{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T15:07:25Z","timestamp":1780499245745,"version":"3.54.1"},"reference-count":11,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2019,7]]},"abstract":"<jats:sec><jats:title>OBJECTIVE<\/jats:title><jats:p>In this study, the authors sought to identify the relationship between breathing and elbow flexion in patients with a traumatic brachial plexus injury (TBPI) who undergo a phrenic nerve (PN) transfer to restore biceps flexion. More specifically, the authors studied whether biceps strength and the maximal range of active elbow flexion differ between full inspiration and expiration, and whether electromyography (EMG) activity in the biceps differs between forced maximum breathing during muscular rest, normal breathing during rest, and at maximal biceps contraction. All these variables were studied in a cohort with different intervals of follow-up, as the authors sought to determine if the relationship between breathing movements and elbow flexion changes over time.<\/jats:p><\/jats:sec><jats:sec><jats:title>METHODS<\/jats:title><jats:p>The British Medical Research Council muscle-strength grading system and a dynamometer were used to measure biceps strength, which was measured 1) during a maximal inspiratory effort, 2) during respiratory repose, and 3) after a maximal expiratory effort. The maximum range of elbow flexion was measured 1) after maximal inspiration, 2) during normal breathing, and 3) after maximal expiration. Postoperative EMG testing was performed 1) during normal breathing with the arm at rest, 2) during sustained maximal inspiration with the arm at rest, and 3) during maximal voluntary biceps contraction. Within-group (paired) comparisons, and both correlation and regression analyses were performed.<\/jats:p><\/jats:sec><jats:sec><jats:title>RESULTS<\/jats:title><jats:p>Twenty-one patients fit the study inclusion criteria. The mean interval from trauma to surgery was 5.5 months, and the mean duration of follow-up 2.6 years (range 10 months to 9.6 years). Mean biceps strength was 0.21 after maximal expiration versus 0.29 after maximal inspiration, a difference of 0.08 (t = 4.97, p &lt; 0.001). Similarly, there was almost a 21\u00b0 difference in maximum elbow flexion, from 88.8\u00b0 after expiration to 109.5\u00b0 during maximal inspiration (t = 5.05, p &lt; 0.001). Involuntary elbow flexion movement during breathing was present in 18\/21 patients (86%) and averaged almost 20\u00b0. Measuring involuntary EMG activity in the biceps during rest and contraction, there were statistically significant direct correlations between readings taken during normal and deep breathing, which were moderate (r = 0.66, p &lt; 0.001) and extremely strong (r = 0.94, p &lt; 0.001), respectively. Involuntary activity also differed significantly between normal and deep breathing (2.14 vs 3.14, t = 4.58, p &lt; 0.001). The degrees of involuntary flexion were significantly greater within the first 2.6 years of follow-up than later.<\/jats:p><\/jats:sec><jats:sec><jats:title>CONCLUSIONS<\/jats:title><jats:p>These results suggest that the impact of breathing on elbow function is considerable after PN transfer for elbow function reconstruction following a TBPI, both clinically and electromyographically, but also that there may be some waning of this influence over time, perhaps secondary to brain plasticity. In the study cohort, this waning impacted elbow range of motion more than biceps muscle strength and EMG recordings.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2018.4.jns173248","type":"journal-article","created":{"date-parts":[[2018,8,24]],"date-time":"2018-08-24T14:00:01Z","timestamp":1535119201000},"page":"165-174","source":"Crossref","is-referenced-by-count":22,"title":["Phrenic to musculocutaneous nerve transfer for traumatic brachial plexus injuries: analyzing respiratory effects on elbow flexion control"],"prefix":"10.3171","volume":"131","author":[{"given":"Mariano","family":"Socolovsky","sequence":"first","affiliation":[{"name":"Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martijn","family":"Malessy","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Leiden School of Medicine, Leiden, Holland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gonzalo","family":"Bonilla","sequence":"additional","affiliation":[{"name":"Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gilda","family":"Di Masi","sequence":"additional","affiliation":[{"name":"Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mar\u00eda Eugenia","family":"Conti","sequence":"additional","affiliation":[{"name":"Unit of Neurophysiology, Department of Neurology, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana","family":"Lovaglio","sequence":"additional","affiliation":[{"name":"Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"Hand Clin","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1016\/j.hcl.2008.04.005","article-title":"Cortical plasticity following nerve transfer in the upper extremity","volume":"24","author":"Anastakis DJ","unstructured":"Anastakis DJ, Malessy MJ, Chen R, Davis KD, Mikulis D: Cortical plasticity following nerve transfer in the upper extremity. Hand Clin 24:425\u2013444, vi\u2013vii, 200810.1016\/j.hcl.2008.04.00518928891"},{"issue":"5","key":"b2","series-title":"Neurosurg Focus","doi-asserted-by":"publisher","first-page":"E7","DOI":"10.3171\/foc.2004.16.5.8","article-title":"Restoration of hand function and so called \u201cbreathing arm\u201d after intraspinal repair of C5-T1 brachial plexus avulsion