Review Article | Published:

Physiotherapy interventions for increasing muscle strength in people with spinal cord injuries: a systematic review

Spinal Cord (2019) | Download Citation

Abstract

Study design

A systematic review.

Objective

The aim of this review was to determine the effectiveness of physiotherapy (PT) interventions for increasing voluntary muscle strength in people with spinal cord injuries (SCI).

Methods

We included randomised controlled trials of PT interventions for people with SCI. We were interested in two comparisons: PT interventions compared with sham or no intervention, and PT interventions compared to each other. The outcome of interest was voluntary strength of muscles directly affected by SCI. All included studies were rated according to the Cochrane Risk of Bias Tool and results of similar trials were pooled using meta-analyses where possible.

Results

Twenty-six trials met the inclusion criteria and provided useable data. A statistically significant between-group difference was found in four comparisons, namely, resistance training versus no intervention (standardised mean difference (SMD) = 0.64; 95% CI, 0.22–1.07; p = 0.003); resistance training combined with electrical stimulation versus no intervention (mean difference (MD) = 14 Nm; 95% CI, 1–27; p = 0.03); a package of PT interventions versus no intervention (MD = 4.8/50 points on the Lower Extremity Motor Score (LEMS); 95% CI 1.9–7.7; p = 0.01); and robotic gait training versus overground gait training (MD = 3.1/50 points on the LEMS; 95% CI, 1.3–5.0; p = 0.0008).

Conclusion

There is evidence that a small number of PT interventions increase voluntary strength in muscles directly affected by SCI.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  1. 1.

    Bye EA, Harvey LA, Gambhir A, Kataria C, Glinsky JV, Bowden JL, et al. Strength training for partially paralysed muscles in people with recent spinal cord injury: a within-participant randomised controlled trial. Spinal Cord. 2017;55:460–65.

  2. 2.

    Glinsky J, Harvey L, van Es P, Chee S, Gandevia SC. The addition of electrical stimulation to progressive resistance training does not enhance the wrist strength of people with tetraplegia: a randomized controlled trial. Clin Rehabil. 2009;23:696–704.

  3. 3.

    Popovic MR, Thrasher TA, Adams ME, Takes V, Zivanovic V, Tonack MI. Functional electrical therapy: retraining grasping in spinal cord injury. Spinal Cord. 2006;44:143–51.

  4. 4.

    Beekhuizen KS, Field-Fote EC. Sensory stimulation augments the effects of massed practice training in persons with tetraplegia. Arch Phys Med Rehabil. 2008;89:602–8.

  5. 5.

    Field-Fote EC, Roach KE. Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial. Phys Ther. 2011;91:48–60.

  6. 6.

    Alcobendas-Maestro M, Esclarin-Ruz A, Casado-Lopez RM, Munoz-Gonzalez A, Perez-Mateos G, Gonzalez-Valdizan E, et al. Lokomat robotic-assisted versus overground training within 3 to 6 months of incomplete spinal cord lesion: randomized controlled trial. Neurorehabil Neural Repair. 2012;26:1058–63.

  7. 7.

    Hornby TG, Campbell DD, Zemon DH, Kahn JH. Clinical and quantitative evaluation of robotic-assisted treadmill walking to retrain ambulation after spinal cord injury. Top Spinal Cord Inj Rehabil. 2005;11:1–17.

  8. 8.

    Tuszynski MH, Steeves JD, Fawcett JW, Lammertse D, Kalichman M, Rask C, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP Panel: clinical trial inclusion/exclusion criteria and ethics. Spinal Cord. 2007;45:222–31.

  9. 9.

    Lammertse DP. Clinical trials in spinal cord injury: lessons learned on the path to translation. The 2011 International Spinal Cord Society Sir Ludwig Guttmann Lecture. Spinal Cord. 2013;51:2–9.

  10. 10.

    Steeves JD, Lammertse D, Curt A, Fawcett JW, Tuszynski MH, Ditunno JF, et al. Guidelines for the conduct of clinical trials for spinal cord injury (SCI) as developed by the ICCP panel: clinical trial outcome measures. Spinal Cord. 2007;45:206–21.

  11. 11.

    Harvey L, Lin CM, Glinsky J, De Wolf A. The effectiveness of physical interventions for people with spinal cord injuries: a systematic review. Spinal Cord. 2009;47:184–95.

  12. 12.

    Harvey LA, Glinsky JV, Bowden JL. The effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injury: a systematic review. Spinal Cord. 2016;54:914–23.

  13. 13.

    Mehrholz J, Harvey LA, Thomas S, Elsner B. Is body-weight-supported treadmill training or robotic-assisted gait training superior to overground gait training and other forms of physiotherapy in people with spinal cord injury? A systematic review. Spinal Cord. 2017;55:722–9.

  14. 14.

    Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ. 1994;309:1286–91.

  15. 15.

