adduction,
abduction and opposing movements (Table 1). At this time his hand was in a claw
position, with passive range of motion preserved.
At his final assessment in May 2016, which was performed by the same
physiotherapist who carried out the initial evaluation, the adduction and abduction
of the fingers, flexion and extension of the metacarpophalangeal joints, and opposition
of the thumbs remained weak (score of 1 on the Kendall scale). The patient still found
it difficult to perform activities that required dexterity. The occupational therapist
therefore implemented training and adaptation for the use of utensils. Constraint scars
were still observed in the bilateral axillary region (Figures 12a and 12b); however,
the superficial and deep sensations in both upper limbs had completely recovered.
a
b
Figure 12. The patient’s left (a) and right (b) armpit at his final assessment.
Note the large scars caused by mechanical restraint
DISCUSSION
This study reported motor recovery from a brachial plexus injury caused by mechanical
restraint. Motor irradiation exercises were performed throughout the treatment period,
especially during the initial recovery phases when voluntary muscular activation was
poor or non-existent. The patient demonstrated satisfactory recovery of wrist and elbow
movements, with some limitations to his finger movements. He was able to return to
work at the end of the treatment.
Rehabilitation when there is no muscular strength is a huge challenge for
physiotherapists because even though the nerve fibres are moving toward its target
muscle, the patient is not able to activate the corresponding muscles. During this
phase, the physiotherapist aims to prevent secondary alterations, such as contractures,
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deformities and muscular atrophy (Smania et al, 2012). Motor irradiation appears
to be a promising and cheap procedure in this scenario. Although the mechanisms
involved are not clear, motor irradiation can recruit motor units in weak muscles
through the application of resistance to strong muscle segments (Kabat, 1961; Pink,
1981); electromyographic signals have captured the muscular activation generated
by motor irradiation (Mills and Quintana, 1985; Meningroni et al, 2009; Abreu et al,
2015; Reznik et al, 2015). This study used motor irradiation to activate the muscles
in the acute phase, because of the possible presence of preserved nerve fibres, and
aimed to restore functionality through re-innervation. It is important to highlight that
brachial plexus injury mostly affects young individuals (Mello Junior et al, 2012) who
are at employment age. Therefore, this type of injury can have an economic impact on
society, and so efficient rehabilitation techniques are required to help these patients
get back to work.
The use of excitomotor currents as an early option for brachial plexus injury
rehabilitation (Kaas and Collins, 2003) has been reported to prevent amyotrophy and
to induce the regeneration of peripheral nerves; however, the electrostimulation was
found to negatively affect recovery of muscular function during the acute injury phase
(Gigo-Benato et al, 2010). Therefore, this strategy was not adopted in this study.
Rehabilitation following peripheral nerve injuries usually takes a long time. This can
be explained by the slow regeneration of peripheral nerves (1 mm per day depending on
the nerve) (Bijos and Guedes, 2010) and reorganisation of the central nervous system
that is required (Navarro et al, 2007). Rehabilitation time is also influenced by the
complexity of the injury, patient cooperation, the time between the injury and onset
of treatment, and psychosocial issues (Kretschmer et al, 2009; Smania et al, 2012).
Reports of brachial plexus injury caused by mechanical restraints during a psychiatric
episode have not previously been described in the literature. It is not known whether
the lack of available information is due to the rarity of the problem or a lack of interest
in reporting its occurrence. Unfortunately, mechanical restraints are still widely used
in psychosocial units (Bonfada and Guimarães, 2012; Zeferino et al, 2016).
CONCLUSIONS
Conflict of interest
The authors declare no conflict of interest.
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