Measurement of coronary artery calcification by electron beam computerized tomography in persons with chronic spinal cord injury: evidence for increased atherosclerotic burden.

BACKGROUND/OBJECTIVE: Individuals with spinal cord injury (SCI) have been reported to have an increased prevalence of premature cardiovascular disease. Whether the increased risk of disease is owing to clustering of traditional cardiac risk factor or is over and above that predicted by risk factors was addressed. METHODS: Ninety-one persons with chronic SCI were studied for subclinical atherosclerosis. Cardiac risk factors and coronary artery calcium (CAC) was compared to matched non-SCI controls. The 273 controls were 3:1 matched for age, gender, ethnicity and risk factors and were drawn from a national database of over 30,000 asymptomatic persons undergoing coronary scanning. RESULTS: Seventy-six men and 15 women were studied. Average age was 49.7+/-12 years. Duration of injury was 19.7+/-10 years. The ethnicity of the study cohort included 36% Caucasian, 49% Latino, 10% African American, and 5% other. The mean calcium score of the SCI group was significantly greater than the control group (75+/-218 versus 28+/-104, P<0.001). The prevalence of any CAC score was greater in the SCI population than the control population (51 versus 39%, P<0.05), as was CAC score >100 (16 versus 7%, P<0.01). Women with SCI had a significantly lower CAC score than men (mean score: 12 versus 86, P<0.01). CONCLUSION: Patients with SCI were shown to have greater atherosclerotic burden than able-bodied controls. Of note, and unexplained, this finding is beyond that explained by the clustering of traditional risk factors. On the basis of these findings, increased attention should be directed toward the prevention of coronary heart disease in those with SCI.

Rehabilitation of the arm and hand following stroke--a clinical trial with BIONs.

This paper reports the clinical experiences and preliminary observations from implanted microstimulators used to reduce some impairments following a stroke. Ongoing research protocols to reduce shoulder subluxation and hand contractures using BION stimulation are described. Comparison of compliance and patient satisfaction between individuals exercising at home with surface stimulation and implanted stimulation are characterized. The effectiveness of the two home based stimulation programs are compared.

Levels of plasma homocysteine in persons with spinal cord injury.

BACKGROUND: Premature coronary vascular disease is a leading cause of morbidity and mortality in persons with chronic spinal cord injury (SCI). Evidence indicates that an elevated plasma homocysteine level is an independent risk factor for vascular disease. METHODS: Plasma homocysteine levels were collected in 845 subjects with SCI and compared to those in a reference population. Differences in plasma homocysteine were determined for sex, race/ethnicity, neurological deficit, and age, as well as for serum creatinine concentration. RESULTS: Plasma homocysteine was significantly higher in men than in women. Men were more likely to have moderately or severely elevated plasma homocysteine levels. Stratifying by male sex, greater percentages of whites and African Americans had severely elevated plasma homocysteine levels (>20 micromol/L) compared with Latinos (12% and 14% versus 8%; P > .01). For the total group with SCI, plasma homocysteine levels were not significantly different by race/ethnicity or neurological deficit subgroup. For the total group (P < .05) and within each sex (men, P < .05; women, P < .01), the older age group with SCI (>50 years) had significantly higher mean plasma homocysteine levels than the younger age group. Age was positively related to plasma homocysteine levels in men (P < .05) and women (P < .01). Plasma homocysteine levels were higher among men for any given age than among women (P < .0001) by an average of 3.19 +/- 0.51 micromol/L. Regardless of age or sex, persons with SCI tended to have higher levels of plasma homocysteine than able-bodied persons matched for age and sex. CONCLUSION: Because the risk of a vascular event increases with age, elevated levels of plasma homocysteine place older persons with SCI at further increased risk for a vaso-occlusive event. Of note, there was a stepwise increase in plasma homocysteine concentration for each quartile of higher serum creatinine concentration. Patients who have elevated levels of plasma homocysteine should receive a trial course of daily supplementation with oral folic acid and vitamin B12. If that is ineffective, they should receive vitamin B6 supplementation to lower their plasma homocysteine levels.

The effect of dietary intervention on lipid profiles in individuals with spinal cord injury.

