Proprioceptive Neuromuscular Facilitation Approach for Functioning Muscle Transfer: A Case Report

Background: This case report of a patient with a an avulsion brachial plexus injury demonstrates the effectiveness of proprioceptive neuromuscular facilitation (PNF) integrated into hand therapy following a pedicled latissimus dorsi (LD) musculocutaneous flap transfer for elbow and fingers extension. Methods: A 29-year-old right-hand dominant male suffered from high-energy crushing and avulsion injury at the workplace. He presented with pain (5/10), numbness over right upper limb, shoulder strength weakness (2/5), and brachial plexus injury including median, radial and ulnar nerve palsies. A pedicled LD musculocutaneous flap was performed to reconstruct the elbow and hand function simultaneously in the primary stage. The treatment program was divided into three phases: (1) immobilization phase (within 4 weeks after surgery), (2) facilitation phase (4 to 8 weeks after surgery), (3) strengthening phase (8 weeks after surgery). Application of PNF principles (manual contact, visual input and verbal instructions) and techniques (rhythmic initiation, repeated stretch, combination of isotonics and irradiation with D1 extension) were guided in the facilitation phase and early stage of strengthening phase to facilitate active control of elbow and finger extension. Results: The patient could actively move the elbow and finger extensors after 2-weeks of PNF therapy. Up to 4 months after reconstructive surgery, the patient's elbow and fingers extensor reached strength of M4 and M3. In the next months, several palliative surgeries (e.g. elbow joint arthroplasty, thumb and wrist extension reconstruction) were performed. The patient returned to his original job as a manufactory worker 2 years after the accident. Conclusion: PNF may be an effective and specific component of rehabilitation in the recovery of function in the early phase post injury for a patient with a major upper arm traction avulsion amputation reconstructed by a pedicled latissimus dorsi muscle.