Received: 13 April 2020

DOI: 10.1002/pri.1873

RESEARCH ARTICLE
- -
Revised: 13 July 2020 Accepted: 24 July 2020

Proprioceptive neuromuscular facilitation compared to

conventional physiotherapy for adults with traumatic upper
brachial plexus injury: A protocol for a randomized clinical
trial

Alessandra Carolina de Santana Chagas1 | Débora Wanderley1 |

Paulo José Moté Barboza2 | José Vicente Pereira Martins3 | Alexa Alves de Moraes1 |
Fernando Henrique Morais de Souza4 | Daniella Araújo deOliveira1

1
Department of Physiotherapy, Federal
University of Pernambuco, Recife, Brazil Abstract
2
Integrated Rehabilitation and Aquatic Background: Traumatic upper plexus injury affects daily living activities perfor-
Therapy Center, Rio de Janeiro, Brazil
mance and participation of individuals. Physical therapy treatment has a funda-
3
Department of Physiotherapy, Federal
University of Rio de Janeiro, Rio de Janeiro,
mental role on functional recovery, but it is still an unexplored and challenging field.
Brazil Aim: To develop a protocol to evaluate the efficacy of Proprioceptive Neuromus-
4
Peripheral Nerve Neurosurgery Clinic of the cular Facilitation (PNF) compared to conventional physiotherapy (CPT group) on
Hospital da Restauração, Recife, Brazil
functionality and quality of life.
Correspondence Methods: A committee was formed by four physical therapists to develop the
Daniella Araújo de Oliveira, Department of
treatment protocol. A Delphi study was carried out in order to quantify the level of
Physical Therapy, Federal University of
Pernambuco, Av. Jorn. Aníbal Fernandes, 173 agreement. A protocol for a randomized controlled trial was proposed to evaluate
‐ Cidade Universitária, Recife, Pernambuco
the effectiveness of the protocol in improving functionality and quality of life, ac-
50740‐560, Brazil.
Email: [email protected] cording Consolidated Standards of Reporting Trials. Participants will be randomly
assigned (1:1) to PNF or CPT group and two weekly sessions will be carried out for
Funding information
Coordenação de Aperfeiçoamento de Pessoal
12 months postsurgery, with a three‐month follow‐up. The main outcome mea-
de Nível Superior, Grant/Award Number: 001 surements are: upper limb functionality, quality of life, range of motion, muscle
strength, tactile sensitivity, and pain, which will be assessed at baseline, on the 6th,
9th, and 12th months postsurgery.
Result: A PNF protocol was developed for traumatic upper brachial plexus injury,
consisting of 11 illustrated exercises, three for immediate postoperative and eight
for postoperative. Biomechanical objectives, observations, positions of patients and
therapists and PNF principles, procedures and techniques have been described. An
80% agreement on all items in the first round of the Delphi study was achieved.
Conclusion: A protocol based on the PNF‐concept was developed with the aim of
improving the functionality and quality of life of individuals undergoing nerve
transfer after traumatic injury to the upper plexus. The detailed description of a
physical therapy treatment protocol through an appropriate method will allow its
use in clinical practice and in future studies with this population.

Physiother Res Int. 2020;e1873. wileyonlinelibrary.com/journal/pri © 2020 John Wiley & Sons Ltd. 1 of 9
https://doi.org/10.1002/pri.1873
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KEYWORDS
brachial plexus injury, nerve transfer, physical therapy modalities, rehabilitation

