Upper limb training: strategies and therapy dose dimensions across the rehabilitation of people in the (sub)acute phase after a cervical spinal cord injury

Abstract

Introduction Different motor training strategies and therapy doses may lead to diverse upper limb treatment outcomes. However, it is unknown how they are used in therapy. This study aims to inventory the current motor training strategies and therapy doses used in upper limb motor training. Methods A longitudinal observational study was executed in three rehabilitation centers (in Belgium and the Netherlands). Active upper limb training during usual care for patients with a cervical spinal cord injury (i.e.lesions ranging from C1 to Th1 and AIS A-D) between 4-8 post-injury weeks at inclusion were observed per patient on three days of the week during three separate weeks, interspaced by eight weeks, and recorded on video. Sessions with 25% of the time upper limb training were included. Motor training strategies (training modalities and task-oriented training components) and therapy dose dimensions were retrieved from observations by trained observers using standard forms. The therapy dose dimensions, subjective difficulty, and intensity perceived by the patient were assessed using a Visual Analogue Scale. Patient characteristics, motor training strategies, and therapy dose dimensions were reported in terms of means (M), standard deviations (SD), and percentages. Results In the ongoing study, 84 upper limb sessions were examined, involving eight patients (AIS B-D, lesion C1-C5, mean age 56.1 years (SD: 12.1) and mean post-injury weeks 7.5 (SD: 1.6) at inclusion). The sessions had a mean planned time of 54’06’’ (SD: 29’15’’), with a mean session length of 40’56’’ (SD: 25’25’’). 80.6% (M: 33’00’’; SD: 23’25’’) of the session length was spent on upper limb training. The sessions had a mean active time of 20’31’’ (SD: 13’56’’) and a session density of 62.2% active and 37.8% inactive time. Patients indicated a subjective difficulty of, on average, 3.9 (SD: 2.4) and a subjective intensity of, on average, 3.9 (SD: 2.2). The frequencies of used training modalities were: skill training: 36.9%, analytical training: 34.6%, strength training: 24.6%, and endurance training: 3.8%. The mean active time and the amount of movements per training modality were, respectively: skill training: 14’38’’ (SD: 14’19’’); 349.5 (SD: 403.3), analytical training 15’28’’ (SD: 11’04’’); 225.9 (SD: 161.8), strength training 8’26’’ (SD: 6’04’’); 213.9 (SD: 180), endurance training 8’51’’ (SD: 10’35’’); 142 (SD: 118.2). The sessions frequently included the task-oriented training components: different movement planes: 67.5%, patient-customized training load: 66.3% and functional movements: 63.9%. In 21.7% of the sessions, real-life objects were used, and 12% were performed in a context-specific environment. Conclusions These preliminary results showed session lengths of only 75.6% of the planned time, and within the session only 62.2% was active upper limb training. Patients indicated a relatively low subjective difficulty and intensity, while a patient-customized training load was observed in 66.3%. Analytical training is frequently used; however, the literature shows no evidence of its effect on upper limb outcomes. Task-oriented training components recommended to improve training outcomes were not frequently used; context-specific environments and real-life objects. Future research is needed to optimize and implement training strategies and therapy doses into upper limb motor training.