the expected outcomes of elbow extension transfers on strength and function of patients with a spinal cord injury. For each goal, the subject rated performance and satisfaction using a 10-point Likert scale, in which 1 was negative (“cannot perform,” “not satisfied”) and 10 was positive (“performs very well,” “very satisfied”). After surgery, performance and satisfaction are rated again for each goal. A positive change is seen in patient-perceived performance and satisfaction with self-identified goals after tendon transfers. A good example of the use of the COPM can be found in a report published by Scott Kozin, thirty-three goals for surgery were established. Following the biceps-to-triceps transfer, improvement in at least one goal was seen in all patients. Performance and satisfaction were greatly improved (an improvement of at least 4 points) in certain activities of daily living, including reaching for objects, recreational activities, wheelchair propulsion, and transfers. Although improvement was seen in most goals, a reduction was reported in 2 goals (one pertaining to dressing and the other to transfer). After tendon transfers, the total mean score statistically increased from 2.6 to 5.6 for performance (p .001) and from 1.8 to 5.7 for satisfaction (p .001). Criteria for surgery General indications for functional surgery of the hand and arm in tetraplegic patients: There are different views on optimal timing of surgery after a spinal cord injury. The general consensus is to operate the patient when he or she is neurologically stable. Some surgeons try to operate a patient as early as possible. The advantages of this are that the patient can take advantage of the new functional possibilities before new adjustments and adaptations develop. Other surgeons operate when it becomes feasible. This is usually 12–18 months after injury (can be shortened to 6–7 months) and only after stabilization of motor function. Important spasticity (see further) and neurovegetative complications (i.e. bladder function, bowel function, pulmonary function and pressure sores) must have been treated already. The patient must be able to sit in a wheelchair so that he/she can move the arm against gravity. Usually a compromise is found between the patient’s wishes and the surgeon when timing the surgery. An indication for biceps-to-triceps surgery is when the patient plateaud for more than 3 months in their motor recovery. It is usually the choice of procedure for patients who have a flexion contractures greater than 45 degrees. The procedure will release the contracture