1 | INTRODUCTION consonance with the ICF (Adler et al., 2014; Guiu‐Tula, Cabanas‐
Valdés, Sitjà‐Rabert, Urrútia, & Gómara‐Toldrà, 2017; Kim, Yi, & Yim,
Traumatic brachial plexus injury (TBPI) in adults is mainly caused by 2019; Smedes, Heidmann; Schäfer, Fischer, & Stępień, 2016; Smedes
blunt trauma, especially as a result of motorcycle accidents, affecting & Silva, 2018; Tedla & Sangadala, 2019).
mostly young, healthy, and economically active individuals (Kaiser, The present study aimed at developing a protocol for a ran-
Waldauf; Ullas, & Krajcová, 2018; Oliveira et al., 2016; Park, Lee, Kim, domized clinical trial in order to evaluate the effectiveness of the
& Chang, 2017; Sakellariou et al., 2014; Verma; Vora; Thatte, & Yardi, intervention with the PNF‐concept compared to conventional
2019). Upper trunk injuries affect C5 and C6 nerve roots, causing physical therapy on the functionality and quality of life of adult pa-
shoulder joint and shoulder girdle dysfunction, as well as loss of tients undergoing surgical intervention after traumatic upper plexus
flexion, abduction and external rotation movements of the shoulder injury.
and also elbow flexion, leading to the emergence of limitations and
disabilities (Hill, Williams, Olver, & Bialocerkowski, 2015; Lim-
thongthang, Bachoura; Songcharoen, & Osterman, 2013; Thatte; 2 | METHODS
Babhulkar, & Hiremath, 2013).
In view of this, the advent of modern surgical techniques rep- 2.1 | Study design
resents a prospect of improvement in functional outcomes after TBPI
(Ferreira, Martins, & Siqueira, 2017; Giuffre, Kakar, Bishop, Spinner, The present study was divided into two steps. The first one consists
& Shin, 2010). Surgical options such as nerve transfers, which use of the development of a PNF‐concept‐based protocol comprising
fascicles or a branch of a functional distal nerve to reinnervate a adults undergoing surgical intervention after traumatic upper plexus
muscle or muscle group, have shown favorable results for shoulder injury, which is already completed. The protocol was prepared
and elbow function (Bengtson et al., 2008; Bunnell & Kao, 2018; Dy following the guidelines of the SPIRIT 2013 Checklist: Recommended
et al., 2015; Mancuso et al., 2015). Items to Address in a Clinical Trial Protocol (Appendix S1). The
Nevertheless, increments in muscle strength itself do not second step is a randomized controlled clinical trial proposal, in
represent improvements in performing daily living activities, once accordance to the Related Documents and the Consolidated Stan-
upper limb's functional status involves many factors, besides dards of Reporting Trials (CONSORT) guidelines for RCTs, which will
requiring an adequate positioning and stability of several joints (Hill be aimed at evaluating the effectiveness of the protocol in improving
et al., 2015; Kretschmer et al., 2009). Furthermore, although physical functionality and quality of life of adults undergoing surgical inter-
therapy treatment after TBPI is recognized as an important inter- vention after traumatic upper plexus injury, when compared to
vention that should be started early and requires a prolonged conventional physical therapy approach, throughout a 12‐month
treatment period, rehabilitation of patient with TBPI remains a period.
challenging and relatively unexplored field, in contrast with the This study was approved by the Human Research Ethics Com-
evident progress of microsurgical techniques (Giuffre et al., 2010; mittee of the Health Sciences Center at Federal University of Per-
Smania et al., 2012). nambuco (UFPE), Recife ‐ PE, Brazil (protocol number – 3.443.002).
The importance of performance and functional expectations of The research was registered on the Brazilian Registry of Clinical
patients with TBPI reinforces the need for a physical therapeutic Trials ‐ ReBEC (RBR‐3yc3bg) digital platform.
approach focused not only on the structural level, but also on com-
ponents of activities and participation in their personal and envi-
ronmental contexts, as highlighted by the International Classification 2.1.1 | Protocol—Step 1
of Functioning, Disability and Health (ICF). In this context, the Pro-
prioceptive Neuromuscular Facilitation (PNF) concept emerges as a Prior to the elaboration of the protocol, a committee was formed
therapeutic option for patients with TBPI, once its approach is based comprising four physical therapists with PNF‐concept training, two of
on neurophysiological principles of motor learning and control, them PNF instructors (one was an advanced instructor) certified by
emphasizing functional movement (Adler, Beckers, & Buck, 2014). the International Proprioceptive Neuromuscular Facilitation Associ-
The PNF‐concept has evolved over the last few decades into a ation—IPNFA, an organization that aims at maintaining continuity
complete rehabilitation approach that has been applied in pop- education and promoting further worldwide development of the
ulations presenting with different types of neurological and muscu- clinical use of PNF, besides educating and training new PNF in-
