Rehabilitation Professionals' Perspectives on Human Rights, Disability, and Science: A Qualitative Study.

Objective: To investigate the attitudes and knowledge of rehabilitation professionals concerning human rights within the context of disability, science, and technology access. Design: A qualitative study using in-depth semi-structured interviews. Setting: A large, urban, academically-affiliated rehabilitation research center. Participants: We conducted semi-structured interviews with rehabilitation professionals who specialize in spinal cord injury (SCI) care, including 6 physicians, 3 physical therapists, 2 occupational therapists, 2 nurses, 1 rehabilitation engineer, and 1 rehabilitation psychologist (N=15). Participants were purposively recruited through e-mail letters to members of the American Spinal Injury Association. Efforts were made to recruit a diverse cohort of rehabilitation professionals based on profession, sex, age, and race. Interviews were conducted in person during the 2018 annual meeting or by phone after the meeting. Interventions: Not applicable. Main Outcome Measures: Interviews were recorded, transcribed verbatim, and coded to identify emerging themes within and across participants' content. Results: Primary findings show that most respondents were unaware of disability-relevant human rights doctrine. None was aware of the right to science as articulated in Article 15 of the International Covenant on Economic, Social, and Cultural Rights. Only 2 respondents had previously considered injustices experienced by their clients as human rights violations, yet nearly all were intrigued by framing access difficulties within the right to science paradigm. Overall, participants reported they would find value in implementing human rights in their work. Conclusions: Rehabilitation professionals are receptive to a human rights framework. Further research is needed to identify actionable steps for implementing principles of human rights to increase access to technology by individuals with SCI.

Seeking sufficient and appropriate care during the first year after spinal cord injury: a qualitative study.

STUDY DESIGN: Longitudinal qualitative study, based on a constructivist grounded theory and transformative approach. OBJECTIVES: This study investigated experiences of individuals with spinal cord injury (SCI) while navigating rehabilitation, resources for recovery, and community reintegration during the first year after injury. SETTING: An acute inpatient rehabilitation facility in the Midwest United States. METHODS: In-depth, semi-structured interviews were conducted with 20 individuals with newly-acquired SCI. Interviews were conducted approximately every other month for one year, beginning at acute inpatient rehabilitation. Data were analyzed and interpreted using a constructivist grounded theory approach and transformative paradigm, which examines power and social structures within and across institutions and gives voice to people at risk for marginalization. RESULTS: Participants experienced variable post-injury trajectories, with an average of four transitions within and across healthcare institutions in the first three months. Half of the cohort was discharged to a skilled nursing facility (SNF). Emergent themes included discharge (un)readiness; length of stay uncertainty and insurance impacts; challenges choosing a SNF including time-sensitive decisions; and early cessation of therapy in the SNF. Participants experienced resource navigation challenges such as communication/information access barriers and contending with many concerns at once. CONCLUSIONS: The experiences of this cohort reveal significant challenges to attaining sufficient and appropriate rehabilitation. Acute inpatient rehabilitation is a critical aspect of recovery, but does not ensure sufficient intervention for maximization of functional skills and community reintegration. Innovative rehabilitation models need to be developed for positive impacts on successful transition to independent living in the community.

Definitions of recovery and reintegration across the first year: A qualitative study of perspectives of persons with spinal cord injury and caregivers.

STUDY DESIGN: Longitudinal, qualitative cohort study. OBJECTIVES: To understand how people with newly acquired spinal cord injury (PWS) and their support person (SP) define recovery and successful community reintegration (CR) across the first 12 months post-injury (mpi) and their satisfaction with the rate of recovery and reintegration experienced. SETTING: Academic and Veterans hospitals in Midwest USA. METHODS: In-depth, semi-structured interviews were conducted in two cohorts of PWS and SP during the initial inpatient rehabilitation stay, at 6 mpi, and at 12 mpi. Recordings were transcribed; four authors independently undertook line-by-line coding. The team discussed codes to reach consensus and synthesize into broader themes within the International Classification of Function, Disability, and Health and Transformative frameworks. RESULTS: Data are reported on 23 PWS and 21 SP. PWS and SP are similar in defining recovery as gaining motor function and achieving independence. However, SP more frequently define recovery in terms of maintaining positivity and emotional recovery. At 12 mpi both groups shift to define recovery according to progress. Social roles, being active, and employment are persistent themes of how PWS and SP define successful CR. However, SP also frequently define successful CR as reestablishing identity and emotional adjustment. Veterans with SCI less frequently defined successful CR as employment. CONCLUSIONS: This study is the first to reveal how PWS and SP define recovery and reintegration during the first 12 mpi. Given decreasing lengths of stay, this information can be used to tailor rehabilitation strategies during the critical first year of injury to optimize recovery.

