The lived experience of motor recovery of elbow flexion following Oberlin nerve transfer: A qualitative analysis

Abstract

Introduction

Nerve injuries to the upper trunk, lateral cord and musculocutaneous nerve can result in the loss of active biceps contraction. Oberlin nerve transfer surgery is often performed to re-animate the biceps muscle. Outcome studies following this surgery almost exclusively focus on muscle strength. To date, no research has focused on the lived experience of motor recovery following Oberlin nerve transfer.

Methods

A focus group discussion (n = 6) allowed participants to give their accounts of successful restoration of active elbow flexion. Qualitative analysis of the transcript identified ‘significant statements’ which were used to generate themes and capture participants’ lived experience.

Results

Four main themes were identified as being important components of the lived experience: ‘pain’, ‘patience and positive thought’, ‘functionality and daily lifestyle’ and ‘the biceps muscle’ itself. Each theme was identified to have several subthemes and constituent parts.

Conclusions

The lived experience of motor recovery is complex, multifaceted and individual to the patient. This study has identified areas where clinicians may be able to better tailor their care to the individual and suggested adjuncts to therapy have been included.

Keywords

Brachial plexus injury Oberlin nerve transfer motor recovery lived experience

Introduction

The brachial plexus is a network of nerves which arise from the nerve roots of C5 to T1 and contributes to the movement and sensibility within the upper limb. Brachial plexus injuries (BPIs) are complex and can have a profound effect on patients’ lives.^1–3 Nerve injuries to the upper trunk, lateral cord and musculocutaneous nerve can all result in the loss of active elbow flexion. Surgeries such as nerve repair, grafting or nerve transfer are often required to allow axonal re-growth into the de-innervated muscles. Nerve transfer techniques are akin to tendon transfers, whereby they identify a sacrifice-able “donor” structure for transfer in order to provide a more useful function.⁴ One advantage of a nerve transfer is the proximity of the viable donor nerve to the target muscle, allowing for earlier re-innervation.⁴ Oberlin et al.⁵ developed a nerve transfer procedure to re-innervate elbow flexion using selected fascicles from the ulnar nerve as a donor. This surgery involves transferring healthy “donor” fascicles from a functioning ulnar (and/or median) nerve to the non-functioning musculocutaneous nerve. More recently, surgical practice has evolved to use both ulnar and median nerve fascicles as donors to the biceps and brachialis muscles⁶ (see Figure 1). Fascicles that innervate the wrist flexors are usually used.⁷ Following a period of time, the axons from the donor nerve grow into the biceps muscle and allow contraction. Initially the biceps is activated by the activation of the old function from the donor (i.e. wrist flexion). After a period of rehabilitation, control of this movement is relearnt and becomes more natural.⁸

Figure 1.

Oberlin nerve transfer surgery involves transferring fascicles from a functioning ulnar (and/or median) nerve to the musculocutaneous nerve. If both Biceps and Brachialis branches have been transferred to it is sometimes referred to as a “double” Oberlin procedure (depicted within the illustration). This illustration was kindly drawn and provided by the senior author Mr Tom Quick, Consultant Peripheral Nerve Surgeon.

Dy et al.⁹ conducted a systematic review of outcome reporting for BPI. Quantitative measures of outcome were almost exclusively used to determine the efficacy and effectiveness of interventions. Furthermore, the majority of the literature specific to Oberlin nerve transfer focuses on muscle strength, reporting outcome using the Medical Research Council (MRC) grade IV in 60–100% of cases.^5,6,10,11 Successful transfer is therefore associated with an isolated return of biceps muscle strength. However, this empirical approach does not consider the wider impact of loss of active elbow flexion. Activities that involve hand to mouth for feeding and hand to midline to allow for independent dressing are commonly reported functional goals within this patient group.³

Patient perceptions and satisfaction are now considered with equal status to a clinician’s “objective” outcome. In response to this, many institutions endorse the use of patient reported outcome measures (PROs) as a means to improve clinical care.¹² Several studies have adopted the use of PROs to evaluate the quality of life (QoL) following BPI.^2,13,14 Despite the devastating nature of their injuries, patients generally report satisfactory to good QoL and have returned to some form of employment within the first few years following injury.^13. However, a study by Davidson² demonstrated significantly higher levels of disability rated in a BPI group compared to patients with unilateral upper limb amputations. The authors postulated that the definitive nature of an amputation versus the somewhat unknown prognosis following BPI could incite differences in time scales of acceptance. These studies demonstrate that PROs can offer some information with regard to how a patient is living with an injury. However, they are restricted in the information they can provide, as they use a defined set of questions which may not offer an understanding of the impact of a nerve injury.¹⁵

There have been two qualitative studies focussing on the patient experience of BPI. Wellington¹ used semi-structured interviews to explore QoL issues. The study centred around four subjective experiences that the participants had identified as being significant following their BPI: employment, pain, body image and sexuality/emotions. Further to this, McDonald and Pettigrew³ interviewed patients and used a phenomenological approach to examine the core concepts of the lived experiences of people with BPI. Once more, QoL, motor function, activities of daily living (ADL) and societal roles were noted to be key concepts.