loskeletal disorders, with safety and efficacy, besides being in structors (IPNFA, 2020).
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The committee met several times during the 12‐month period in 2.2 | Participants
order to select the exercises, discuss, and review the final protocol.
The developed protocol recommended principles, techniques, and Participants will be recruited from specialized outpatient clinics.
procedures of the PNF‐concept, considering the main limitations Inclusion criteria: (1) age between 18 and 65 years old, men and
presented by the patients, as well as the desired post‐surgical women, with traumatic upper plexus injury ICD‐10 S14.3; (2) clinical
objectives after the nerve transfers procedures. diagnosis and confirmed by an Electroneuromyography (ENMG)
Thus, the protocol consists of 11 exercises, three of which are exam and/or Magnetic Resonance Neurography; and (3) patients
intended for the immediate postoperative period, where specific undergoing nerve transfer surgery: accessory nerve to suprascapular
recommendations should be followed and, after this period, the other nerve, Somsak technique (motor branch of the triceps brachii muscle
exercises can be incorporated into the treatment. The following to the anterior division of the axillary nerve), Oberlin technique
aspects are reported for each exercise: biomechanical objectives; (transfer of motor fasciculus from the ulnar nerve to the motor
observations regarding posture and further precautions; type of branch of the biceps brachii muscle) or all techniques combined.
direct or indirect treatment; PNF technique, principles, and proced- Exclusion criteria: (1) patients with some type of joint ankylosis (e.g.,
ures employed; patient's posture; positioning of therapist and verbal shoulder, elbow, and wrist joints); and (2) patients with disabling
command during the exercise; besides illustrative images taken by neuropathic pain that is not controlled by medication.
the instructors.
Additionally, in view of the patient's progress over time, some
exercises have one or more progressions, which are variations in at 2.3 | Recruitment
least one aspect, for example, patient positioning or technique of
choice, where the same objectives are maintained, but adding a Participants' recruitment will be consecutive and carried out by two
greater degree of difficulty. researchers (A and B) on medical appointment days at the outpatient
clinics. Researchers A and B will collect clinical and sociodemographic
Delphi study data.
Once the protocol was developed, a Delphi study was carried out
aiming at quantifying the level of agreement among physical thera-
pists with PNF‐concept training, in order to achieve a consensus 2.4 | Randomization and allocation concealment
regarding whether the protocol was understandable or not.
The form comprised six questions for each exercise and five Eligible participants will be randomized, before patients undergo
questions regarding the protocol in general at the end. All questions surgery, into two groups: PNF‐concept (PNF group) or conventional
needed to be answered on a five‐point Likert Scale of response and physical therapy (CPT group) through a random sequence generated in
space for observations and justifications for the answers when the website randomization.com, with an allocation rate of 1:1. The
pertinent. The methodological criteria for carrying out this study randomization and allocation process will be carried out by another
were based on a systematic review that proposed a standard set of researcher, who will not be involved in the study, using opaque and
quality indicators to improve the reporting of Delphi studies (Dia- sealed envelopes numbered sequentially that will only be opened from
mond et al., 2014). the moment the participant is irreversibly included in the study. A
Thirty‐five physical therapists were invited by the committee, flowchart of participants and randomization is exhibited in Figure 1.
however four of them did not completely fill the questionnaire, thus
they were considered sample losses and final sample comprised 31
participants. The majority of judges presented with master's degree 2.5 | Blinding
(71%), less than 10 years of graduation in physical therapy (77.4%),
and the main expertise fields were neurology (45%) and orthopedics Both participants and researchers A and B will be blinded regarding
(35%). With regards to PNF‐concept training, 71% had the basic level allocation of treatment, however, due to the nature of the inter-
formation, 26% presented with the advanced level 3, and the other vention, the researcher C will be aware of therapies. In order to
one (3%) had advanced level 4 certification; in addition, 71% of reduce the risk of study bias, researcher C will advise participants not
physical therapists had completed their current PNF training less to comment the treatment they receive either with the evaluators or
than five years ago. An 80% agreement on all items in the first round other participants. All statistical analyzes will be carried out by
of the Delphi study was achieved. researcher D, blinded to the allocation of groups.