Clinical Outcomes of "Paralyzed" Nerve Transfer for Treating Spinal Cord Injury: A Proof of Concept in a Human Model.

Functional electrical stimulation (FES) is an option to restore function in individuals after high cervical spinal cord injury (SCI) who have limited available options for tendon or nerve transfer. To be considered for FES implantation, patients must possess upper motor neuron (UMN) type denervation in potential recipient muscles, which can be confirmed by response to surface electrical stimulation during clinical evaluation. Lower motor neuron (LMN) denervated muscles will not respond to electrical stimulation and, therefore, are unavailable for use in an FES system. Previous animal studies have demonstrated that a "paralyzed" nerve transfer of a UMN-denervated motor branch to an LMN-denervated motor branch can restore electrical excitability in the recipient. In this study, we report the indications, surgical technique, and successful outcome (restoration of M3 elbow flexion) after the first "paralyzed" nerve transfer in a human patient.

Safety and efficacy of transcranial direct current stimulation in upper extremity rehabilitation after tetraplegia: protocol of a multicenter randomized, clinical trial.

STUDY DESIGN: A multisite, randomized, controlled, double-blinded phase I/II clinical trial. OBJECTIVE: The purpose of this clinical trial is to evaluate the safety, feasibility and efficacy of pairing noninvasive transcranial direct current stimulation (tDCS) with rehabilitation to promote paretic upper extremity recovery and functional independence in persons living with chronic cervical spinal cord injury (SCI). SETTING: Four-site trial conducted across Cleveland Clinic, Louis Stokes Veterans Affairs Medical Center of Cleveland and MetroHealth Rehabilitation Rehabilitation Institute of Ohio, and Kessler Foundation of New Jersey. METHODS: Forty-four adults (age ≥18 years) with tetraplegia following cervical SCI that occurred ≥1-year ago will participate. Participants will be randomly assigned to receive anodal tDCS or sham tDCS given in combination with upper extremity rehabilitation for 15 sessions each over 3-5 weeks. Assessments will be made twice at baseline separated by at least a 3-week interval, once at end-of-intervention, and once at 3-month follow-up. PRIMARY OUTCOME MEASURE(S): Primary outcome measure is upper extremity motor impairment assessed using the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) scale. Functional abilities will be assessed using Capabilities of Upper Extremity-Test (CUE-T), while functional independence and participation restrictions will be evaluated using the self-care domain of Spinal Cord Independent Measure (SCIM), and Canadian Occupational Performance Measure (COPM). SECONDARY OUTCOME MEASURES: Treatment-associated change in corticospinal excitability and output will also be studied using transcranial magnetic stimulation (TMS) and safety (reports of adverse events) and feasibility (attrition, adherence etc.) will also be evaluated. TRIAL REGISTRATION: ClincalTrials.gov identifier NCT03892746. This clinical trial is being performed at four sites within the United States: Cleveland Clinic (lead site), Louis Stokes Cleveland Veterans Affairs Medical Center (VAMC) and MetroHealth Rehabilitation Institute in Ohio, and Kessler Foundation in New Jersey. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014 is the awarding and administering acquisition office.

Risk-benefit value of upper extremity function by an implanted electrical stimulation device targeting chronic cervical spinal cord injury.

Study design: A cross-sectional stated-preference survey using direct-assessment questions. Objective: To determine the relative value placed on different outcomes to be used in a pivotal trial for the upper extremity configuration of the Networked Neuroprosthesis (NNP) as well as the tolerance of the expected adverse event profile. Setting: Academic medical center in the United States. Methods: Distribution of an online survey to adults living with tetraplegia; extent of agreement with each question/statement was obtaining using a 1-7 Likert scale. Results: There were 8 statements about potential benefits in arm/hand function; for all statements, more than 70% of participants rated the functions as "1-very important" to regain. There were variable degrees of concern related to risks that could occur during the 30-day post-surgical period and increasing degrees of concern related to risks that could occur in the first 5 years, potentially due to the device, based on the increasing degree of invasiveness of the intervention required to address the event. When analysing the results based on all degrees of interest, more than 64% of responders were interested in getting the NNP with a success rate threshold as low as 50% regardless of time post-injury. Chi-squared analyses revealed some associations between responses and sex, injury level, and injury duration; however, none of these were statistically significant upon post-hoc analysis. Conclusion: Data here indicate that people with tetraplegia are highly interested in a range of arm/hand functions and are tolerant of expected risks that may be associated with implanted neuroprosthetics. Sponsorship: The Institute for Functional Restoration funded this project through a sub-contract to K.D. Anderson from a larger Special Projects Award (grant number FP0020773) from the Craig H. Neilsen Foundation.

