Case Report

Motor recovery after bilateral brachial

plexus injury using motor irradiation:
a case report
Laura Alice Santos de Oliveira, Professor of Physiotherapy1, Carla Andressa Pedron,
Master’s student2, Fernanda Guimarães de Andrade, Professor of Physiotherapy3,
Carlos Henrique Ramos Horsczaruk, PhD student4, José Vicente Pereira Martins,
Professor of Physiotherapy5

1Postgraduate Rehabilitation
Sciences Programme,
Augusto Motta University
Center and Physiotherapy
Course, Federal Institute
of Rio de Janeiro, Rio de
Janeiro, Brazil
2Postgraduate Rehabilitation
Sciences Programme,
Augusto Motta University
Center, Rio de Janeiro, Brazil
3Federal
Institute of Rio
de Janeiro, Rio de Janeiro,
Brazil
4Postgraduate Rehabilitation
Sciences Programme,
Augusto Motta University
Center, Rio de Janeiro, Brazil
5Deolindo Couto
Neurological Institute,
Federal University of Rio de
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
was observed in the proximal and distal segments, respectively.
Conclusions The efficacy of motor irradiation in improving muscle strength following
brachial plexus injuries should be investigated in future clinical trials.
Key words: ■ Brachial plexus ■ Motor irradiation ■ Physiotherapy
■ Proprioceptive neuromuscular facilitation
Submitted: 18 January 2018; accepted following double blind peer review: 19 September 2018
INTRODUCTION
Brachial plexus injury leads to partial or total loss of motor, sensory and autonomic
function in the affected limb (Flores, 2006; Bonham and Greaves, 2011). Secondary
alterations, such as balance impairment, may also occur (Souza et al, 2016). When
experienced together, these impairments can affect functionality, work and activities
of daily living, compromising social participation and quality of life (Jaquet et al,
2001). Epidemiological studies indicate that the majority (85–98%) of brachial
plexus injuries in Brazil occur in young males, and that a large proportion (60–79%)
are caused by motorcycle crashes (Flores, 2006; Junior et al, 2011; Faglioni et al,
© 2019 MA Healthcare Ltd

Janeiro, Brazil
Correspondence to:
Laura Alice Santos de Oliveira
Email:
laura.oliveira@ifrj.edu.br
2014). Bilateral brachial plexus injuries are a rare condition that can be caused
How to cite this article: Oliveira LAS, Pedron CA, Andrade FG, Horsczaruk CHR, Martins JVP (2019)
Motor recovery after bilateral brachial plexus injury using motor irradiation: a case report. Int J Ther
Rehabil [online] 26(4):1–13. https://doi.org/10.12968.ijtr.2017.0170

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 1

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

by trauma, the use of crutches, inadequate positioning during surgical procedures

or immobilisation (Raikin and Froimson, 1997; Silber et al, 1999; Akinbingol et al,
2002; Kent and Cheney, 2007; Hida et al, 2008; Anwar et al, 2012; Kasahara et al,
2012). Reports indicate that bilateral brachial plexus injuries may also occur after
mechanical restraint during psychiatric episodes (Laranjeira et al, 2000).
Surgical techniques, such as neurolysis, neurorrhaphy, nerve grafting, neurotisation
and muscular transference, aim to facilitate peripheral plasticity mechanisms involved
in the recovery of brachial plexus injuries (Navarro et al, 2007), promoting functional
recovery (Silva et al, 2010; Batista and Araújo, 2013; Sinha et al, 2016). For satisfactory
surgical results, physiotherapy and occupational therapy approaches are essential.
These approaches are the only treatment options when surgery is not performed.
Case reports based on the physiotherapeutic treatment of unilateral brachial plexus
injury suggest that neural mobilisation and laser therapy (Marcolino et al, 2008),
conventional kinesiotherapeutic approaches, and electrical stimulation can be used
(Cunha et al, 2013).
One of the major problems faced by physiotherapists is in activating paralysed
muscles, especially during the acute phase. This is a challenge because the connection
between the muscle and the brain is damaged. Proprioceptive neuromuscular
facilitation is a treatment concept used by physiotherapists to rehabilitate people
with locomotor disorders.
Motor irradiation is a basic proprioceptive neuromuscular facilitation procedure
that has shown promise in treating individuals with these disorders (Adler et al,
2008; Bijos and Guedes, 2010). In this procedure, resistance is applied to a strong
corporal segment to generate contraction in a weak segment (Kabat, 1961; Pink,
1981). Electromyography studies have confirmed the occurrence of indirect muscle
activation in healthy individuals (Abreu et al, 2015), people with hemiplegia (Mills
and Quintana, 1985; Reznik et al, 2015) and those with Charcot–Marie–Tooth disease
(Meningroni et al, 2009). Furthermore, in the acute phase of brachial plexus injury,
motor irradiation would be able to reach the remaining unaffected nerve fibres.
Although motor irradiation is widely used by physiotherapists, its efficacy in motor
recovery following peripheral injuries remains uninvestigated and no brachial plexus
injury recovery programmes using this approach have yet been described. This study
reports a case of bilateral brachial plexus injury caused by mechanical restraint and
motor function recovery in the upper limbs through the use of motor irradiation, among
other approaches. This is an uncommon case beacuse of the bilateral involvement,
the mechanism of injury and the use of motor irradiation; therefore, this report may
be useful for physiotherapists who face similar issues.

