Evidence-based framework to optimize active upper limb motor training in subacute cervical spinal cord injury

Abstract

Introduction Motor training may enhance upper limb (UL) functioning in people with cervical spinal cord injury. While the literature recommends task-specific motor training with a certain dose, in clinical practice, the use of specific training variables, such as motor training strategies and dosages, to optimize UL training is unclear. This project aims to develop a framework for arm-hand training incorporating crucial training variables to guide therapists to improved clinical practice.

Methods The framework is established using a multiphase and multidimensional approach to gather evidence. (1) A systematic literature review to assess motor training strategies and dosages utilized in active UL motor training. (2) A longitudinal observational study across three rehabilitation centers in Belgium and the Netherlands to observe motor training strategies and therapy dosages in usual UL training. (3) A qualitative study with three focus groups comprising experienced therapists from the aforementioned rehabilitation centers to capture practice-based evidence and identify needs to optimize UL training.

Results Within the framework, a four-phase approach is proposed consisting of 1) gathering knowledge about the person and the client system, which is needed for 2) the process of thinking in which a goal-setting process leads to a patient-tailored therapy plan; 3) the process of acting by providing the goal and task-oriented therapy content and individualized therapy dose; and 4) providing practice beyond therapy. This individualized training approach aims to enhance persons' motivation and the execution of the relearned UL activities beyond therapy. Concerning the intervention, the systematic review and focus groups revealed that the content should include skill training incorporating task-oriented training components with additional strength and endurance training. Although therapists indicated the importance of task-oriented training, this was not seen yet in clinical practice, where observations revealed that analytical training (62,5%) is most used, followed by skill training (52.5%), strength training (42.9%) and endurance training (10.8%) and only three task-oriented training components, i.e., functional movements, exercise variety, and multiple movement planes are employed over 50% of the sessions. About therapy dose, the results of the systematic review indicated a minimum of eight weeks of training to enhance UL functioning; information on other dose dimensions was not available. While therapists stress the need for personalized training doses, the observation study found that therapists tend to overestimate the active therapy time, difficulty, and intensity of the training. Patients scored the dose elements relatively low. Therapists ask for guidance in applying customized motor training strategies and therapy doses into individualized UL therapy. A personalized goal-oriented approach is advised to improve patients' motivation, leading to enhanced rehabilitation engagement. Participating in meaningful tasks during therapy leads to executing these tasks beyond therapy, increasing the therapy dose, and optimizing functional outcomes.

Conclusions The proposed UL framework, employing a multi-methodological approach, outlines a highly individualized approach. It involves four phases, where the personalized goal-setting process leads toward goal-and-task-oriented interventions using individualized motor training strategies and therapy doses. Therapists need guidance in the application of the different essential training variables. Therefore, clinical practice tools will be developed based on this framework.