OBJECTIVE: The purpose of this study was to evaluate the effects of a simple dietary intervention for individuals with chronic spinal cord injury (SCI) and moderately elevated total cholesterol. METHODS: Baseline and follow-up serum lipid values were obtained on 222 persons with SCI. Eighty-six individuals with total cholesterol >200 mg/dL were referred for dietary consultation (group 1). The remainder with values <200 mg/dL and no consultation served as controls (group 2). RESULTS: At average follow-up of 16 months, group 1 demonstrated significant declines in total cholesterol and low-density lipoprotein cholesterol (LDL-C), whereas group 2 demonstrated significant increases in total cholesterol. Triglyceride levels followed similar but nonsignificant patterns. There were no significant changes in high-density lipoprotein cholesterol for either group. In group 1, 17% had clinically significant reductions in total cholesterol to <200 mg/dL and 21% had reductions of LDL-C from >135 mg/dL to <135 mg/dL. CONCLUSIONS: Dietary intervention should be an initial treatment for those with SCI and moderately elevated total cholesterol, with the expectation that approximately 20% will respond favorably.

Forced vital capacity in two large outpatient populations with chronic spinal cord injury.

OBJECTIVE: To determine the expected vital capacity in persons with chronic spinal cord injury (SCI) in relation to injury level, completeness of injury, smoking and duration of injury, as an aid to diagnosis and management of respiratory complications. SETTING: A New York City veterans' hospital and a Los Angeles public rehabilitation hospital. METHODS: Case series from the two hospitals were pooled. Participants (adult outpatients with SCI of duration >1 year, not ventilator-dependent) were evaluated by conventional forced expiratory spirometry. Cross-sectional analysis was performed, using multiple regression, on the entire population and defined subgroups. The principal outcome measure was forced vital capacity (FVC). RESULTS: In the subjects with complete-motor lesions, FVC ranged from near 100% of normal predicted values in the group with low paraplegia, to less than 50% in those with high tetraplegia. Incomplete lesions mitigated FVC loss in tetraplegia. In subjects with paraplegia, longer duration of injury was associated with greater loss, and smoking-related loss was evident at older but not at younger ages, presumably due to greater pack years in older subjects. CONCLUSIONS: Vital capacity/SCI level relationships determined here may have diagnostic and prognostic value. Smoking-related FVC loss is important in persons with SCI as in others, although at higher levels it may be obscured by SCI-related loss.

Pulmonary function in chronic spinal cord injury: a cross-sectional survey of 222 southern California adult outpatients.

OBJECTIVES: To evaluate risk factors for respiratory morbidity in chronic spinal cord injury (SCI). SETTING: Model SCI care system based at an urban public rehabilitation medical center. DESIGN: Case series with evaluation of pulmonary function by conventional spirometric testing. PARTICIPANTS: Two hundred twenty-two adults with SCI of more than 1-year duration who were not chronically dependent on mechanical ventilation, including 98 with tetraplegia (62 with complete and 26 with incomplete motor lesions) and 124 with paraplegia (87 with complete and 37 with incomplete motor lesions). MAIN OUTCOME MEASURES: Forced vital capacity (FVC), forced expired volume in 1 second (FEV1), and peak expiratory flow rate (PEFR), all measured in the supine and erect seated positions and compared with predicted normal values for industrial workers. RESULTS: FVC and FEV1 were normal in persons with low-level paraplegia who had never smoked, but both decreased similarly with rising SCI level, more markedly in those with tetraplegia. PEFR decreased with rising SCI level. Incomplete lesions mitigated function loss in those with tetraplegia. In middle-aged individuals with tetraplegia, longer duration of injury was associated with greater function loss, independent of age. Current smokers showed excess function loss, except for those with high tetraplegia. Most people with complete tetraplegia showed FVC and FEV1 increases in the supine position relative to the erect position. CONCLUSIONS: Pulmonary function is compromised by most lesions of the spinal cord, even in those with paraplegia, and is affected relative to the level of lesion. Efforts to help SCI patients minimize respiratory complications-in particular, assistance in smoking cessation-should be given high priority.

The effect of residual neurological deficit on oral glucose tolerance in persons with chronic spinal cord injury.

