外傷性的臂神經叢損傷多起因於高能量的衝擊傷害，會造成上肢功能嚴重缺失。然而，目前對於外傷性的臂神經損傷術後功能表現尚缺乏量化的評估結果。因此，本研究有兩個主要目的，第一個部份是要探討上臂型損傷(第五到第六或第五到第七頸神經損傷)患者接受雙神經接合手術後上肢肌肉量化肌力表現，以及經過6-8個月握力訓練後的肌力結果。第二部份是探討上臂型損傷及全損傷患者(第五頸神經到第一胸椎神經損傷)在執行基本關節動作與側邊繞環動作時的運動學表現。在肌力量化部份共收取了18位上臂型損傷患者進行測試，主要是利用手持式肌力計針對上肢肌力進行量測，並評估握力訓練後肘關節屈曲力量的改變情形。在運動學評估部分共收取了12位上臂型損傷患者與4位全損傷患者進行測試，利用動作分析系統收取執行關節動作及繞環動作時的表現。以肩關節中心為座標原點描述肢體在空間中的位置，並計算動作角度、速度、側向環繞所圍繞出的面積進行比較。
結果發現第五六頸神經損傷和第五六七頸神經損傷患者在量化肌力上有顯著差異，並且經過訓練後肘關節屈曲肌力與握力的改變量呈現高度正相關。在運動學結果發現患側肢體的動作角度較小且速度較健側慢，全損傷患者的角度和速度也較上臂型損傷患者的結果較差。肘關節屈曲時，患側會合併肩關節內轉，呈現朝向腹部或胸部的情況。側向繞圈投射到矢狀面的面積並分成前後上下四區域結果發現，患側肢體在後方相對前方與上方相對下方比例較健側小，且全損傷患者在這兩個比例結果也較上臂型損傷較小。
因此，由本研究可知量化肌力可協助分辨不同損傷程度患者的術後表現，對於復健訓練後的結果也可有效偵測。本研究結果提供了量化的數據以及有效復健計畫的證據。此外，臂神經損傷患者在肢體上舉的過程中除了動作角度和速度之外，上舉的平面也會受到影響，進而影響功能性動作表現。而側向繞環的面積計算方式，可作為臨床評估一個簡單但量化的方法，進而評估術後恢復表現。

Background & Purpose: Adult brachial plexus injuries (BPI) are devastating and mostly caused by the high energy trauma, but few studies investigated the quantitative outcomes of traumatic BPI patients. Therefore, the specific aims of the current study were (1) to evaluate the quantitative strength and training effects in upper arm type BPI patients after double nerve transfer, and (2) to evaluate the kinematics results of joint motion and circumduction task in upper and total arm type BPI patients.
Methods: There were 18 upper arm type (C5-C6 or C5-C7) BPI patients after double nerve transfer recruited for the first purpose. After the first evaluation, patients had a grip power training for 6-8 months. The quantitative strength was measured by the handheld dynamometer (HHD). For the second purpose, 12 upper arm and 4 total arm type BPI patients after reconstruction were recruited. The kinematics values were collected by the PTI motion capture system. The orientation of limb segments in the space were used to describe the movement patterns and the origin of coordinated system was set at shoulder joint center. The motion range, movement velocity, and the area drawn by the circumduction task were calculated for further comparison.
Results: The quantitative strength values between the C5-C6 and C5-C7 BPI patients were significantly different, even though both groups had similar BMRC scores. After the grip power training, patients showed the positive correlation between the changes of elbow flexion strength and grip power. In the results of kinematics, significant differences of yaw angle between both arms were found at abduction 75°and abduction 90°. The average yaw angles at the maximum elbow flexion represented that patients combined internal rotation with elbow flexion while moving the involved arm. Patients in total type BPI had less motion range and velocity than those in upper type BPI, and the yaw angles during shoulder flexion and scapular flexion were different between the two groups. The area drawn by the circumduction task was projected to the sagittal plane and divided into four sections. The ratios of posterior/anterior and superior/inferior for the involved arm were less than the non-involved arm. The ratios of posterior/anterior and superior/inferior area in total arm type BPI were significantly lower than that of the upper type BPI.