injury. Case report","volume":"16","author":"Carlstedt T","year":"2004","unstructured":"Carlstedt T, Anand P, Htut M, Misra P, Svensson M: Restoration of hand function and so called \u201cbreathing arm\u201d after intraspinal repair of C5-T1 brachial plexus avulsion injury. Case report. Neurosurg Focus 16(5):E7, 200410.3171\/foc.2004.16.5.815174827"},{"key":"b3","series-title":"Front Neurol","doi-asserted-by":"publisher","first-page":"72","DOI":"10.3389\/fneur.2017.00072","article-title":"Rehabilitation, using guided cerebral plasticity, of a brachial plexus injury treated with intercostal and phrenic nerve transfers","volume":"8","author":"Dahlin LB","year":"2017","unstructured":"Dahlin LB, Andersson G, Backman C, Svensson H, Bj\u00f6rkman A: Rehabilitation, using guided cerebral plasticity, of a brachial plexus injury treated with intercostal and phrenic nerve transfers. Front Neurol 8:72, 20172831659010.3389\/fneur.2017.00072"},{"key":"b4","series-title":"Neuroimage Clin","doi-asserted-by":"publisher","first-page":"277","DOI":"10.1016\/j.nicl.2016.07.008","article-title":"Reduced functional connectivity within the primary motor cortex of patients with brachial plexus injury","volume":"12","author":"Fraiman D","year":"2016","unstructured":"Fraiman D, Miranda MF, Erthal F, Buur PF, Elschot M, Souza L, : Reduced functional connectivity within the primary motor cortex of patients with brachial plexus injury. Neuroimage Clin 12:277\u2013284, 201610.1016\/j.nicl.2016.07.00827547727"},{"key":"b5","series-title":"J Hand Surg Eur","doi-asserted-by":"publisher","first-page":"170","DOI":"10.1016\/J.JHSB.2006.11.011","article-title":"Motor recovery and the breathing arm after brachial plexus surgical repairs, including re-implantation of avulsed spinal roots into the spinal cord","volume":"32","author":"Htut M","year":"2007","unstructured":"Htut M, Misra VP, Anand P, Birch R, Carlstedt T: Motor recovery and the breathing arm after brachial plexus surgical repairs, including re-implantation of avulsed spinal roots into the spinal cord. J Hand Surg Eur Vol 32:170\u2013178, 200710.1016\/J.JHSB.2006.11.011"},{"key":"b6","series-title":"Nunn\u2019s Applied Respiratory Physiology","first-page":"73","author":"Lumb AB","year":"2016","unstructured":"Lumb AB: Nunn\u2019s Applied Respiratory Physiology, ed 8. Amsterdam: Elsevier, 2016, pp 73\u201389"},{"issue":"Suppl","key":"b7","series-title":"Clin Neurol Neurosurg","doi-asserted-by":"publisher","first-page":"S95","DOI":"10.1016\/0303-8467(93)90044-H","article-title":"Respiration-related activity in the biceps brachii muscle after intercostal-musculocutaneous nerve transfer","volume":"95","author":"Malessy MJ","year":"1993","unstructured":"Malessy MJ, van Dijk JG, Thomeer RT: Respiration-related activity in the biceps brachii muscle after intercostal-musculocutaneous nerve transfer. Clin Neurol Neurosurg 95 (Suppl):S95\u2013S102, 1993846760510.1016\/0303-8467(93)90044-H"},{"key":"b8","series-title":"Acta Neurochir (Wien)","doi-asserted-by":"publisher","first-page":"1077","DOI":"10.1007\/s00701-015-2387-7","article-title":"The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis","volume":"157","author":"Socolovsky M","year":"2015","unstructured":"Socolovsky M, di Masi G, Bonilla G, Dom\u00ednguez Paez M, Robla J, Calvache Cabrera C: The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis. Acta Neurochir (Wien) 157:1077\u20131086, 201510.1007\/s00701-015-2387-7"},{"issue":"3","key":"b9","series-title":"Neurosurg Focus","doi-asserted-by":"publisher","first-page":"E13","DOI":"10.3171\/2016.12.FOCUS16431","article-title":"Current concepts in plasticity and nerve transfers: relationship between surgical techniques and outcomes","volume":"42","author":"Socolovsky M","year":"2017","unstructured":"Socolovsky M, Malessy M, Lopez D, Guedes F, Flores L: Current concepts in plasticity and nerve transfers: relationship between surgical techniques and outcomes. Neurosurg Focus 42(3):E13, 20172824566510.3171\/2016.12.FOCUS16431"},{"key":"b10","series-title":"Muscle Nerve","first-page":"125","article-title":"The breathing arm","volume":"17","author":"Swift TR","year":"1994","unstructured":"Swift TR: The breathing arm. Muscle Nerve 17:125\u2013129, 19948264697"},{"key":"b11","series-title":"J Hand Surg Am","doi-asserted-by":"publisher","first-page":"1304","DOI":"10.1016\/j.jhsa.2010.04.006","article-title":"Phrenic nerve transfer for elbow flexion and intercostal nerve transfer for elbow extension","volume":"35","author":"Zheng MX","year":"2010","unstructured":"Zheng MX, Xu WD, Qiu YQ, Xu JG, Gu YD: Phrenic nerve transfer for elbow flexion and intercostal nerve transfer for elbow extension. J Hand Surg Am 35:1304\u20131309, 20102061955810.1016\/j.jhsa.2010.04.006"}],"container-title":["Journal of Neurosurgery"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/131\/1\/article-p165.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/131\/1\/article-p165.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/131\/1\/article-p165.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,23]],"date-time":"2025-03-23T03:53:54Z","timestamp":1742702034000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/131\/1\/article-p165.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,7]]},"references-count":11,"journal-issue":{"issue":"1"},"URL":"https:\/\/doi.org\/10.3171\/2018.4.jns173248","relation":{},"ISSN":["0022-3085","1933-0693"],"issn-type":[{"value":"0022-3085","type":"print"},{"value":"1933-0693","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,7]]}}}