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.

History and presentation

The patient was a 32-year-old man who complained that he was unable to move
© 2019 MA Healthcare Ltd

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

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 2

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

(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.

© 2019 MA Healthcare Ltd

Figure 1. The patient 1 week after mechanical restraint. Note the scars over
the pectoral region

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 3

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

Table 1. Kendall scores for muscular strength before and after treatment

Before intervention After intervention

Movement Right Left Right Left

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.

Interventions for muscles with a Kendall score of 0–1

Each upper limb joint was passively mobilised using techniques that aimed to
maintain range of motion until the patient was able to independently move his upper
limbs. With the patient lying on their side (lateral decubitus position), active‑assisted
exercises were performed on the muscles that had a Kendall score of 1.
Isometric home exercises were prescribed that involved supporting the upper
limb on the wall to generate flexion, extension and abduction of the shoulder. Motor
irradiation was used to recover movements in the shoulders, wrists, fingers and elbows
using muscular strength from the scapular and pelvic girdles, trunk and lower limbs
(described further on in this section).
Two exercises were used to activate the shoulder abductors and elbow and wrist
© 2019 MA Healthcare Ltd

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

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 4

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

Figure 2. Posterior depression of left scapula. The goal is motor irradition to

the right shoulder abductors and elbow, wrist and finger extensors

Figure 3. The physiotherapist is applying resistance against the posterior

depression of the pelvis. The goal is motor irradiation to the right shoulder
abductors and wrist and finger extensors

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
© 2019 MA Healthcare Ltd

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

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 5

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

Figure 4. Bridging with one arm support. The physiotherapist is applying

resistence on the iliac crest. The goal is motor irradiation to shoulder and
elbow extension

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).

Interventions for muscles with a Kendall score of 1–2

Motor irradiation exercises were continued. Home isometric exercises for the
upper limbs and self-mobilisation exercises were added to maintain joint range of
movement. Some motor irradiation exercises were also added. For the shoulder and
elbow extension, the patient remained in the seated position with the hand of the upper
limb undergoing treatment in contact with the treatment table. The patient began
© 2019 MA Healthcare Ltd

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

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 6

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

Figure 6. The physiotherapist is applying resistence against lower trunk

rotation. The goal is motor irradiation to the right shoulder external rotators
and wrist and finger extensors

Figure 7. The physiotherapist is applying resistance against lower trunk

rotation. The goal is motor irradiation to the right wrist and finger flexors

© 2019 MA Healthcare Ltd

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

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 7

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

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

Interventions for muscles with a Kendall score of 2–3

Self-assisted and active-assisted exercises against gravity were added to the motor
irradiation exercises. For example, the seated patient flexed and extended his
elbow and then moved his hand between his mouth and the treatment table in an
active‑assisted manner. Self-assisted home exercises were performed for all muscles
with a Kendall score of 2.
A finger flexion exercise was added at this point. The patient rested on their
stomach (in the ventral decubitus position) with his elbows flexed and in line with
the shoulders, his forearms in contact with the treatment table, and his fingers on the
edge of the treatment table. Resistance was applied to the shoulders in the caudal
direction, while the patient tried to hold the position (Figure 10).
Mobilisation of the medial, ulnar and radial nerves was also added to restore the
patient’s movement and elasticity (Butler, 1991; Marcolino et al, 2008).

Interventions for muscles with a Kendall score of 3

Antigravity, light resistance and isotonic combination (concentric, isometric and
eccentric contractions of the same muscular group) exercises were implemented
(Adler et al, 2008). Diagonal upper limb movements were added in flexion and
extension. Functional task training was increased at this stage.
A motor irradiation wrist extension exercise was added. In the dorsal decubitus
position, the patient performed flexion, abduction and external rotation of the upper
limb, with elbow flexion against resistance. Halfway through this movement, more
manual resistance to stop the movement was applied by the physiotherapist while
© 2019 MA Healthcare Ltd

the patient was required to extend his wrist (Figure 11).