Discussion & Conclusion: The different outcomes between C5-C6 and C5-C7 BPI patients appeared in muscles responding to hand grip, wrist extension and sagittal movements in shoulder and elbow joints. In the kinematics, the differences between total and upper type BPI were found in the range and mean velocity of shoulder elevation, while there were no significant differences in the elbow flexion. The kinematics of the scapula is an important factor to affect the movements in BPI patients.

1.Agre JC, Magness JL, Hull SZ, Wright KC, Baxter TL, Patterson R, Stradel L. Strength testing with a portable dynamometer: reliability for upper and lower extremities. Arch Phys Med Rehabil 68(7):454-458, 1987.
2.Amasay T, Karduna AR. Scapular kinematics in constrained and functional upper extremity movements. J Orthop Sports Phys Ther 39(8):618-627, 2009.
3.Amrami KK, Port JD. Imaging the brachial plexus. Hand clinics 21(1):25-37, 2005.
4.An KN, Browne AO, Korinek S, Tanaka S, Morrey BF. Three-dimensional kinematics of glenohumeral elevation. J Orthop Res 9(1):143-149, 1991.
5.Andrews AW, Thomas MW, Bohannon RW. Normative values for isometric muscle force measurements obtained with hand-held dynamometers. Phys Ther 76(3):248-259, 1996.
6.Bertelli JA, Ghizoni MF. Clinical findings in C5-C6 and C5-C7 root palsies with brachial plexus traction lesions. J Hand Surg Eur 38(3):237-241, 2013.
7.Bertelli JA, Ghizoni MF. Nerve Root Grafting and Distal Nerve Transfers for C5-C6 Brachial Plexus Injuries J Hand Surg Am 35(5):769–775, 2010.
8.Bertelli JA, Ghizoni MF. Transfer of the accessory nerve to the suprascapular nerve in brachial plexus reconstruction. J Hand Surg Am 32(7):989-998, 2007.
9.Bhardwaj P, Bhardwaj N. Motor grading of elbow flexion - is Medical Research Council grading good enough? J Brachial Plex Peripher Nerve Inj 4:3, 2009.
10.Bialocerkowski AE, Galea M. Comparison of visual and objective quantification of elbow and shoulder movement in children with obstetric brachial plexus palsy. J Brachial Plex Peripher Nerve Inj 1:5, 2006.
11.Bishop AT. Functioning free-muscle transfer for brachial plexus injury. Hand clinics 21(1):91-102, 2005.
12.Blana D, Hincapie JG, Chadwick EK, Kirsch RF. A musculoskeletal model of the upper extremity for use in the development of neuroprosthetic systems. J Biomech. 41(8):1714-1721, 2008.
13.Boettcher CE, Cathers I, Ginn KA. The role of shoulder muscles is task specific. J Sci Med Sport 13(6):651-656, 2010.
14.Bohannon RW. Reference values for extremity muscle strength obtained by hand-held dynamometry from adults aged 20 to 79 years. Arch Phys Med Rehabil 78(1):26-32, 1997.
15.Bohannon RW. Test-retest reliability of hand-held dynamometry during a single session of strength assessment. Phys Ther 66(2):206-209, 1986.
16.Brochard S, Alter K, Damiano D. Shoulder strength profiles in children with and without brachial plexus palsy. Muscle Nerve 50(1):60-66, 2014.
17.Brophy RH, Wolfe SW. Planning brachial plexus surgery: treatment options and priorities. Hand clinics 21(1):47-54, 2005.
18.Byl NN, Richards S, Asturias J. Intrarater and interrater reliability of strength measurements of the biceps and deltoid using a hand held dynamometer. J Orthop Sports Phys Ther 9(12):395-398, 1988.
19.Carlsen BT, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Comparison of single versus double nerve transfers for elbow flexion after brachial plexus injury. Plast Reconstr Surg 127(1):269-276, 2011.
20.Chalidapong P, Sananpanich K, Klaphajone J. Electromyographic comparison of various exercises to improve elbow flexion following intercostal nerve transfer. J Bone Joint Surg Br 88(5):620-622, 2006.
