Abstract
Individuals with cervical spinal cord injury experience tetraplegia with dramatic impairment of upper limb (UL) including hand function and decreased autonomy. In absence of very recent evidence and meta-analysis, we addressed UL rehabilitation effectiveness after tetraplegia. Two independent reviewers performed the systematic review and meta-analysis addressing Pubmed, Pedro, Central and Scopus ® . We considered studies with a randomized controlled trial design, published in English language, which included individuals with tetraplegia and measured UL rehabilitation effect on strength, somesthesia, hand function and autonomy. From 573 records identified, 24 studies were included totaling 517 participants with C2 to C7 tetraplegia (ASIA A to D). Interventions lasted from 66 to 3780 minutes. Three different strategies were used i) bottom-up (namely massed practice, Functional Electrical Stimulation – FES, resistance or robotic training), ii) neuromodulation (i.e. electrical nerve, trans-cranial or magnetic stimulations), or iii) top-down (brain computer interfaces with FES or virtual reality). The 17 studies analyzed displayed heterogeneity for all outcomes except for strength. Overall, strength significantly increased with positive but non-significant effect on hand function and autonomy. Sub-analysis revealed a significant effect on strength only for bottom-up strategy. All other sub-analyzes albeit non-significant revealed at least a medium effect size for all outcomes with exception to the very small effect size displayed for somesthesia. These results support the effectiveness of UL rehabilitation on strength using. There is a potential interest of using bottom-up and neuromodulation strategies to improve hand function and autonomy but with heterogeneity between interventions and participants. Conversely, there is no evidence for top-down strategy and interventions targeting somesthesia appear ineffective. Further effort on funding may promote high-quality multi-centric studies with increased standardization in intervention and participants to completely address UL rehabilitation effectiveness after tetraplegia while separating recovery and compensation effects.
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