    Brazg G, Fahey M, Holleran CL, Connolly M, Woodward J, Hennessy PW, et al. Effects of training intensity on locomotor performance in individuals with chronic spinal cord injury: A randomized crossover study. Neurorehabil Neural Repair. 2017;31:944–54.

  16. 16.

    Gomes-Osman J, Tibbett JA, Poe BP, Field-Fote EC. Priming for improved hand strength in persons with chronic tetraplegia: a comparison of priming-augmented functional task practice, priming alone, and conventional exercise training. Front Neurol. 2016;7:242.

  17. 17.

    The Cochrane Collaboration. Cochrane Handbook for Systematic Reviews of Interventions Version 5. 1.0 [updated March 2011]. The Cochrane Collaboration, 2011. www.cochrane-handbook.org. 2011.

  18. 18.

    Review Manager (RevMan). The Nordic Cochrane Centre. Copenhagen: The Cochrane Collaboration; 2015.

  19. 19.

    Labruyère R, van Hedel HJ. Strength training versus robot-assisted gait training after incomplete spinal cord injury: A randomized pilot study in patients depending on walking assistance. J Neuroeng Rehabil. 2014;11:4. https://doi.org/10.1186/1743-0003-11-4.

  20. 20.

    Beekhuizen KS. New perspectives on improving upper extremity function after spinal cord injury. J Neurol Phys Ther. 2005;29:157–62.

  21. 21.

    Dobkin B, Apple D, Barbeau H, Basso M, Behrman A, Deforge D, et al. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology. 2006;66:484–493.

  22. 22.

    Glinsky J, Harvey L, Korten M, Drury C, Chee S, Gandevia SC. Short-term progressive resistance exercise may not be effective for increasing wrist strength in people with tetraplegia: a randomised controlled trial. Aust J Physiother. 2008;54:103–8.

  23. 23.

    Harvey LA, Fornusek C, Bowden JL, Pontifex N, Glinsky J, Middleton JW, et al. Electrical stimulation plus progressive resistance training for leg strength in spinal cord injury: a randomized controlled trial. Spinal Cord. 2010;48:570–5.

  24. 24.

    Harvey LA, Dunlop SA, Churilov L, Galea MP. Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury (‘Hands On’): a randomised trial. J Physiother. 2017;63:197–204.

  25. 25.

    Jones ML, Evans N, Tefertiller C, Backus D, Sweatman M, Tansey K. et al. Activity-Based Therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial. Arch Phys Med Rehabil. 2014;95:2239–46.

  26. 26.

    Kim DI, Lee H, Lee BS, Kim J, Jeon JY. Effects of a six-week indoor hand-bike exercise program on health and fitness levels in people with spinal cord injury: a randomized controlled trial study. Arch Phys Med Rehabil. 2015: https://doi.org/10.1016/j.apmr.2015.1007.1010.

  27. 27.

    Klose KJ, Needham BM, Schmidt D, Broton JG, Green BA. An assessment of the contribution of electromyographic biofeedback as an adjunct therapy in the physical training of spinal cord injured persons. Arch Phys Med Rehabil. 1993;74:453–6.

  28. 28.

    Needham-Shropshire BM, Broton JG, Cameron TL, Klose KJ. Improved motor function in tetraplegics following neuromuscular stimulation-assisted arm ergometry. J Spinal Cord Med. 1997;20:49–55.

  29. 29.

    Popovic MR, Kapadia N, Zivanovic V, Furlan JC, Craven BC, McGillivray C. Functional electrical stimulation therapy of voluntary grasping versus only conventional rehabilitation for patients with subacute incomplete tetraplegia: a randomized clinical trial. Neurorehabil Neural Repair. 2011;25:433–42.

  30. 30.

    Varoqui D, Niu X, Mirbagheri MM. Ankle voluntary movement enhancement following robotic-assisted locomotor training in spinal cord injury. J Neuroeng Rehabil. 2014;11:46.

  31. 31.

    Alexeeva N, Sames C, Jacobs PL, Hobday L, Distasio MM, Mitchell SA, et al. Comparison of training methods to improve walking in persons with chronic spinal cord injury: a randomized clinical trial. J Spinal Cord Med. 2011;34:362–79.

  32. 32.

    Galea MP, Panisset MG, El-Ansary D, Dunlop SA, Marshall R, Clark JM, et al. SCIPA Switch-On: A Randomized Controlled Trial Investigating the Efficacy and Safety of Functional Electrical Stimulation-Assisted Cycling and Passive Cycling Initiated Early after Traumatic Spinal Cord Injury. Neurorehabil Neural Repair. 2017;31:540–51.

  33. 33.

    Gorman PH, Scott W, York H, Theyagaraj M, Price-Miller N, McQuaid J, et al. Robotically assisted treadmill exercise training for improving peak fitness in chronic motor incomplete spinal cord injury: a randomized controlled trial. J Spinal Cord Med. 2016;39:32–44.