STUDY DESIGN: Oral glucose tolerance testing was performed prospectively in 201 subjects with spinal cord injury (SCI). The dependent variables included the values from the oral glucose tolerance test (glucose and insulin) and diagnostic classification (i.e., diabetes mellitus, impaired glucose tolerance, normal glucose tolerance); the independent variables consisted of study group, gender, ethnic group, age, age at onset of SCI, duration of injury, and anthropometric measurements. OBJECTIVE: To determine the potential effects of level and completeness of SCI on oral glucose tolerance testing. In addition, the effects of gender ethnicity, age, age at onset of SCI, duration of injury, and anthropometric measurements on glucose tolerance were investigated. SETTING: Subjects with chronic SCI were recruited during their annual physical examination at the Comarr Spinal Injury Clinic at Rancho Los Amigos Medical Center, Downey, California. METHODS: An oral 75 g glucose load was administered after an overnight fast. Serum glucose was determined by autoanalyzer and plasma insulin levels, by radioimmunoassay. The results are reported as mean plus or minus standard error of the mean (mean+/-SEM). Analysis of variance (ANOVA) applying a Scheffe' post hoc F ratio was used for the continuous variables. Chi-squared analyses were performed to determine differences between the groups and among the subgroups for per cent distribution. Linear regression analyses were performed between variables of interest. Stepwise regression analyses were used to predict peak serum glucose concentration and peak plasma insulin level from potential determinants. RESULTS: The total group consisted of 169 men with a mean age of 38+/-0.80 (range=20 - 73) years and 32 women with a mean age of 44+/-2.13 (range =20 - 72) years. The distribution by ethnicity for the total group with SCI consisted of 114 (57%) Latino, 54 (27%) white, and 28) 14%) African American individuals. There was no significant difference in ethnic distribution among the subgroups for neurological deficit. Subjects were grouped by tetraplegia (Tetra; n=81) or paraplegia (Para; n=120) and by subgroup for degree of neurological deficit: complete Tetra (n=56), incomplete Tetra (n=25), complete Para (n=84), and incomplete Para (n=36). Of the total group, 27 subjects (13.4%) had diabetes mellitus and 56 (28.8%) had impaired glucose tolerance. Significantly more subjects in the complete Tetra group were classified with a disorder of carbohydrate metabolism than in the other neurological deficit subgroups (73 vs 44%, 24% and 31%, respectively for level of decreasing neurological deficit; X2=36.9, P<0.0001). The complete Tetra group had significantly higher serum glucose concentrations at 60 min, 90 min, and 120 min and serum insulin concentration at 90 and 120 min compared with the other neurological subgroups (P<0.05 for each time point). No differences for plasma glucose were evident between men and women, however, plasma insulin levels were significantly higher for men at the intermediate time points (30 min, 60 min and 90 min), suggesting a relative state of insulin resistance in men. By stepwise regression analyses, higher peak serum glucose concentrations were associated with increased total body %fat, highest level of lesion (complete Tetra vs other neurological subgroups), older age at time of injury, and male gender; higher peak plasma insulin was associated with increased total body %fat and male gender. CONCLUSIONS: This study is the first to report that those individuals with the greatest levels of neurological deficit have increased risk of developing disorders of carbohydrate metabolism. Males with SCI are more insulin resistant than females. Glucose tolerance appears to be independent of the effects of ethnicity.

The energy expenditure of normal and pathologic gait.

Physiological energy expenditure measurement has proven to be a reliable method of quantitatively assessing the penalties imposed by gait disability. The purpose of this review is to outline the basic principles of exercise physiology relevant to human locomotion; detail the energy expenditure of normal walking; and summarize the results of energy expenditure studies performed in patients with specific neurologic and orthopedic disabilities. The magnitude of the disabilities and the patients' capacity to tolerate the increased energy requirements are compared. This paper also will examine the effectiveness of rehabilitation interventions at mitigating the energetic penalties of disability during ambulation.

Emergency, acute, and surgical management of spine trauma.

OBJECTIVES: To assess trends in emergency, acute, and surgical management of spinal cord injury (SCI), and evaluate the relations between surgery and the occurrence of specific complications. SETTING: Model SCI Care Systems. DESIGN: Case series. PARTICIPANTS: Consecutive samples of 3,756 acute spinal injuries admitted to the Midwest Regional Spinal Cord Injury Care System between 1990 and 1999, 2,204 individuals admitted to a Model SCI System within 24 hours of injury before 1995, and 941 individuals who were injured between December 1995 and August 1998 and were admitted to a Model System within 24 hours of injury. MAIN OUTCOME MEASURES: Frequencies of injury types, nonoperative treatment and types of spine surgeries, and time sequence associated complications including postoperative wound infections, pressure ulcers, deep vein thrombophlebitis, pulmonary embolism, and pneumonia or atelectasis. RESULTS: Eighty-eight percent of cases entering a Model System through acute care were admitted within 72 hours of injury, 85% were admitted within 24 hours. Comparing 1990 with 1998, the number of persons admitted to Model Systems within 72 hours of injury declined 11%. Operative treatment within the Model Systems increased 5% (p < .01), with increases due to decompression surgeries. Complication rates of nonoperative and surgical cases were not different. CONCLUSIONS: The reduction in 72-hour admissions suggests an increasing percentage of admissions are directly to rehabilitation at a Model System after receiving acute care elsewhere. The increase in the use of surgical procedures involving surgical decompression of the spine is probably due to advances in surgical technology and increased experience and confidence in spine surgery. Surgery does not influence complication development beyond the usual expectations for those who sustain SCI.