21.Chen W, Xiong C, Huang X, Sun R, Xiong Y. Kinematic analysis and dexterity evaluation of upper extremity in activities of daily living. Gait posture 32(4):475-481, 2010.
22.Cho AB, Paulos RG, de Resende MR, Kiyohara LY, Sorrenti L, Wei TH, Bolliger Neto R, Mattar R Júnior. Median nerve fascicle transfer versus ULNAR nerve fascicle transfer to the biceps motor branch in C5-C6 and C5-C7 brachial plexus injuries: Nonrandomized prospective study of 23 consecutive patients. Microsurgery doi: 10.1002/micr.22263 [Epub ahead of print], 2014.
23.Choi PD, Novak CB, Mackinnon SE, Kline DG. Quality of life and functional outcome following brachial plexus injury. J Hand Surg Am 22(4):605-612, 1997.
24.Chuang DC, Lee GW, Hashem F, Wei FC. Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 96(1):122-128, 1995.
25.Chuang DC, Yeh MC, Wei FC. Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients. J Hand Surg Am 17(5):822–828, 1992.
26.Chuang DC. Nerve transfer with functioning free muscle transplantation. Hand Clin. 24(4):377-388, 2008.
27.Chung KC, Yang LJS, McGillicuddy JE. Practical Management of Pediatric and Adult Brachial Plexus Palsies, Philadelphia: Elsevier Health, 198-211, 2011.
28.de los Reyes-Guzman A, Gil-Agudo A, Penasco-Martin B, Solis-Mozos M, del Ama-Espinosa A, Perez-Rizo E. Kinematic analysis of the daily activity of drinking from a glass in a population with cervical spinal cord injury. J Neuroeng Rehabil. 7:41, 2010
29.Doheny EP, Lowery MM, Fitzpatrick DP, O'Malley MJ. Effect of elbow joint angle on force-EMG relationships in human elbow flexor and extensor muscles. J Electromyogr Kinesiol 18(5):760-770, 2008.
30.Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand clinics 15(4):757-767, 1999.
31.Doi K, Sakai K, Ihara K, Abe Y, Kawai S, Kurafuji Y. Reinnervated free muscle transplantation for extremity reconstruction. Plast Reconstr Surg 91(5):872-883, 1993.
32.Dubuisson AS, Kline DG. Brachial plexus injury: a survey of 100 consecutive cases from a single service. Neurosurgery 51(3):673-682, 2002.
33.Duff SV, Dayanidhi S, Kozin SH. Asymmetrical shoulder kinematics in children with brachial plexus birth palsy. Clin Biomech 22(6):630-638, 2007.
34.Edouard P, Calmels P, Degache F. The effect of gravitational correction on shoulder internal and external rotation strength. Isokinet Exerc Sci 17:35-39, 2009.
35.Edouard P, Samozino P, Julia M, et al. Reliability of isokinetic assessment of shoulder-rotator strength: a systematic review of the effect of position. J Sport Rehabil 20(3):367-383, 2011.
36.Elhassan B, Bishop A, Shin A, Spinner R. Shoulder tendon transfer options for adult patients with brachial plexus injury. J Hand Surg Am 35(7):1211-1219, 2010.
37.Estrella EP. Functional outcome of nerve transfers for upper-type brachial plexus injuries. J Plast Reconstr Aesthet Surg 64(8):1007-1013, 2011.
38.Fitoussi F, Maurel N, Diop A, Laassel EM, Ilharreborde B, Presedo A, Mazda K, Pennecot GF. Upper extremity kinematics analysis in obstetrical brachial plexus palsy, Orthop Traumatol Surg Res 95(5):336-342, 2009.
39.Flores LP. Brachial plexus surgery: the role of the surgical technique for improvement of the functional outcome. Arq Neuropsiquiatr 69(4):660-665, 2011.
40.Giphart JE, Brunkhorst JP, Horn NH, Shelburne KB, Torry MR, Millett PJ. Effect of plane of arm elevation on glenohumeral kinematics: a normative biplane fluoroscopy study. J Bone Joint Surg Am 95(3):238-245, 2013.