Neuromodulation for Functional Electrical Stimulation.

This article describes the application of neuromodulation in different ways to motor recovery, to replace lost function, or to improve function of organ systems for those who have experienced spinal cord injury or stroke. Multiple devices have been developed and are currently available for use whereas others are still in the experimental stage. Multiple uses of neuromodulation are described.

Voluntary activation of biceps-to-triceps and deltoid-to-triceps transfers in quadriplegia.

The biceps or the posterior deltoid can be transferred to improve elbow extension function for many individuals with C5 or C6 quadriplegia. Maximum strength after elbow reconstruction is variable; the patient's ability to voluntarily activate the transferred muscle to extend the elbow may contribute to the variability. We compared voluntary activation during maximum isometric elbow extension following biceps transfer (n = 5) and deltoid transfer (n = 6) in three functional postures. Voluntary activation was computed as the elbow extension moment generated during maximum voluntary effort divided by the moment generated with full activation, which was estimated via electrical stimulation. Voluntary activation was on average 96% after biceps transfer and not affected by posture. Individuals with deltoid transfer demonstrated deficits in voluntary activation, which differed by posture (80% in horizontal plane, 69% in overhead reach, and 70% in weight-relief), suggesting inadequate motor re-education after deltoid transfer. Overall, individuals with a biceps transfer better activated their transferred muscle than those with a deltoid transfer. This difference in neural control augmented the greater force-generating capacity of the biceps leading to increased elbow extension strength after biceps transfer (average 9.37 N-m across postures) relative to deltoid transfer (average 2.76 N-m across postures) in our study cohort.

Posture-Dependent Corticomotor Excitability Differs Between the Transferred Biceps in Individuals With Tetraplegia and the Biceps of Nonimpaired Individuals.

BACKGROUND: Following biceps transfer to enable elbow extension in individuals with tetraplegia, motor re-education may be facilitated by greater corticomotor excitability. Arm posture modulates corticomotor excitability of the nonimpaired biceps. If arm posture also modulates excitability of the transferred biceps, posture may aid in motor re-education. OBJECTIVE: Our objective was to determine whether multi-joint arm posture affects corticomotor excitability of the transferred biceps similar to the nonimpaired biceps. We also aimed to determine whether corticomotor excitability of the transferred biceps is related to elbow extension strength and muscle length. METHODS: Corticomotor excitability was assessed in 7 arms of individuals with tetraplegia and biceps transfer using transcranial magnetic stimulation and compared to biceps excitability of nonimpaired individuals. Single-pulse transcranial magnetic stimulation was delivered to the motor cortex with the arm in functional postures at rest. Motor-evoked potential amplitude was recorded via surface electromyography. Elbow moment was recorded during maximum isometric extension trials, and muscle length was estimated using a biomechanical model. RESULTS: Arm posture modulated corticomotor excitability of the transferred biceps differently than the nonimpaired biceps. Elbow extension strength was positively related and muscle length was unrelated, respectively, to motor-evoked potential amplitude across the arms with biceps transfer. CONCLUSIONS: Corticomotor excitability of the transferred biceps is modulated by arm posture and may contribute to strength outcomes after tendon transfer. Future work should determine whether modulating corticomotor excitability via posture promotes motor re-education during the rehabilitative period following surgery.

Upper Extremity Assessment in Tetraplegia: The Importance of Differentiating Between Upper and Lower Motor Neuron Paralysis.