2.1.2 | Clinical trial (pilot study)—Step 2 2.6 | Intervention

The following topics refer to the sequential steps for conducting the Two weekly sessions will be carried out over a 12‐month period in
clinical trial. both groups, after post‐surgery recovery period (15 days), by
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F I G U R E 1 Consolidated Standards of
Patients who suffered upper TBPI and
Reporting Trials flow diagram. CPT,
initiated treatment in specialized
conventional physical therapy; PNF, outpatient service.
proprioceptive neuromuscular facilitation
Assessed for eligibility (n)

Enrollment Excluded (n)

♦ Not meeting inclusion criteria (n)
♦ Declined to participate (n)
♦ Other reasons (n)

Pre-surgical assessment

Randomized (n=8)

Allocation
Allocated to PNF group (n=4) Allocated to CPT group (n=4)

Clinical assessment within 6, 9 and 12 Clinical assessment within 6, 9 and 12

months of intervention months of intervention

Follow-Up – 3 months

Lost to follow-up (n= ) Lost to follow-up (n= )

Discontinued intervention (n= ) Discontinued intervention (n= )

Analysis

Analysed (n=4) Analysed (n=4)

researcher C—who should present with the required expertise for therapist can use objects such as cups, comb and toothbrush to
conducting the interventions. Each session has approximately a simulate such ADLs.
40‐min duration (Figure 2). The exercises will be performed in 2 or 3 series with 5 to 8 ex-
ercise repetitions, with a 1‐minute interval between each set of the
same exercise and 2 min of rest between one type of exercise to
2.6.1 | PNF group another.

This group will undertake the proposed postoperative protocol

(Appendix S2). The protocol was developed based on task‐oriented 2.6.2 | CPT group
exercises, considering that patients who suffered upper brachial
plexus injury usually preserve manual functionality that enables This group will undergo conventional physical therapy using kinesi-
holding objects, thus functional activities such as drinking water, otherapy with: (1) passive and active‐assisted exercises to range of
shaving, and combing hair are possible. In this context, exercises 1 motion (ROM) for flexion, abduction and external rotation of the
to 9 focus on body structure and body function levels, in order to shoulder, and elbow flexion (15 repetitions each); (2) muscle
prepare the patient for the activity, while exercise 10 simulate strengthening with progressive resistance exercises, according to
movements at the activity level, working on structural level in lower patient's clinical progress, for general movements of the upper limb,
positions, starting from easier tasks for the patient, using the pos- mainly the above mentioned (2 sets of 15 repetitions); (3) motor re‐
itive approach, which is one of the PNF philosophy pillars. In ex- education training for muscle activation targeted by the nerve
ercise 11, the patient will continue to simulate movements on the transfer and dissociation of the original movement executed by the
activity level, but now with a task‐oriented focus and the physical donor nerve; and (4) stretching of shortened muscles (3 repetitions of
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F I G U R E 2 Schematic diagram of timeline

of enrollment, interventions and assessments.
Adapted from SPIRIT Group 2013. CPT,
conventional physical therapy; PNF,
proprioceptive neuromuscular facilitation.
†
The initial outcomes assessment will be
performed in the same week that the surgery
will be carried out (t0)

30 s) and relaxation of the overactive muscles, for example, trapezius first appointment with the neurosurgeon, time between the first
muscle. A 1‐minute interval will be undertaken between each series appointment and the surgery, and medication use.
and 2 min of rest between series with different types of exercise.