To date, no research has focused solely on the lived experience of motor recovery following Oberlin nerve transfer. The purpose of this study was to give an account through the voice of patients who have undergone surgery with successful restoration of ability to flex the elbow against resistance.

Methods

The aim of the research was to explore the opinions of those who have a lived experience of a nerve injury with the successful return of elbow flexion strength to MRC grade IV (ability to flex the elbow against gravity and resistance) following an Oberlin nerve transfer. Qualitative methods were chosen to explore, in detail, the lived experience of motor recovery. This study was designed and reported in accordance with the COREQ guidelines (COnsolidated criteria for REporting Qualitative research).¹⁶

Participant recruitment and selection

Clinical lists of patients under the care of the host institution (a tertiary referral centre in Middlesex, UK) were assessed. Medical records were reviewed to assess for eligibility against the inclusion criteria. A convenience sample of participants who had a diagnosis of BPI and had undergone Oberlin nerve transfer were selected. In accordance with the quantitative literature, a “successful surgery” was defined as a patient who had achieved MRC grade IV.

Participants had to be over 18 years of age speak fluent English, able to participate verbally with the process, at least 24 months but up to 5 years post-surgery (to allow a suitable time to have elapsed for the experience of motor recovery to be present and the key features of their lived experience to still be memorable). Exclusion criteria were: less than 24 months post nerve transfer, more than 5 years post-surgery, impaired cognitive functioning, difficulties in verbal communication or a birth-related BPI.

Patients were approached and invited via letter. Informed written consent was gained from each participant. The study was approved by the South East Coast Surrey Research Ethics Committee (REC ref: 16/LO/0623; IRAS ID: 202847).

Data collection and analysis

Data were collected via a focus group discussion led by one researcher (KJ) with a moderator (HB). The participants had no prior relationship with the two researchers but were aware that the researchers had a special interest to improve patient care in this subject area.

A focus group discussion was utilised in place of semi-structured interviews (which are more common for this type of research) because interaction between participants was being sought to allow them to discuss key points and directly compare and contrast their thoughts and feelings with each other.¹⁷ Discussions were held during the working hours in the institute’s premises in central London.

The discussion guide (Figure 2) was developed by the team and was informed by the results of a previous departmental questionnaire study regarding the patient’s perceived ability to resist elbow flexion and lift objects following Oberlin nerve transfer. The focus group started with a video of active elbow flexion. This aimed to frame the discussion towards the outcomes that they had achieved following restoration of elbow flexion. The focus group was audio recorded and transcribed verbatim; KJ and HB annotated the transcription with field notes. Two researchers (HB and TQ) analysed the data using a qualitative approach. Significant statements were initially identified within the transcript. The meaning of each significant statement was then discussed by the researchers prior to coding. This method of data analysis was based on a method described by Colaizzi,¹⁸ using a seven step approach, to maintain the voice of the participants throughout. A thematic analysis was then undertaken to group these significant statements (and their meanings) according to the interpreted nature of the statement. Repeat interviews and participant validation were not conducted due to resource limitations. However, the transcription, coding of statements and journal manuscript were sent to the participants to allow opportunity for feedback and corrections to be made. Four participants replied and stated that they believed the analysis to be in accordance with their experiences and was true to their memory of the day. An independent fourth researcher (AG) who was unfamiliar with the subject area but experienced in qualitative methods was asked to review the process, codes and themes in order to assist with transferability and accuracy. Data saturation was not sought in this study, in part due to the limited resources available (the team was able to run only one focus group) and because the purpose of the study was to glean a general overview of patient experience following nerve transfer. It is anticipated that an overview, such as the one offered in this study, would stimulate further research where the achievement of data saturation would be more appropriate.

Figure 2.

Focus group discussion guide.

Results

The screening of clinical lists by HB and TQ yielded a cohort of 68 eligible patients. All were sent a written invitation to participate. Ten responded and wished to participate, seven were able to attend on the given day and one did not attend on the day. A final group of six participants consented and attended (see Table 1).

Table 1.

Demographics of participants.