Scientific advances are increasing the options for improved upper limb function in people with cervical level spinal cord injury (SCI). Some of these interventions rely on identifying an aspect of paralysis that is not uniformly assessed in SCI: the integrity of the lower motor neuron (LMN). SCI can damage both the upper motor neuron and LMN causing muscle paralysis. Differentiation between these causes of paralysis is not typically believed to be important during SCI rehabilitation because, regardless of the cause, the muscles are no longer under voluntary control by the patient. Emerging treatments designed to restore upper extremity function (eg, rescue microsurgical nerve transfers, motor learning-based interventions, functional electrical stimulation) all require knowledge of LMN status. The LMN is easily evaluated using surface electrical stimulation and does not add significant time to the standard clinical assessment of SCI. This noninvasive evaluation yields information that contributes to the development of a lifetime upper extremity care plan for maximizing function and quality of life. Given the relative simplicity of this assessment and the far-reaching implications for treatment and function, we propose that this assessment should be adopted as standard practice for acute cervical SCI.

Implanted neuroprosthesis for restoring arm and hand function in people with high level tetraplegia.

OBJECTIVE: To develop and apply an implanted neuroprosthesis to restore arm and hand function to individuals with high level tetraplegia. DESIGN: Case study. SETTING: Clinical research laboratory. PARTICIPANTS: Individuals with spinal cord injuries (N=2) at or above the C4 motor level. INTERVENTIONS: The individuals were each implanted with 2 stimulators (24 stimulation channels and 4 myoelectric recording channels total). Stimulating electrodes were placed in the shoulder and arm, being, to our knowledge, the first long-term application of spiral nerve cuff electrodes to activate a human limb. Myoelectric recording electrodes were placed in the head and neck areas. MAIN OUTCOME MEASURES: Successful installation and operation of the neuroprosthesis and electrode performance, range of motion, grasp strength, joint moments, and performance in activities of daily living. RESULTS: The neuroprosthesis system was successfully implanted in both individuals. Spiral nerve cuff electrodes were placed around upper extremity nerves and activated the intended muscles. In both individuals, the neuroprosthesis has functioned properly for at least 2.5 years postimplant. Hand, wrist, forearm, elbow, and shoulder movements were achieved. A mobile arm support was needed to support the mass of the arm during functional activities. One individual was able to perform several activities of daily living with some limitations as a result of spasticity. The second individual was able to partially complete 2 activities of daily living. CONCLUSIONS: Functional electrical stimulation is a feasible intervention for restoring arm and hand functions to individuals with high tetraplegia. Forces and movements were generated at the hand, wrist, elbow, and shoulder that allowed the performance of activities of daily living, with some limitations requiring the use of a mobile arm support to assist the stimulated shoulder forces.

Posture-dependent changes in corticomotor excitability of the biceps after spinal cord injury and tendon transfer.

Following tendon transfer of the biceps to triceps after cervical spinal cord injuries (SCI), individuals must learn to activate the transferred biceps muscle to extend the elbow. Corticomotor excitability of the transferred biceps may play a role in post-operative elbow extension strength. In this study, we evaluated whether corticomotor excitability of the transferred biceps is related to an individuals' ability to extend the elbow, and whether posture and muscle length affects corticomotor excitability after SCI and tendon transfer similarly to the nonimpaired biceps. Corticomotor excitability was assessed in twelve nonimpaired arms and six arms of individuals with SCI and biceps-to-triceps transfer using transcranial magnetic stimulation (TMS) delivered at rest. Maximum isometric elbow extensor moments were recorded in transferred arms and the fiber length of the transferred biceps was estimated using a musculoskeletal model. Across the SCI subjects, corticomotor excitability of the transferred biceps increased with elbow extension strength. Thus, rehabilitation to increase excitability may enhance strength. Excitability of the transferred biceps was not related to fiber length suggesting that similar to nonimpaired subjects, posture-dependent changes in biceps excitability are primarily centrally modulated after SCI. All nonimpaired biceps were most excitable in a posture in the horizontal plane with the forearm fully supinated. The proportion of transferred biceps in which excitability was highest in this posture differed from the nonimpaired group. Therefore, rehabilitation after tendon transfer may be most beneficial if training postures are tailored to account for changes in biceps excitability.

Standard task set for evaluating rehabilitation interventions for individuals with arm paralysis.