2.7.1 | Primary outcomes

2.6.3 | Criteria for discontinuity the study
The outcome functionality will be assessed using the Brachial
Throughout the intervention period, patients are instructed not to Assessment Tool (BrAT, ICC ¼ 0.97). The 31‐item questionnaire
seek other treatment for their injury, in order to ensure compara- comprises four response options reported by the patient: 0 (cannot
bility between groups. Patients who discontinue the study will be do now), 1 (very hard to do now), 2 (a little hard to do now), and 3
included in intention‐to‐treat analysis. (easy to do now; Hill et al., 2016; Hill, Williams, Olver, Ferris, &
Bialocerkowski, 2018).
Quality of life will be assessed using the WHOQOL‐Bref,
2.6.4 | Treatment adherence composed of 26 items divided into four domains: physical, psycho-
logical health, social relationships, and environment, with test‐retest
Some strategies will be applied to ensure patient compliance and the reliability coefficients above 0.7 (Fleck et al., 2000).
continuity of clinical evaluation: keeping both patient and their family
informed about the disease and treatment goals, maintaining regular
communication with patients and scheduling sessions considering 2.7.2 | Secondary outcomes
patient's availability, besides motivating the patient and encouraging
their active and collaborative participation throughout treatment. Articular ROM will be assessed with a universal goniometer for
each passive and active movement of the shoulder joint (flexion,
abduction, and external rotation) and elbow flexion. Muscle
2.7 | Outcomes assessment strength will be evaluated using the Medical Research Council
(MRC, 1976; Limthongthang, Bachoura, Songcharoen, & Osterman,
Table 1 describes which data will be collected and the outcome 2013). Tactile sensitivity will also be assessed using a cotton pad in
measures. In addition, the following demographic data will be the area corresponding to C5 and C6 dermatomes at two pre‐
collected: gender, age, height, weight, hometown, educational level, determined points (proximal and distal) for each root (NHS, 2016).
family income and employment status, injury mechanism, dominant Sensitivity will be classified as normal, altered (hyper or hypes-
arm and affected limb, associated traumas, previous access to phys- thesia) or absent. These tests will be carried out in both affected
ical therapy intervention, period of time between the injury and the and healthy upper limbs.
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TABLE 1 Summary of measures

Outcomes Outcome measurement instruments Timeline for data collection

Primary

Functionality Summed score of all 31‐items of BrAT (Hill et al., 2016) 0, 6, 9, and 12 months, and
after 3‐months follow‐up
Quality of life WHOQOL‐Bref overall and domain scores (Fleck et al., 2000)

Secondary

Active and passive ROM Universal Goniometer (Santos et al., 2012) 0, 6, 9, and 12 months, and
after 3‐months follow‐up
Muscle strength MRC Scale (0–5 score, where 0 ¼ no contraction, 5 ¼ normal strength against great
resistance; Medical Research Council, 1976)

Pain intensity NRS Scale (0–10 score, where 0 ¼ absence of pain, 10 ¼ the worst pain possible; Breivik
et al., 2008)

Neuropathic pain DN4 Questionnaire (0–10 score, where neuropathic pain ≥4; Santos et al., 2010)

Tactile sensitivity In C5 and C6 dermatomes (tactile sensitivity classified into present,

absent or altered; NHS, 2016)

Treatment satisfaction PGIC‐VP (1–7 score, where “1 ¼ no change or worse” and “7 ¼ a great deal better”; 12 months
Domingues & Cruz, 2012)

Treatment adherence Number of absences and dropouts recorded by researcher C 12 months

Adverse events Occurrence of adverse events recorded by researcher C 6, 9, and 12 months

Abbreviations: BrAT, Brachial Assessment Tool; DN4, Douleur Neuropathique 4 Questionnaire; NRS, Numerical Rating Scale; PGIC‐VP, Patient Global
Impression of Change Scale—Portuguese version; WHOQOL‐Bref, World Health Organization Quality of Life Group—abbreviated version.

Pain intensity will be evaluated through the Numerical Rating participants per group will be necessary for the pilot study sample
Scale (0–10; Breivik et al., 2008). Neuropathic pain will be and, based on its results, the final sample should be calculated (Hill
tracked through the Douleur Neuropathique 4 Questionnaire (DN4; et al., 2019).
ICC ¼ 0.84; Santos et al., 2010; Timmerman et al., 2017).
Adverse effects such as pain, fatigue or any other unintended
and unfavorable symptoms that may or may not be attributed to the 2.9 | Statistical methods
intervention will be recorded. If necessary, the protocol will be
interrupted and the patient will be referred to a medical appointment Data will be entered into a database created in Microsoft Office®
with the neurosurgeon. Excel 2013 as they are collected. The statistical analysis of the results
After the 12‐month intervention, the global assessment of the will be carried out using the SPSS software version 20.0, with a sig-
treatment effects will be investigated by researchers A and B, who nificance level of 95% (p 0.05).
will administer the Patient Global Impression of Change Scale (PGIC‐ Descriptive analysis of quantitative variables will be conducted
VP) which has a high and negative construct validity (r ¼ 0.822; using mean and confidence interval, and if any of these have irregular
Domingues & Cruz, 2012). (non‐normal) distribution, median and interquartile interval will be
considered. Regarding qualitative variables, the analyzes will be
performed by measures of absolute (n) and relative (percentage)
2.8 | Sample size frequency. The analyzes will follow the intention‐to‐treat principle.