Identifier	Age	Gender	Injury	Time since Oberlin transfer	Injured side
P1	45–50	M	C5 avulsionC6 avulsion	42 months	L (ND)
P2	45–50	F	MCN iatrogenic	29 months	R (D)
P3	45–50	M	C5 avulsionC6 neuroma	45 months	L (ND)
P4	25–30	M	C5 avulsionC6 rupture	29 months	L (ND)
P5	50–55	M	MCN rupture	56 months	L (ND)
P6	35–40	M	C5 avulsionC6 avulsion	28 months	R (D)

Four primary themes were identified and named using extracts from the discussion as ‘significant statements’ made by the participants. Figure 3 demonstrates the themes and subthemes that were generated. No hierarchy was determined during the analysis and equal importance assigned to each theme. This was endorsed during the participant feedback.

Figure 3.

Themes and subthemes.

Pain

All of the participants reported the experience of pain during their period of motor recovery.

The severity, nature and intensity of the descriptors of pain varied from an aching sensation to accounts of much higher severity:

Oh my god the pain! – it shoots down this side, these two fingers and at times it’s like I’ve got a really tight elastic band. P2

I do get pain, but not that sort of pain. What I do suffer with is just a bit of arm ache. P5

The characterisation of pain also varied from strange feelings (paraesthesia) through to unpleasant feelings (dysesthesia). The trend through all participants was for the pain to slowly change as time progressed. Descriptions changed from impassioned words suggestive of difficulty with coping with pain through to more aching type sensations as they recovered:

It’s changed over time, I mean at the very start some of the pains were horrific but you become used to it a little bit, like anything. You understand your body as well. You cope with it. P3

One participant described the sensation of “fixing pains” in his biceps when he initially felt and saw signs of re-innervation:

I didn’t know if they [the pains] were fixing pains or if the pain was just there. P6

Patients reported that external influences such as work, weather or an escalation over time often worsened their pain and could affect their daily routine:

I don’t think I thought or had any concept of what the nerve pain was going to be like… by Friday, just lifting the arm on Friday is just exhausting, doing your hair and all kinds of regular tasks. P2

Participant 3 suggested that improved education from health care providers on the likely nature and the impact of pain on an individual were something that the cohort as a whole considered a useful resource.

Patience and positive thought

Several of the subthemes demonstrated the participants’ resilience following injury. Hope and expectation following surgery were often simple and clear: participants wanted their elbow to be able to bend again. The perceived delay and effect of prolonged healing times were not always factored into people’s expectations and hopes for recovery – despite the explanation of nerve axon re-growth of ‘1mm a day’. Some believed the nerve would be fixed immediately with surgery. This led to expressions of emotion (particularly feelings of frustration and anger) with regard to perceptions of delayed recovery:

I think I was told but I don’t think I believed it, I was told I was going to have to be patient but I thought ‘I don’t think so’. P2

I didn’t think it had worked so I was kind of getting really despondent about it. P1

Feelings of ‘frustration’ were seen to give way to ‘acceptance’. However, this timeframe was variable between individuals. There was consensus and recognition within the group that recovery can be complex, different and personal. Once again improved patient information and education regarding the realistic expectation of outcome were requested:

It is going to be different for different people because some of you have lost one of the nerve functions but not everything, you still had some. I had total loss of the arm; it was just hanging there no ability to move it at all not [even be able to] flick one little finger…. Just to move it was a reasonable outcome, imagine if you felt that you want to do a lot more with it … you [the health care providers] could give the person scenarios [of] a realistic idea of what they can expect, some people will have unrealistic expectations, everyone is different. P3

Functionality and daily lifestyle

The ability to care for oneself, have independence and feelings of self-respect were repeatedly mentioned. Each individual quoted ADL as clear markers of function and personalised metrics for rehabilitation. The group also recognised that their individual functional goals were different and that as time went by and markers were met, their goals would change:

Any function is better than none so that is kind of just the starting point… Everybody’s goals are different because of lifestyle and all injuries are different. P6

One of my goals was that I could wash and dress. P1

Being able to drive was the first milestone for me, being able to use the gear stick and then put my hand back on the steering wheel, those sort of movements. Once I got those, the milestones have just been personal. P4

Perception of function also changed. Participants recognised that compensation and avoidance strategies were initially used to allow independence. But once they were able to integrate their arm they would actively force themselves to use the affected limb:

I make a really conscious effort to use my weaker arm far more than I would have done previously because it is not my natural arm to use. P1

I am avoiding it, don’t know if that is good thing not using it. Writing, marking kids work, I really struggle [because] the pain increases. P2

I swapped sides of the mouse, as I normally use it with my dominant hand but I used it with my left hand and I do a lot of mouse work and CAD drawings, I use a small mouse as well and just doing that a lot makes a real difference. P1

The stress of returning to everyday life was a challenge for some with the complaint of fatigue and general tiredness being a factor:

It is quite hard when you go back to everyday life, and you are back in work. P2

I started off doing half days and I was dead. Now I do two full days a week and I am still quite tired. P4

The biceps muscle

The participants frequently referred to their muscle not feeling like a biceps despite the elbow flexors having been re-innervated and volitional contraction against resistance being possible. Patient discussions included references to the biceps’ initial signs of re-innervation, the learnt control of movement, elements of fatigue with use and the altered perceptions in body image.