We have developed a set of upper-limb functional tasks to guide the design and test the performance of rehabilitation technologies that restore arm motion in people with high tetraplegia. Our goal was to develop a short set of tasks that would be representative of a much larger set of activities of daily living (ADLs), while also being feasible for a user of a unilateral, implanted functional electrical stimulation (FES) system. To compile this list of tasks, we reviewed existing clinical outcome measures related to arm and hand function and were further informed by surveys of patient desires. We ultimately selected a set of five tasks that captured the most common components of movement seen in ADLs and is therefore highly relevant for assessing FES-restored unilateral arm function in individuals with high cervical spinal cord injury. The tasks are intended to be used when setting design specifications and for evaluating and standardizing rehabilitation technologies under development. While not unique, this set of tasks will provide a common basis for comparing different interventions (e.g., FES, powered orthoses, robotic assistants) and testing different user command interfaces (e.g., sip-and-puff, head joysticks, brain-computer interfaces).

Implanted neuroprosthesis for assisting arm and hand function after stroke: a case study.

Loss of arm and hand function is common after stroke. An implantable, 12-channel, electromyogram (EMG)-controlled functional electrical stimulation neuroprosthesis (NP) may be a viable assistive device for upper-limb hemiplegia. In this study, a research participant 4.8 yr poststroke underwent presurgical screening, surgical installation of the NP, training, and assessment of upper-limb impairment, activity limitation, and satisfaction over a 2.3 yr period. The NP increased active range of finger extension from 3 to 96 degrees, increased lateral pinch force from 16 to 29 N, increased the number of objects from 1 to 4 out of 6 that the participant could grasp and place in a Grasp-Release Test, and increased the Arm Motor Abilities Test score by 0.3 points. The upper-limb Fugl-Meyer score increased from 27 at baseline to 36 by the end of the study. The participant reported using the NP at home 3-4 d/wk, up to 3 h/d for exercise and household tasks. The effectiveness of the NP to assist with activities of daily living was dependent on the degree of flexor tone, which varied with task and level of fatigue. The EMG-based control strategy was not successfully implemented; button presses were used instead. Further advancements in technology may improve ease of use and address limitations caused by muscle spasticity.

Technology for spinal cord injury rehabilitation and its application to youth.

Spinal cord injury (SCI) often results in a sudden, devastating loss of function. SCI is particularly challenging for the pediatric and adolescent populations who, under normal circumstances, are still achieving developmental milestones, but following SCI face additional barriers posed by paralysis and the accompanying secondary complications. Advancing technology in rehabilitation is changing the course of how people with spinal cord injury participate in rehabilitation. Technology plays an ever-increasing role in both restorative and compensatory rehabilitative interventions. While the practical or functional needs of the pediatric patient may differ from those of the adult, technology can and does play a role in restoring function for this population. Applications of technology span broad areas, providing improved options for care in grasp and manipulation, seating and mobility, augmentative and alternative communication, electronic aids to daily living, and computer access and use. This article reviews select applications of technology that have great impact on the functional needs of people with spinal cord injury (SCI): therapeutic and functional stimulation, EMG biofeedback and EMG-triggered stimulation, assistive technology for computer access, and implanted functional electrical stimulation systems. Some of these technologies are already in use in the pediatric population, while some are not - yet have great potential for restoring function in this group. The challenges and potential solutions for implementing these technologies in the pediatric population are discussed.

Surgical restoration of arm and hand function in people with tetraplegia.

Improved hand and arm function is the most sought after function for people living with a cervical spinal cord injury (SCI). Surgical techniques have been established to increase upper extremity function for tetraplegics, focusing on restoring elbow extension, wrist movement, and hand opening and closing. Additionally, more innovative treatments that have been developed (implanted neuroprostheses and nerve transfers) provide more options for improving function and quality of life. One of the most important steps in the process of restoring upper extremity function in people with tetraplegia is identifying appropriate candidates - typically those with American Spinal Injury Association (ASIA) motor level C5 or greater. Secondary complications of SCI can pose barriers to restoring function, particularly upper extremity spasticity. A novel approach to managing spasticity through high-frequency alternating currents designed to block unwanted spasticity is being researched at the Cleveland FES Center and may improve the impact of reconstructive surgery for these individuals. The impact of these surgeries is best measured within the framework of the World Health Organization's International Classification of Function, Disability and Health. Outcome measures should be chosen to reflect changes within the domains of body functions and structures, activity, and participation. There is a need to strengthen the evidence in the area of reconstructive procedures for people with tetraplegia. Research continues to advance, providing more options for improved function in this population than ever before. The contribution of well-designed outcome studies to this evidence base will ultimately help to address the complications surrounding access to the procedures.

Measurement issues related to upper limb interventions in persons who have tetraplegia.