Interventions for muscles with a Kendall score of 4

Resistance exercises were predominantly employed at this stage using elastic
and manual resistance during diagonal upper limb patterns from proprioceptive

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 8

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

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

neuromuscular facilitation. The central focus was on improving performance activities,

such as picking up objects, cleaning the desk, opening the door.

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
© 2019 MA Healthcare Ltd

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

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 9

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

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,
© 2019 MA Healthcare Ltd

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

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 10

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

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

Satisfactory results were achieved following rehabilitation in this patient, although

he only partially recovered his hand movements. This case report does not provide
sufficient evidence to affirm that the observed recovery was strictly due to the motor
irradiation technique, and the possibility that recovery occurred spontaneously cannot
be completely ruled out. It is therefore necessary to investigate the efficacy of motor
irradiation in future controlled clinical trials.

Conflict of interest
The authors declare no conflict of interest.

REFERENCES

Abreu R, Lopes AA, Sousa ASP, Pereira S, Castro MP. Force irradiation effects during upper limb diagonal
exercises on contralateral muscle activation. J Electromyogr Kinesiol. 2015;25(2):292–297. https://doi.
org/10.1016/j.jelekin.2014.12.004
Adler S, Beckers D, Buck M. PNF in practice: an illustrated guide. 3rd edn. Berlin: Springer; 2008
Akinbingol G, Borman H, Maral T. Bilateral brachial plexus palsy after a prolonged surgical procedure of
reduction mammaplasty, abdominoplasty, and liposuction. Ann Plast Surg. 2002;49(2):219–220. https://
doi.org/0.1097/01.SAP.0000022228.30091.44
Anwar F, McLaughlin D, Panesar BS. Bilateral brachial plexus injury. J Coll Physicians Surg Pak. 2012;
22(3):176–178. https://doi.org/02.2012/JCPSP.176178
© 2019 MA Healthcare Ltd

Batista KT, Araújo HJ. Reabilitação na paralisia parcial do plexo braquial. Rev Bras Cir Plást.
2013;28(1):175–179. https://doi.org/10.1590/S1983-51752013000100030
Bijos P, Guedes F. Plexo braquial. Rio de Janeiro: DiLivros; 2010
Bonfada D, Guimarães J. Serviço de atendimento móvel de urgência e as urgências psiquiátricas. Psicol Estud.
2012;17(2):227–236. https://doi.org/10.1590/S1413-73722012000200006

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 11

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.

 Case Report

Bonham C, Greaves I. Brachial plexus injuries. Trauma. 2011;13(4):353–363. https://doi.