Patients reported the importance of a return in movement within the elbow flexors and described it as a momentous experience:

It was the best feeling in the world when you see it move. P3

It made sense then that everything was going to work again. P1

Following the return of activity, many commented on the process of learning to control the muscle as very challenging. Several participants commented on the overuse of other muscles as a limiting factor as well as the difficulty in learning how to isolate the contraction without using the donor nerve muscles (wrist flexors) to initiate the movement. In some cases, the passage of time had not helped with the disconnection of the movement patterns with many participants feeling after a prolonged period of time that was still a work of conscious effort and the movement was not easily integrated.

I had to absolutely concentrate on what I was doing try and switch off all the other muscles to try to get it to work because everything was firing instead for it. P2

I thought originally I was going to have a biceps but what they have done is fixed it to my ulnar nerve. I have got a clip of a biceps, but it doesn’t work as a biceps. It doesn’t flex when I do that [tries to bend elbow by itself] it flexes when I do that [makes a fist and bends elbow]. In terms of bulk I look relatively normal, but it doesn’t work as a biceps. If you measured me this way [resisted biceps curl] it is still weak. P5

Tools such as bio-feedback and hydrotherapy were highlighted as being most useful to the patient in their early days of recovery.

Doing the biofeedback more would help, because your day is so busy at times you don’t think and I think as long as you are in a habit then you are almost having to undo that habit to make the biceps kick in again. It is having that space and time to think - am I using my biceps here or is everything else working? and that is quite hard. P2

It just moved slightly in the water and then it got better over time. But the biofeedback when it gave me that message and being able to send that message out of the water, that is how I was able to isolate it. P3

Significant fatigue within the muscle was also expressed by all of the participants. In many cases, this was linked to the performance of ADLs.

I think the repetitive tasks are difficult…, like everyone has said you get tired. But one flexion - one lift of the kettle [is ok] but if you are doing stuff repeatedly that’s when I struggle. P2

The importance of self-esteem and not just relating to functional loss of the arm but ‘body image impairment’ was also raised within the discussion. The participants reported both the atrophy within the muscle as being unsettling with the hope to look normal and an importance for others not to be able to see any physical marker of disability.

It’s vain but when you talk about looks you can see it, you can see the atrophy. P2

It’s quite amazing how quick your muscles waste away. I was a really big guy with massive biceps and they just disappeared to bone in 3 months. You do become very conscious of that, and vain. I was aware of an imbalance in my body. P3

My ultimate goal is always that nobody that doesn’t know me would know that I have got an injury. P1

I am there, because nobody knows, they just have no idea. An elderly lady picked me out of a group of people and said you’re a large person; I need some muscles to lift. I thought oh no! but I did it. It was carrying a plant pot and I was able to do it. P5

Discussion

This study focused on the lived experience of motor recovery to the elbow flexors following Oberlin nerve transfer. As such, it provides a patient reported insight that outcome focused papers have been unable to provide.

Despite the research being directed towards motor recovery, pain was highlighted as an important feature for patients. This is recognised within much of the literature surrounding BPI.¹⁹ Causes of pain are numerous and it is common for patients to describe both nociceptive and neuropathic pain, as well as psychological and social contributors.^19,20 In the present study, the accounts of pain appear to be related to stress, repeated movement and fatigue. This study also highlighted that the experience of pain was common to all participants. These findings are comparable to those of Wellington¹ whose participants unanimously reported experiencing pain which affected their interaction with those around them. It is known that pain interferes with the ability to recognise or control movement, affects motivation and concentration and can directly inhibit movement.^8,21 Many participants referred to pain being more severe in the initial stages of recovery and reducing once signs of re-innervation were apparent. Interestingly, when one participant described the time when he believed re-innervation may be occurring that a change in pain sensation was attributed to possible “fixing pains.” Another participant described when he was first able to flex his arm in the pool as “the best feeling in the world to see it move.” It is beyond the scope of this article to determine but perhaps signs of re-innervation lead to a de-catastrophising of the meaning of pain and a dampening of pain sensation through descending pathways when the hope of recovery has been realised.²¹

With regard to the specific motor recovery in this cohort, it is clear that the theme of functionality and daily lifestyle defines the experience of motor recovery more than the regaining of strength in the muscle alone. P4 provided written feedback following the focus group and review of the transcript:

Measuring the recovery on the [MRC] scale of 1–5 doesn’t really show the true measure. Looking into day to day living will help others to understand the injury and how independent it is to each person with this injury.