  34. 34.

    Hartkopp A, Harridge SD, Mizuno M, Ratkevicius A, Quistorff B, Kjaer M, et al. Effect of training on contractile and metabolic properties of wrist extensors in spinal cord-injured individuals. Muscle Nerve. 2003;27:72–80.

  35. 35.

    Hoffman LR, Field-Fote EC. Functional and corticomotor changes in individuals with tetraplegia following unimanual or bimanual massed practice training with somatosensory stimulation: a pilot study. J Neurol Phys Ther. 2010;34:193–201.

  36. 36.

    Jayaraman A, Thompson CK, Rymer WZ, Hornby TG. Short-term maximal-intensity resistance training increases volitional function and strength in chronic incomplete spinal cord injury: a pilot study. J Neurol Phys Ther. 2013;37:112–7.

  37. 37.

    Kapadia N, Zivanovic V, Popovic MR. Restoring voluntary grasping function in individuals with incomplete chronic spinal cord injury: pilot study. Top Spinal Cord Inj Rehabil. 2013;19:279–87.

  38. 38.

    Klose KJ, Schmidt DL, Needham BM, Brucker BS, Green BA, Ayyar DR. Rehabilitation therapy for patients with long-term spinal cord injuries. Arch Phys Med Rehabil. 1990;71:659–62.

  39. 39.

    Kohlmeyer KM, Hill JP, Yarkony GM, Jaeger RJ. Electrical stimulation and biofeedback effect on recovery of tenodesis grasp: a controlled study. Arch Phys Med Rehabil. 1996;77:701–6.

  40. 40.

    Kowalczewski J, Chong SL, Galea M, Prochazka A. In-home tele-rehabilitation improves tetraplegic hand function. Neurorehabil Neural Repair. 2011;25:412–22.

  41. 41.

    Piira A, Lannem AM, Sorensen M, Glott T, Knutsen R, Gjesdal N, et al. Effects of locomotor training in subjects with incomplete sci-a randomized controlled trial. Arch Phys Med Rehabil. 2017;98:e60–1.

  42. 42.

    Postans NJ, Hasler JP, Granat MH, Maxwell DJ. Functional electrical stimulation to augment partial weight-bearing supported treadmill training for patients with acute incomplete spinal cord injury: a pilot study. Arch Phys Med Rehabil. 2004;85:604–10.

  43. 43.

    Senthilvelkumar T, Magimairaj H, Fletcher J, Tharion G, George J. Comparison of body weight-supported treadmill training versus body weight-supported overground training in people with incomplete tetraplegia: a pilot randomized trial. Clin Rehabil. 2015;29:42–9.

  44. 44.

    Shin JC, Kim JY, Park HK, Kim NY. Effect of robotic-assisted gait training in patients with incomplete spinal cord injury. Ann Rehabil Med. 2014;38:719–25.

  45. 45.

    Wu M, Landry JM, Schmit BD, Hornby TG, Yen SC. Robotic resistance treadmill training improves locomotor function in human spinal cord injury: a pilot study. Arch Phys Med Rehabil. 2012;93:782–9.

  46. 46.

    Wu M, Landry JM, Kim J, Schmit BD, Yen SC, McDonald J, et al. Repeat exposure to leg swing perturbations during treadmill training induces long-term tetention of increased step length in human SCI: A pilot randomized controlled study. Am J Phys Med Rehabil. 2016;95:911–20.

  47. 47.

    Yang JF, Musselman KE, Livingstone D, Brunton K, Hendricks G, Hill D, et al. Repetitive mass practice or focused precise practice for retraining walking after incomplete spinal cord injury? A pilot randomized clinical trial. Neurorehabil Neural Repair. 2014;28:314–24.

  48. 48.

    Kraemer WJ, Adams K, Cafarelli E, Dudley GA, Dooly C, Feigenbaum MS, et al. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2002;34:364–80.

Download references

Acknowledgements

LAH’s position is supported by Icare and SIRA, NSW, Australia.

Funding

This systematic review was in part funded by Icare, NSW, Australia.

Author contributions

All authors conceived the review, contributed to culling papers, extracted data, rated trials for bias, interpreted results and wrote up the final paper.

Author information

Affiliations

  1. John Walsh Centre for Rehabilitation Research, Sydney Medical School, University of Sydney, Sydney, Australia

    • Nisha Aravind
    • , Lisa A. Harvey
    •  & Joanne V. Glinsky

Authors

  1. Search for Nisha Aravind in:

  2. Search for Lisa A. Harvey in:

  3. Search for Joanne V. Glinsky in:

Conflict of interest

The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Lisa A. Harvey.

Supplementary Information

About this article

Publication history

Received

Revised

Accepted

Published

DOI

https://doi.org/10.1038/s41393-019-0242-z