Is immobilization associated with an abnormal lipoprotein profile? Observations from a diverse cohort.

OBJECTIVE: The potential effects of ethnicity, gender, and adiposity on the serum lipid profile in persons with spinal cord injury (SCI) were determined. SUBJECTS: Subjects with SCI were recruited during their annual physical examination from Rancho Los Amigos Medical Center, Downey, California. Sedentary able-bodied controls were Bridge and Tunnel Officers of the Triboro Bridge and Tunnel Authority of the New York City metropolitan area. METHODS: Serum lipid profiles were investigated in 320 subjects with SCI and compared to those obtained from 303 relatively sedentary able-bodied controls. Serum lipid studies were obtained in the fasting state. Data were collected between 1993 and 1996. All lipid determinations were performed by the same commercial laboratory. MAIN OUTCOME MEASURES: The dependent variables were the values from the lipid profile analysis. The independent variables consisted of study group, gender, ethnic group, age, duration of injury, and anthropometric measurements. RESULTS: The serum high-density lipoprotein cholesterol (HDL-c) level was reduced in the SCI compared with the control group (mean+/-SEM) (42+/-0.79 vs 47+/-0.67 mg/dl, P<0.0005). The serum HDL-c level was significantly lower in males with SCI than males in the control group (39+/-0.83 vs 45+/-0.70 mg/dl, P<0.0001), but not for females (51+/-1.54 vs 54 1.52 mg/dl, n.s.). Within the subgroups for whites and Latinos, HDL-c values were also lower in subjects with SCI than in controls (whites: 41+/-1.02 vs 46+/-0.86 mg/dl, P<0.0001; Latinos: 37+/-1.53 vs 42+/-1.59 mg/dl, P<0.05), but not for African Americans (49+/-1.56 vs 51+/-1.27 mg/dl, n.s.). African Americans had higher HDL-c values than whites or Latinos (SCI: 49+/-1.56 vs 41+/-1.02 or 37+/-1.53 mg/dl, P< 0.0001; controls: 51+/-1.27 vs 46+/-0.86 mg/dl, P<0.01 or 42+/-1.59 mg/dl, P<0.0005). In persons with SCI, the serum HDL-c values were inversely related to body mass index and estimated per cent body fat (r=0.27, P<0.0001). CONCLUSION: In white and Latino males, but not in females or African Americans, immobilization from SCI appears to be associated with lower HDL-c values than in controls.

Donal Munro Lecture: Functional and neurologic recovery following acute SCI.

Patient management in the current health care environment requires the provider to make reliable and valid clinical decisions regarding patient care, decisions that are cost effective and will lead to optimal functional improvement. Neurologic examination, according to the Standards for Neurological and Functional Classification of Spinal Injury developed by the American Spinal Injury Association, provides every clinician with simple clinical tools that are highly predictive of functional recovery following a spinal cord injury. The ability to predict motor recovery provides a rational basis to help support the provider's recommendation for the patient's goals and care planning, as well as differentiates care that is essential for improving functional outcomes from care that is not.

Postrehabilitation outcomes after spinal cord injury caused by firearms and motor vehicle crash among ethnically diverse groups.