Measurement of upper limb function in persons with tetraplegia poses significant issues for clinicians and researchers. It is crucial that measures detect the small but significant improvements in hand function that may or may not occur as a result of our interventions. Before determining how we measure changes from upper limb interventions, we must establish what outcomes are of greatest interest, and for whom. Many issues have an impact on both the measurement and interpretative process.

An implanted upper-extremity neuroprosthesis using myoelectric control.

PURPOSE: The purpose of this study was to evaluate the potential of a second-generation implantable neuroprosthesis that provides improved control of hand grasp and elbow extension for individuals with cervical level spinal cord injury. The key feature of this system is that users control their stimulated function through electromyographic (EMG) signals. METHODS: The second-generation neuroprosthesis consists of 12 stimulating electrodes, 2 EMG signal recording electrodes, an implanted stimulator-telemeter device, an external control unit, and a transmit/receive coil. The system was implanted in a single surgical procedure. Functional outcomes for each subject were evaluated in the domains of body functions and structures, activity performance, and societal participation. RESULTS: Three individuals with C5/C6 spinal cord injury received system implantation with subsequent prospective evaluation for a minimum of 2 years. All 3 subjects demonstrated that EMG signals can be recorded from voluntary muscles in the presence of electrical stimulation of nearby muscles. Significantly increased pinch force and grasp function was achieved for each subject. Functional evaluation demonstrated improvement in at least 5 activities of daily living using the Activities of Daily Living Abilities Test. Each subject was able to use the device at home. There were no system failures. Two of 6 EMG electrodes required surgical revision because of suboptimal location of the recording electrodes. CONCLUSIONS: These results indicate that a neuroprosthesis with implanted myoelectric control is an effective method for restoring hand function in midcervical level spinal cord injury.

An implanted myoelectrically-controlled neuroprosthesis for upper extremity function in spinal cord injury.

A second generation implantable neuroprosthesis has been developed which provides improved control of grasp-release, forearm pronation, and elbow extension for individuals with cervical level spinal cord injury. In addition to the capacity to stimulate twelve muscles, the key technological feature of the advanced system is the capability to transmit data out of the body. This allows the use of myoelectric signal recording via implanted electrodes, thus minimizing the required external components. Clinical studies have been initiated with a second generation neuroprosthesis that consists of twelve stimulating electrodes, two myoelectric signal recording electrodes, an implanted stimulator-telemeter device and an external control unit and transmit/receive coil. This system has now been implemented in nine arms in seven C5/C6 spinal cord injured individuals. The results from these subjects demonstrate that myoelectric signals can be recorded from voluntary muscles in the presence of electrical stimulation of nearby muscles. The functional results show that the neuroprosthesis provides significantly increased pinch force and grasp function for each subject. All subjects have demonstrated increased independence and improved function in activities of daily living. We believe that these results indicate that implanted myoelectric control is a desirable option for neuroprostheses.

Triceps denervation as a predictor of elbow flexion contractures in C5 and C6 tetraplegia.

OBJECTIVE: To determine whether the existence of elbow flexion contractures in persons with C5 or C6 tetraplegia is related to a lack of residual voluntary triceps function and triceps denervation (ie, lower motoneuron damage). DESIGN: A retrospective study of impairment data from 74 arms to identify the incidence of elbow flexion contractures and the contributing factors toward this deformity. SETTING: Five spinal cord injury (SCI) rehabilitation centers in the United States, 1 in England, and 1 in Australia. PARTICIPANTS: Forty-three subjects with motor complete C5 or C6 traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Active and passive elbow extension, triceps voluntary muscle strength, and triceps response to electric stimulation. RESULTS: Subjects with weak voluntary triceps had significantly fewer and less severe elbow flexion contractures than those with paralyzed triceps ( P =.024). Subjects with completely denervated triceps (ie, no response to electric stimulation) had significantly more elbow flexion contractures than subjects with even a weak response to electric stimulation ( P =.003). Overall, 51% of the arms could not be passively extended to zero. Forty-six percent of the arms classified as C5 lacked full passive elbow extension, compared with 63% of the arms classified as C6 ( P =.302). CONCLUSIONS: A relationship has been found between elbow flexion contractures and lack of residual voluntary triceps and triceps denervation in subjects with C5 or C6 tetraplegia. There should be a greater awareness of the elbow flexion contractures that may develop as a result of this relationship. A better understanding of this deformity and its characteristics can lead to more effective clinical treatment and prevention strategies.