The sample size will be based on the primary outcome—function-

ality, a self‐reported measure of the individual's perception 3 | DISCUSSION
regarding the use of the affected arm in day‐to‐day activities, given
its relevance in reflecting the success of treatment and rehabilita- Traumatic upper plexus injury causes severe limitations that impair
tion (Hill et al., 2015; Hill, Williams, & Bialocerkowski, 2011). This functional activities performed with the upper limb. The number of
measure will be evaluated by the summed score of BrAT question- surgical treatment options aiming at promoting functional recovery
naire. Sample size was calculated using G*Power Software 3.1.9.4, have grown in recent decades, however, the same pattern did not
considering ANOVA for two groups, five repeated measurements, occur in rehabilitation, which plays an essential role in the recovery
with significance level of 0.05, a power of 0.90 and an effect size of process of such patients. Thus, adequate physical therapy treatment
0.8 to obtaining a minimal detectable change (MDC90) of 10.3 points remains an underexplored field. Considering this, a crescent urgency
at the summed score of BrAT. Based on these criteria, at least four for a direction in physical therapeutic treatment emerged,
CHAGAS ET AL.
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culminating in the creation of a treatment protocol whose premises application of resistance and diagonal movement patterns that
are based on the current evidence in the literature regarding re- combine movements in three planes of motion, simulating most
covery after TBPI. activities of daily living (Adler et al., 2014). Thus, an increase in neural
The loss of sensory and motor functions resulting from dener- recruitment is observed in these PNF‐patterns, which involve a more
vation caused by peripheral nerve injuries affects not only the pe- complex sequence of movements when compared to movements in a
ripheral nervous system, but also the central (CNS) system, which single plane; besides an improvement in movement efficiency,
experiences sudden changes in cortical activity (Anastakis, Malessy, inducing changes in the sequence in which the muscles are activated
Chen, Davis, & Mikulis, 2008; Novak & von der Heyde, 2015; Simon, (Moreira et al., 2017; Shimura & Kasai, 2002).
Franz, Gupta, Alden, & Kliot, 2016; Sturma, Hruby, Farina, & Asz- In addition, agonistic techniques (rhythmic initiation and combi-
mann, 2019). The consequences on cortical representations are nation of isotonics) and antagonistic techniques (stabilizing reversal
evident and can be long‐lasting, such as the topographic reorgani- and dynamic reversal) from the PNF‐concept were selected in order
zation of the somatosensory cortex, a fundamental area that is to promote functional movement, and functional task‐oriented
responsible for coordinating movements in space (Anastakis et al., treatment enhances motor learning (Smedes et al., 2016). Motor
2008; Shumway‐cook & Woolacott, 2012; Simon et al., 2016). learning after a nerve transfer requires from patients the develop-
Function restoration after TBPI therefore depends on the re- ment of the ability to start a movement again in early stages of
covery of its representation in the brain, and this understanding has recovery after surgery. Thus, rhythmic initiation technique was the
become even clearer with the expansion of treatment with nerve first choice in several exercises, aiming at providing patient an initial
transfers (Kahn & Moore, 2016; Sturma et al., 2019). Although this explanation of the movement increasing their coordination and sense
surgical option has exhibited favorable results, control of the rein- of motion, stimulating motor planning and improving the rhythm of
nervated muscle without activation of the donor muscle can only be movements (Adler et al., 2014; Smedes et al., 2016).
achieved with the establishment of new motor patterns and cortical Besides recovering mobility, restoring stability is also essential
remapping, which requires time and a well‐structured rehabilitation for these patients, as all tasks require postural control, which implies
based on concepts such as neuroplasticity, relearning, and motor not only a component of orientation but also a component of sta-
control (Anastakis et al., 2008; Novak & von der Heyde, 2015; Simon bility, thus scapular positioning and mobility are essential for func-
et al., 2016; Sturma, Hruby, Prahm, Mayer, & Aszmann, 2018). tional stability (Kibler et al., 2013; Peteraitis; Smedes, 2020;
Magnetic resonance studies have demonstrated that cortical Shumway‐cook & Woolacott, 2012). So, the stabilizing reversal
