Motor training strategies, therapy dose and person's motivation of arm-hand training in people with cervical spinal cord injury: a systematic review

Abstract

Introduction Motor training may improve arm-hand functioning in people with cervical spinal cord injuries. Literature advocates task-specific motor training programs with a certain amount of training to improve arm-hand functioning. Furthermore, adequate attention and motivation are essential in promoting engagement in the (re)learned arm-hand motor task. However, the optimal motor training strategies, training dosages, and optimal motivational cues are yet unknown.

Methods Systematic literature research in five databases (PubMed, Cochrane, CINAHL, EMBASE, DARE) between January 1970 and May 2022, including papers on active arm-hand motor training programs. The analysis was divided into a narrative and a quantitative part. Methodological quality was assessed using the Van Tulder checklist. Effect sizes were calculated using Hedge's g; mean effect sizes were calculated to compare outcomes on the International Classification of Functioning, Disability, and Health levels of function and activity.

Results Eleven studies included in the narrative analysis reported mainly on skill training alone or combined with strength and/or endurance training. Skill training programs reported on the incorporation of the following task-oriented training components: functional movements, clear functional goals, real-life object manipulation, multiple movement planes, and bimanual practice. Most of the included studies reported therapy doses ranging from 3-12 weeks and 3-7 intervention days/week. Based on seven studies, the quantitative analyses demonstrated the highest effect size on arm-hand skilled performance for skill training with additional strength and/or endurance training. The task-oriented training components with a mean effect size of more than 0.5 were: functional movements, multiple movement planes, total skill practice, real-life object manipulation, context-specific environment, clear functional goal, exercise variety, and bimanual practice. Training at least eight weeks with at least three intervention days/week resulted in the largest effect size. Using client-centered goals, resulting in high effect sizes on persons' perception of arm-hand activities. Conclusions Training to improve arm-hand functioning should include skill training with at least eight task-oriented training components with additional strength and/or endurance training. The required training dose should be at least eight weeks with at least three sessions a week. Other therapy dose dimensions were not discussed in the included studies; however, to guide clinical practice on therapy dose, more in-depth research on currently used therapy dose dimensions and how they can be objectively measured, is necessary. Client-centered goals positively impact persons' motivation, but they are still not widely used in motor training programs. Furthermore, other motivational cues were not included in the studies, although they may have an important impact on arm-hand functioning training outcomes.