41.Gregory J, Cowey A, Jones M, Pickard S, Ford D. The anatomy, investigations and management of adult brachial plexus injuries. Orthopaedics and Trauma 23(6):420-432, 2009.
42.Happee R. Goal-directed arm movements: I. Analysis of EMG records in shoulder and elbow muscles. J Electromyogr Kinesiol 2(3):165-178, 1992.
43.Hill BE, Williams G, Bialocerkowski AE. Clinimetric evaluation of questionnaires used to assess activity after traumatic brachial plexus injury in adults: a systematic review. Arch Phys Med Rehabil 92(12):2082-2089, 2011.
44.James MA. Use of the Medical Research Council muscle strength grading system in the upper extremity. J Hand Surg Am 32(2):154-156, 2007.
45.Kelly BM, Leonard JA. Rehabilitation concepts for adult brachial plexus injuries. In Chung KC, Yang LJS, McGillicuddy JE (Eds), Elsevier Health Science, pp301-317, 2011.
46.Kilmer DD, McCrory MA, Wright NC, Rosko RA, Kim HR, Aitkens SG. Hand-held dynamometry reliability in persons with neuropathic weakness. Arch Phys Med Rehabil 78(12):1364-1368, 1997.
47.Kim DH, Cho YJ, Tiel RL, Kline DG. Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center. J Neurosurg 98(5):1005-1016, 2003.
48.Kinlaw D. Pre-/postoperative therapy for adult plexus injury. Hand clinics 21(1):103-108, 2005.
49.Kirjavainen MO, Nietosvaara Y, Rautakorpi SM, Remes VM, Pöyhiä TH, Helenius IJ, Peltonen JI. Range of motion and strength after surgery for brachial plexus birth palsy: 107 patients followed for 12-year. Acta Orthop 82(1):69-75, 2011.
50.Kostas-Agnantis I, Korompilias A, Vekris M, Lykissas M, Gkiatas I, Mitsionis G, Beris A. Shoulder abduction and external rotation restoration with nerve transfer. Injury 44(3):299-304, 2013.
51.Kretschmer T, Ihle S, Antoniadis G, Seidel JA, Heinen C, Börm W, Richter HP, König R. Patient satisfaction and disability after brachial plexus surgery. Neurosurgery 65 (4 Suppl):A189-196, 2009.
52.Krishnan KG, Martin KD, Schackert G. Traumatic lesions of the brachial plexus: an analysis of outcomes in primary brachial plexus reconstruction and secondary functional arm reanimation. Neurosurgery 62(4):873-885, 2008.
53.Langer JS1, Sueoka SS, Wang AA. The importance of shoulder external rotation in activities of daily living: improving outcomes in traumatic brachial plexus palsy. J Hand Surg Am 37(7):1430-1436, 2012.
54.Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Malungpaishrope K. Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg Am 31(2):183-189, 2006.
55.Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Ketmalasiri W. Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg Am 23(4):711-716, 1998.
56.Liverneaux PA, Diaz LC, Beaulieu JY, Durand S, Oberlin C. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstr Surg 117(3):915-919, 2006.
57.Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther 39(2):90-104, 2009.
58.Magermans DJ, Chadwick EK, Veeger HE, van der Helm FC. Requirements for upper extremity motions during activities of daily living. Clin Biomech 20(6):591-599, 2005
59.Matsuki K, Matsuki KO, Mu S, Yamaguchi S, Ochiai N, Sasho T, Sugaya H, Toyone T, Wada Y, Takahashi K, Banks SA. In vivo 3-dimensional analysis of scapular kinematics: comparison of dominant and nondominant shoulders. J Shoulder Elbow Surg 20(4):659-665, 2011.
60.McClure PW, Michener LA, Sennett BJ, Karduna AR. Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg 10(3):269-277, 2001.
61.Merlini L, Mazzone ES, Solari A, Morandi L. Reliability of hand-held dynamometry in spinal muscular atrophy. Muscle Nerve 26(1):64-70, 2002.
62.Midha R. Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery 40(6):1182-1189, 1997.
63.Millesi H. Update on the treatment of adult brachial plexus injuries. In:Brachial plexus injuries. ed. by Alain Gilbert, Martin Dunitz, London, pp 77-90, 2001.