OBJECTIVES: To determine the differential effects of impairment, disability, etiology, and selected preinjury and social factors on medical complications, medical resources use, and handicap after rehabilitation for spinal cord injury (SCI). DESIGN: Survey including interview and medical record review. SETTING: Model SCI Care System centered at an urban, public medical center. PARTICIPANTS: A volunteer convenience sample of 164 men, ages 18 to 35yrs at injury, with SCI caused by firearms or motor vehicle crash. MAIN OUTCOME MEASURES: Mean numbers of documented complications, pressure sore episodes, nonroutine clinic visits, postrehabilitation hospitalization days per year, assessment by Functional Independence Measure (FIM), and total score on the Craig Handicap Assessment and Reporting Technique (CHART). RESULTS: Significant factors for postrehabilitation complications were discharge FIM (p < .001) and injury duration (p = .046); for pressure ulcer episodes, they were injury completeness (p < .001), drug abuse following injury (p = .005), and ethnicity (p = .043); for average annual nonroutine clinic visits, they were complications (p < .001), pressure ulcer episodes (p < .001), duration of injury (p = .001), and pain (p = .052); for hospitalization, they were pressure ulcer episodes (p < .001) and complications (p = .043); for CHART scores, they were discharge FIM (p < .001), preinjury education (p < .001), hospitalization (p = .007), chronic pain (p = .01), longest time at one job (p = .02), completeness of injury (p = .042), and preinjury employment (p = .049). CONCLUSIONS: Disability is the most important factor in postrehabilitation outcomes for SCI, followed by injury completeness, which is also associated with multiple outcomes. Postinjury but not preinjury drug abuse is adversely associated with outcomes. Etiology and ethnicity are not important determinates of outcome.

Ethnicity effect on the serum lipid profile in persons with spinal cord injury.

OBJECTIVE: The potential effect of ethnicity on the serum lipid profile and lipoprotein(a) [Lp(a)] was studied in a population with chronic spinal cord injury (SCI). STUDY DESIGN: The distribution and correlates of high density lipoprotein (HDL) cholesterol and Lp(a) were studied in a population of 600 subjects with chronic SCI. RESULTS: Mean +/- SEM serum HDL cholesterol was significantly higher in the African American group than in the white and Latino groups (47 +/- 1 vs 40 +/- 1 and 38 +/- 1 mg/dL, p < .0001, respectively). The African American group had a lower serum total to HDL cholesterol ratio than white and Latino groups (4.46 +/- .153 vs 5.18 +/- .168 and 5.40 +/- .140 mg/dL, p < .01, respectively). Mean serum Lp(a) levels were significantly higher in the African American group than in Latino or white groups (29 +/- 2 vs 18 +/- 1 and 15 +/- 1 mg/dL, p < .0001, respectively). Age, duration of SCI, and level and completeness of lesion had no significant effect on serum Lp(a) level. CONCLUSIONS: In a population with chronic SCI, those in the African American group had the highest serum HDL cholesterol concentrations, the lowest serum total to HDL cholesterol ratios, and elevated levels of serum Lp(a) compared with the Latino and white groups. In a population of individuals with chronic SCI, ethnicity was shown to have a major effect on serum lipids and may be used to assist in the determination of cardiovascular risk.

The effect of residual neurological deficit on serum lipoproteins in individuals with chronic spinal cord injury.

Subjects with spinal cord injury (SCI) have been shown to have an adverse lipid profile. Prior studies performed with smaller numbers of subjects have not been able to demonstrate any relationship between the level and degree of the neurological deficit and plasma lipid levels. Over a 2 year period we investigated the lipid profiles in 541 subjects from Rancho Los Amigos Medical Center, Downey, California. Subjects were grouped by tetraplegia (Tetra; n = 247) or paraplegia (Para; n = 294) and by subgroup for degree of neurological deficit: complete Tetra (n = 156), incomplete Tetra (n = 91), complete Para (n = 206) and incomplete Para (n = 88). The serum high-density lipoprotein (HDL) cholesterol level was lower in the Tetra than in the Para group (38 +/- 0.7 vs 45 +/- 0.8, P < 0.01). The group with Tetra had a higher percentage of subjects with serum HDL cholesterol values < 35 mg/dL [an independent risk factor for coronary heart disease (CHD)] than those with Para (38% vs 21%, P < 0.0001). A significant inverse relationship was found for degree of neurological deficit and mean serum HDL cholesterol level (r = 0.19, P < 0.001), with the greater the deficit, the lower the serum HDL cholesterol level. Serum total cholesterol levels were higher in the Para group than in the Tetra group (198 +/- 2.6 vs 184 +/- 2.6, P < 0.01). However, the ratio of total cholesterol to HDL cholesterol (a discriminator of risk for CHD) was significantly lower in the Para group than the Tetra group (4.8 vs 5.2%, P < 0.01). Thus, in persons with SCI a spectrum of depressed serum HDL cholesterol levels and increased cardiovascular risk occur, with the most adverse lipid changes correlating with the severity of neurological deficit.

Firearm versus motor vehicle related spinal cord injury: preinjury factors, injury characteristics, and initial outcome comparisons among ethnically diverse groups.