representation initially increases as the patient practices motor skill, technique was used in scapular exercises of this protocol, and its
and decreases until it approaches normal levels, highlighting the benefits also extend to the improvement of strength and coordina-
importance of sensorimotor relearning (Anastakis et al., 2008; Novak tion of movements (Adler et al., 2014).
& von der Heyde, 2015). Thus, instead of using only an isolated Regarding exercises focused on strength, ROM and movement
movement itself, rehabilitation using functional tasks are essential, coordination, we highlight the application of the combination of
since both motor learning and functional recovery involves reorga- isotonics technique that encompasses concentric, eccentric, and
nization of perception and action systems related to the specific tasks isometric contractions of the same muscle group, involving various
and environments where they are developed (Shumway‐cook & postures and movement patterns. Dynamic reversal, a technique that
Woolacott, 2012). involves both agonist and antagonist muscles, was adopted to
So, the present study proposed the creation of a treatment improve scapular movement and to mobilize the shoulder (Adler
protocol based on the PNF‐concept that aims to recover functionality et al., 2014). These techniques, combined with rhythmic initiation,
through neurofacilitation approaches focused on motor control and were applied to improve ROM, anterior serratus strength and
motor learning, in remodeling the cortical map (Anastakis et al., 2008; dynamic stabilization of the scapula in a case report of a subacromial
Shumway‐cook & Woolacott, 2012). In addition, the PNF philosophy impingement syndrome that did not respond to conventional physical
also considers the individual as a whole, both mentally and physically, therapeutic treatment (Peteraitis & Smedes, 2020).
in which the weaker segments of the body are indirectly stimulated When it comes to indirect treatment, we emphasize irradiation
by moving stronger parts; uses the positive approach, by selecting procedure, that aim to disseminate the motor response in synergistic
therapeutic activities that the patient can potentially perform; be- muscle groups (Adler et al., 2014), by applying resistance to stronger
sides always looking forward to an active participation of the patient parts of the body, such as the patient's pelvis and healthy upper limb,
considering an adequate dosage, through the mobilization of reserves aiming at the muscular recruitment of the affected limb, especially in
(Adler et al., 2014; Smedes, Heidmann, Schäfer, Fischer, & Stępień, the rehabilitation initial stages. The irradiation principle was applied
2016). in a therapeutic program with a “kinect chain rehabilitation”
The protocol was developed specifically for this population, and approach to activate and strengthen the weak muscles of the
PNF exercises were chosen according to the deficits presented by shoulder and gain active ROM, highlighting sequential patterns of
patients, as well as to the respective surgical objectives, and aim at legs, trunk, and scapula (Mcmullen & Uhl, 2000).
recovering limb function with minimal compensation. The PNF Finally, we highlight the applicability of this protocol, as there are
combines different procedures in specific techniques, with gradual few studies describing physical therapy treatment modalities for
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patients with TBPI, especially considering the need for functional Diamond, I. R., Grant, R. C., Feldman, B. M., Pencharz, P. B., Ling, S. C.,
recovery at CNS level (Simon et al., 2016; Smania et al., 2012). The Moore, A. M., & Wales, P. W. (2014). Defining consensus : A sys-
tematic review recommends methodologic criteria for reporting of
treatment proposal is a low‐cost intervention, since no additional
Delphi studies. Journal of Clinical Epidemiology, 67(4), 401–409.
resources or equipment are required to apply the protocol; the https://doi.org/10.1016/j.jclinepi.2013.12.002
description of the exercises is arranged in a well‐organized and Domingues, L., & Cruz, E. (2012). Adaptação Cultural e Contributo para a
sequenced layout, being a clear and understandable protocol. In Validação da Escala Patient Global Impression of Change. Ifisionline,
2(1), 31–37. Retrieved from http://comum.rcaap.pt/handle/
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it is preferable that the physical therapist has practical experience motor function recovery and daily living activity outcomes after
with the PNF‐concept. In addition, another limitation of the study is brachial plexus surgery. Arquivos de Neuro‐Psiquiatria, 75(9), 631–
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