64.Moran SL, Steinmann SP, Shin AY. Adult brachial plexus injuries: mechanism, patterns of injury, and physical diagnosis. Hand clinics 21(1):13-24, 2005.
65.Mosqueda T, James MA, Petuskey K, Bagley A, Abdala E, Rab G. Kinematic assessment of the upper extremity in brachial plexus birth palsy. J Pediatr Orthop 24(6):695-699, 2004.
66.Murray IA, Johnson GR. A study of the external forces and moments at the shoulder and elbow while performing every day tasks. Clin Biomech 19(6):586-94, 2004.
67.Narakas AO and Hentz VR. Neurotization in Brachial plexus injuries: Indication and results. Clin Orthop Relat Res 237:43-56, 1988.
68.Nelson SG, Duncan PW. Correction of isokinetic and isometric torque recordings for the effects of gravity. A clinical report. Phys Ther 63(5):674-676, 1983.
69.Novak CB. Rehabilitation following motor nerve transfers. Hand Clin 24(4):417-423, 2008.
70.O’Brien MD. Aids to the Examination of the Peripheral Nervous System. 4th ed. London: W. B. Saunders; pp 62, 2000.
71.Oberlin C, Beal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am 19(2):232-237, 1994.
72.Ogston JB, Ludewig PM. Differences in 3-dimensional shoulder kinematics between persons with multidirectional instability and asymptomatic controls. Am J Sports Med. 35(8):1361-1370, 2007.
73.Porcellini G, Caranzano F, Campi F, Paladini P. Instability and rotator cuff tear. Med Sport Sci 57:41-52, 2012.
74.Prinold JA, Villette CC, Bull AM. The influence of extreme speeds on scapula kinematics and the importance of controlling the plane of elevation. Clin Biomech 28(9-10):973-980, 2013.
75.R¨uhmann O, Schmolke S, Bohnsack M, Carls J, Wirth CJ. Trapezius transfer in brachial plexus palsy. Correlation of the outcome with muscle power and operative technique. J Bone Joint Surg Br 87(2):184-190, 2005.
76.Rankine JJ. Adult traumatic brachial plexus injury. Clin Radiol 59(9):767-774, 2004.
77.Reed D, Cathers I, Halaki M, Ginn K. Does supraspinatus initiate shoulder abduction? J Electromyogr Kinesiol 23(2):425-429, 2013.
78.Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther 34(7):385-394, 2004.
79.Schwartz C, Croisier JL, Rigaux E, Denoël V, Brüls O, Forthomme B. Dominance effect on scapula 3-dimensional posture and kinematics in healthy male and female populations. J Shoulder Elbow Surg 23(6):873-881, 2014.
80.Schwartz S, Cohen ME, Herbison GJ, Shah A. Relationship between two measures of upper extremity strength: manual muscle test compared to hand-held myometry. Arch Phys Med Rehabil 73(11):1063-1068, 1992.
81.Shahgholi L, Bengtson KA, Bishop AT, Shin AY, Spinner RJ, Basford JR, Kaufman KR. A comparison of manual and quantitative elbow strength testing. Am J Phys Med Rehabil 91(10):856-862, 2012.
82.Shih AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg 13(6):382-396, 2005.
83.Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86(2):420-428, 1979.
84.Socolovsky M, Di Masi G, Bonilla G, Malessy M. Spinal to accessory nerve transfer in traumatic brachial plexus palsy: is body mass index a predictor of outcome? Acta Neurochir 156(1):159-163, 2014.
85.Socolovsky M, Paez MD. A literature review of intercostal to musculocutaneous nerve transfers in brachial plexus injury patients: Does body mass index influence results in Eastern versus Western countries? Surgical neurology international. 4:152, 2013.
86.Soechting JF, Lacquaniti F, Terzuolo CA. Coordination of arm movements in three-dimensional space. Sensorimotor mapping during drawing movement. Neuroscience 17(2):295-311, 1986.
87.Solonen KA, Vastamaki M, Strom B. Surgery of the brachial plexus. Acta Orthop Scand 55(4):436-440, 1984.