OBJECTIVE: To determine the extent to which individuals with spinal cord injuries caused by firearms differed from those caused by motor vehicle crash (MVC) in terms of selected preinjury factors, injury characteristics and related treatment, and outcomes at discharge from rehabilitation; and to determine the effect of ethnicity on preinjury factors and outcome. DESIGN: Survey including interview of former rehabilitation inpatients and medical records review. SETTING: Model Spinal Cord Injury Care System centered at an urban, public rehabilitation medical center. PARTICIPANTS: Volunteer convenience sample of 164 men who were between the ages of 18 and 35 years at the time of injury and who were injured by firearm or MVC between January 1, 1980 and December 31, 1989. Subjects had completed rehabilitation at a rehabilitation center; they were non-Latino White, African-American, or Latino. Subjects were contacted by mail and telephone. The sample was comprised of 26% of the potential participants; however, differential follow-up rates were highly consistent with distribution of primary characteristics within the population of potential candidates. MAIN OUTCOME MEASURES: The Functional Independence Measure (FIM) and total and rehabilitation lengths of stay were the outcome measures. Groups and outcomes were also compared in terms of preinjury education, employment, and indicators of antisocial behavior, as well as neurological deficit, associated injuries, and surgical treatment. RESULTS: The firearm and MVC groups were different in terms of ethnic distribution. There were no non-Latino Whites in the firearm group and few African-Americans in the MVC group. With the exception of preinjury education, nonparametric and univariate tests showed differences between the firearm and MVC groups in terms of preinjury employment and indicators of antisocial behavior, associated injuries, surgical treatment, neurological deficit, and lengths of stay. Changes in FIM scores, however, were not different between etiologic or ethnic groups. Multiple regression indicated that injury severity accounted for the largest variance in outcomes and that preinjury factors, etiology, and ethnicity did not contribute significantly to the variance in outcome measures. CONCLUSIONS: Although preinjury factors are associated with ethnicity and minorities have higher proportions of SCI caused by firearms, these factors do not significantly influence rehabilitation outcomes at discharge. The primary factors influencing rehabilitation outcomes are related to the deficits, associated physical injuries, and related treatments common to the causes of the injury.

Motor recovery following spinal cord injury associated with cervical spondylosis: a collaborative study.

A prospective multicenter study was conducted within the National Model Spinal Cord Injury System program to examine neurological deficits and recovery patterns following spinal cord injury (SCI) in individuals with cervical spondylosis and without a spinal fracture. Nineteen patients were evaluated. Sixty-eight percent presented initially with motor incomplete lesions. Of those who presented with motor incomplete injuries at their initial examination, 69 percent had less deficit in the lower than in the upper extremities, indicative of a central cord syndrome. At follow-up, 12 subjects were unable to ambulate, four required assistance and three were able to ambulate independently. On the average, subjects doubled their initial Asia Motor Score (AMS) scores by one year following injury. Residual upper extremity weakness, however, limited the ability to ambulate. Recovery of motor strength in this group is comparable to that of individuals with incomplete tetraplegia in general but the proportion who regain ambulatory function is less.

The effect of a flexion contracture of the elbow on the ability to transfer in patients who have quadriplegia at the sixth cervical level.

We studied six patients (twelve upper extremities) who had quadriplegia at the sixth cervical level. Our purpose was to evaluate how the loss of terminal extension of the elbow adversely affected the ability of the patient to perform transfers with a sliding board and so-called depression raises (lifting of the body with use of the extended upper extremities to reduce the pressure on the ischial tuberosities). Function of the triceps muscle was considered to be absent in eight upper extremities and present in four. A flexion contracture of the elbow was simulated with use of a specially fabricated, hinged elbow brace. Terminal extension was progressively limited, in 5-degree increments, until the patient was no longer able to perform the transfer or the depression raise. The mean flexion contracture at which the patient could not perform the transfer or the depression raise was approximately 25 degrees when function of the triceps was absent and approximately 50 degrees when function of the triceps was intact. The results of this study emphasize the importance of maintaining the full range of motion of the elbow in a patient who has high-level quadriplegia. In a patient who has quadriplegia at the sixth cervical level who otherwise would be independent with regard to transfer skills and mobility in bed, a flexion contracture of the elbow of approximately 25 degrees or more can result in the loss of a functional level and render the patient as dependent as one who has quadriplegia at the fifth cervical level.