Individual functional goals were referred to as personal targets and markers of recovery. The participants openly stated that these would be different for everyone but all tended to begin with aims to be independent with personal ADLs. This echoes the findings of McDonald and Pettigrew³ whose participants described these as ‘the little things’ including dressing, washing and eating during their interviews. Furthermore, the participants in this focus group study reported that function or “functionality” outweighed the simplistic measure of MRC grades to assess the ability to bend the arm against increasing resistance. However, the common clinical method of MRC grading was alluded to in that the participants related having no function, noticed gaining a flicker (being a moment of very obvious significance for a number of the participants), then contraction with gravity eliminated (in hydrotherapy for many), then gaining the movement out of the pool and then lifting weight. All but one of the participants related a personal experience of complexity and difficulties with motor control. The specific challenge in a nerve transfer is to re-learn the motor function.²² Despite function being returned to the muscle comments such as “it doesn’t feel like a biceps” and not “functioning like a biceps” may be in reference to perceived lack of control or altered proprioception of the muscle. Studies have demonstrated a change in cortical mapping following nerve transfer.^22,23 Complications arise from the learned motor patterning that has to take place in order to first activate the muscle (through intentionally activating the donor function i.e. wrist flexion). Participants in this study reported the benefits that they had gained from biofeedback and hydrotherapy. Biofeedback in particular has been recognised for its ability to enable patient’s to increase voluntary muscle activity and facilitate relearning following nerve transfer surgery and is recommended for use with this cohort.⁸

Finally, there is clear reference to the impact of fatigue. Both general and specific muscle fatigue are matters of concern. Two forms of muscle specific fatigue were reported as being challenging. Namely, endurance fatigue brought on by tasks requiring sustained contraction and repetitive fatigue brought on by repeated tasks. It is therefore of clinical relevance, that even when muscle function is controlled and the ability to integrate the arm into everyday function regained, the re-innervated muscle still demonstrates significant fatigue. Pacing and activity modification are two modalities which clinicians may regard as important considerations during this time.

This study must be considered in light of its limitations. Although the focus group guide was formed using previous information submitted by patients who had undergone nerve transfer, it was not piloted prior to use. Piloting the focus group guide may have improved its effectiveness to generate discussion with patients although this was not overtly apparent in our study. Involving patients in the design may have enhanced the study; 68 participants were identified as eligible to participate but only 6 attended the focus group which limits the generalisability. Limited resources permitted one focus group only. Offering a range of days and timings may have increased participant availability and wider ranging results. Holding the focus group during work hours may have influenced opinions regarding experience of employment. Furthermore, this study only focussed on those who had a documented grade IV muscle strength in their medical notes as a group that would be classified as a “successful” nerve transfer in the surrounding literature. Those who have less strength within the arm may describe different experiences. The group had a 5:1 ratio of men to women. According to the literature, BPI historically occurs more frequently in young males²⁴ which suggests our study may be representative; however, more female participants might have influenced results. In this context, our ratio is not unusual and is similar to qualitative work in this speciality area.^1,3

Conclusions

In traditional clinical assessments of renervated motor function, the focus is exclusively on the single maximal contractile force assessed by MRC with the almost complete exclusion of wider aspects of patient function or psychology. This study demonstrates that the lived experience of re-innervation and return of muscle function following nerve transfer surgery is multifaceted. One important factor for patients was the experience of pain which was described as being caused by stress, repeated movement and fatigue. In addition, psychosocial factors such as function, motivation and hope are fundamental to their lived experience. It is therefore important for medical professionals to ensure that they consider all these aspects with their patients throughout their rehabilitation.

Footnotes

Acknowledgements

We would like to thank all of the participants who agreed to take part in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Ethical approval was obtained from South East Coast Surrey Research Ethics Committee (REC ref: 16/LO/0623; IRAS ID: 202847).

Guarantor

HB.

Contributorship

HB, KJ and TQ conceived the study. TQ gained ethical approval. HB and TQ researched the literature. HB and KJ were involved in planning the focus group and patient recruitment. HB, TQ and AG undertook the data analysis. HB, TQ and AG wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Informed consent

Written informed consent was obtained from all of the participants prior to the study including that anonymised information may be published.

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