88.Songcharoen P, Mahaisavariya B, Chotigavanich C. Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus. J Hand Surg Am 21(3):387-390, 1996.
89.Songcharoen P, Wongtrakul S, Mahaisavariya B,Spinner RJ. Hemicontralateral C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury. J Hand Surg Am 26(6):1058–1064, 2001.
90.Stokdijk M, Eilers PH, Nagels J, Rozing PM. External rotation in the glenohumeral joint during elevation of the arm. Clin Biomech 18(4):296-302, 2003.
91.Sudarshan D, Margo O, Scott K, Susan D, Andrew K. Scapular kinematics during humeral elevation in adults and children. Clin Biomech 20(6):600-606, 2005.
92.Sungpet A, Suphachatwong C, Kawinwonggowit V, Patradul A. Transfer of a single fascicle from the ulnar nerve to the biceps muscle after avulsions of upper roots of the brachial plexus. J Hand Surg Br 25(4):325-328, 2000.
93.Teboul F, Kakkar R, Ameur N, Beaulieu J-Y, Oberlin C. Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy. J Bone Joint Surg Am 86(7):1485-1490, 2004.
94.Terzis JK, Barmpitsioti A. Secondary shoulder reconstruction in patients with brachial plexus injuries. J Plast Reconstr Aesthet Surg 64(7):843-853, 2011.
95.Terzis JK, Kostas I, Soucacos PN. Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients. Microsurgery 26(4):316-324, 2006.
96.Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 106(5):1097-1122, 2000.
97.Tu YK, Tsai YJ, Chang CH, Su FC, Hsiao CK, Tan JS. Surgical treatment for total root avulsion type brachial plexus injuries by neurotization: a prospective comparison study between total and hemicontralateral C7 nerve root transfer. Microsurgery. 34(2):91-101, 2014.
98.van Andel CJ, Wolterbeek N, Doorenbosch CA, Veeger DH, Harlaar J. Complete 3D kinematics of upper extremity functional tasks. Gait posture 27(1):120-127, 2008.
99.van der Ploeg RJ, Fidler V, Oosterhuis HJ. Hand-held myometry: reference values. J Neurol Neurosurg Psychiatry 54(3):244-247, 1991.
100.Venkatramani H, Bhardwaj P, Faruquee SR, Sabapathy SR. Functional outcome of nerve transfer for restoration of shoulder and elbow function in upper brachial plexus injury. J Brachial Plex Peripher Nerve Inj 3:15, 2008.
101.Waikakul S, Orapin A, Vanadurongwan V. Clinical results of contralateral C7 root neurotization to the median nerve in brachial plexus injuries with total root avulsions. J Hand Surg Br 24(5):556–560, 1999.
102.Waikakul S, Wongtragul S, Vanadurongwan V. Restoration of elbow flexion in brachial plexus avulsion injury: comparing spinal accessory nerve transfer with intercostal nerve transfer. J Hand Surg Am 24(3):571-577, 1999.
103.Walter SD, Eliasziw M, Donner A. Sample size and optimal designs for reliability studies. Stat Med 17(1):101-110, 1998.
104.Wang JS. Petuskey K, Bagley AM, James MA, Rab G, MD. The Contralateral Unimpaired Arm as a Control for Upper Extremity Kinematic Analysis in Children With Brachial Plexus Birth Palsy. J Pediatr Orthop 27(6):709-711, 2007.
105.Wickham J, Pizzari T, Stansfeld K, Burnside A, Watson L. Quantifying 'normal' shoulder muscle activity during abduction. J Electromyogr Kinesiol 20(2):212-222, 2010
106.Wright JG, Feinstein AR. Improving the reliability of orthopaedic measurements. J Bone Joint Surg Br 74(2):287-291, 1992.
107.Yang LJ, Chang KW, Chung KC. A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury. Neurosurgery 71(2):417-429, 2012.
108.Zyaei A, Saied A. Functional outcome of ulnar nerve fascicle transfer for restoration of elbow flexion in upper brachial plexus injury. Eur J Orthop Surg Traumatol 20(4):293-297, 2010.