org/10.1177/1460408611405298
Butler D. Mobilisation of the nervous system. Edinburgh: Churchill Livingstone; 1991
Cunha AS, Junior JHAF, Junior JEGL, Figueiredo ADJ. Intervenção da fisioterapia na lesão do plexo braquial
através de FES e cinesioterapia. Rev Fisioter S Fun. 2013;2(1):62–68
Faglioni W, Siqueira MG, Martins RS, Heise CO, Foroni L. The epidemiology of adult traumatic brachial plexus
lesions in a large metropolis. Acta Neurochir. 2014;156(5):1025–1028. https://doi.org/10.1007/s00701-013-
1948-x
Flores LP. Estudo epidemiológico das lesões traumáticas de plexo braquial em adultos. Arq. Neuro-Psiquiatr.
2006;64(1):88–94
Gigo-Benato D, Russo TL, Geuna S et al. Electrical stimulation impairs early functional recovery and accentuates
skeletal muscle atrophy after sciatic nerve crush injury in rats. Muscle Nerve. 2010;41(5):685–693. https://doi.
org/10.1002/mus.21549
Hida A, Arai T, Nakanishi K, Nagaro T. Bilateral brachial plexus injury after liver transplantation. J Anesth.
2008;22(3):308–311. https://doi.org/10.1007/s00540-008-0636-0
Jaquet JB, Luijsterburg AJ, Kalmijn S, Kuypers PD, Hofman A, Hovius SE. Median, ulnar, and combined
median–ulnar nerve injuries: functional outcome and return to productivity. J Trauma. 2001;51(4):687–692
Junior JSM, Souza TCR, Andrade FG et al. Perfil epidemiológico de pacientes com lesão traumática do plexo
braquial avaliados em um Hospital Universitário no Rio de Janeiro, Brasil. Rev Bras Neurol. 2011;48(3):5–8
Kaas JH, Collins CE. Anatomic and functional reorganizsation of somatosensory cortex in mature primates after
peripheral nerve and spinal cord injury. Adv Neurol. 2003;93:87–95
Kabat H. Proprioceptive facilitation in therapeutic exercise. In: Licht S, Johnson EW, eds. Therapeutic exercise.
2nd edn. Baltimore, MD: Waverly; 1961
Kasahara T, Tokyokura M, Furuno K, Ishida A. Bilateral brachial plexus injury. J Coll Physicians Surg Pak.
2012;22(3):176–178
Kendall FP, McCreary EK. Princípios fundamentais. In: Kendall FP, McCreary EK, eds. Músculos Provas e
Funções. 4th edn. São Paulo: Manole; 1995
Kent CD, Cheney FW. A case of bilateral brachial plexus palsy due to shoulder braces. J Clin Anesth.
2007;19(6):482–484. https://doi.org/10.1016/j.jclinane.2007.01.010
Kretschmer T, Ihle S, Antoniadis G et al. Patient satisfaction and disability after brachial plexus surgery.
Neurosurgery. 2009;65(Suppl 4):A189–A196. https://doi.org/10.1227/01.NEU.0000335646.31980.33
Laranjeira R, Nicastri S, Jerônimo C, Marques AC. Consenso sobre a Síndrome de Abstinência do Álcool (SAA) e
o seu tratamento. Rev Bras Psiquiatr. 2000;22(2):62–71. https://doi.org/10.1590/S1516-44462000000200006
Marcolino AM, Barbosa RI, Fonseca MCR, Mazzer N, Elui VMC. Reabilitação fisioterapêutica na lesão do plexo
braquial: relato de caso. Fisioter Mov. 2008;21(2):53–60.
Mello Junior JS, Souza TCR, Andrade FG et al. Epidemiological profile of patients with traumatic brachial plexus
injury evaluated in a university hospital in Rio de Janeiro, Brazil, 2011. Rev Bras Neurol, 48 (3): 5-8, 2012.
Meningroni PC, Nakada CS, Hata L et al. Irradiação contralateral de força para a ativação do músculo tibial
anterior em portadores da doença de Charcot-Marie-Tooth: efeitos de um programa de intervenção por FNP.
Rev Bras Fisioter. 2009;13(5):438–443. https://doi.org/10.1590/S1413-35552009005000058
Mills VM, Quintana L. Electromyography results of exercise overflow in hemiplegic patients. Phys Ther.
1985;65(7):1041–1045
Navarro X, Vivó M, Valero CA. Neural plasticity after peripheral nerve injury and regeneration. Prog Neurobiol.
2007;82(4):163–201. https://doi.org/10.1016/j.pneurobio.2007.06.005
Pink M. Contralateral effects of upper extremity proprioceptive neuromuscular facilitation patterns. Phys Ther.
1981;61(8):1158–1162
Raikin S, Froimson MI. Bilateral brachial plexus compressive neuropathy (crutch palsy). J Orthop Trauma.
1997;11(2):136–138
Reznik JE, Biros E, Bartur G. An electromyographic investigation of the pattern of overflow facilitated by
manual resistive proprioceptive neuromuscular facilitation in young healthy individuals: a preliminary study.
Physiother Theory Pract. 2015;31(8):582–586. https://doi.org/10.3109/09593985.2015.1061627
Silber E, Reilly M, Al-Moallem M, Murray NMF, Khalil N, Shakir RA. Brachial plexopathy related to alcohol
intoxication. J Neurol Neurosurg Psychiatry. 1999;67(3):411–412
Silva JLB, Silva PG, Gazzalle A. Lesões do plexo braquial. Rev Assoc Med Rio Grande Do Sul. 2010;54(3):344–349
Sinha S, Khani M, Mansoori N, Midha R. Adult brachial plexus injuries: surgical strategies and approaches.
Neurol India. 2016;64(2):289–296. https://doi.org/10.4103/0028-3886.177597
Smania N, Berto G, La Marchina E et al. Rehabilitation of brachial plexus injuries in adults and children. Eur J
© 2019 MA Healthcare Ltd

Phys Rehabil Med. 2012;48(3):483–506

Souza L, Lemos T, Silva DC et al. Balance impairments after brachial plexus injury as assessed through
clinical and posturographic evaluation. Front Hum Neurosci. 2016;9:715
Zeferino MT, Cartana MHF, Fialho MB, Huber MZ, Bertoncello KCG. Percepção dos trabalhadores
da saúde sobre o cuidado às crises na Rede de Atenção Psicossocial. Esc Anna Nery.
2016;20(3):e20160059

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/ijtr.2017.0170 12

Downloaded from magonlinelibrary.com by 130.237.122.245 on September 8, 2019.