Answer to correspondence on 'Arm-hand training strategies and therapy dose dimensions during the subacute rehabilitation of people with cervical spinal cord injury: a longitudinal observational study'

Abstract

Dear editor, We thank Zheng et al. for their thoughtful and constructive correspondence regarding our longitudinal observational study on arm-hand training strategies and therapy dose dimensions during subacute rehabilitation in individuals with cervical spinal cord injury. We appreciate the opportunity to further clarify several methodological considerations and to reflect on directions for future research. ASSESSMENT OF EXERCISE TRAINING STRATEGIES AND CLIENT-CENTERED GOAL SETTING With respect to the operational definitions and thresholds used to classify task-oriented training components, our research team relied on the framework and definitions described by Timmer-mans et al. (2010), who identified and operationalized task-oriented components within upper limb stroke rehabilitation [1]. These definitions were consistently applied in the current study. Prior to data collection, all observers were trained using detailed explanations and video-based examples of therapy sessions to ensure a shared understanding and consistent application of these definitions. While clear quantitative thresholds could not be defined for all components due to their qualitative nature, specific components, such as overload and patient-customized training load, were quantifiable and therefore operationalized accordingly. We agree that the finding that only 53.3% of sessions were perceived by participants as aligned with their personal goals is unexpectedly low, particularly given the well-established benefits of client-centered goal setting in neurological rehabilitation. As discussed in the original article, this discrepancy likely reflects a gap between therapists' perceptions of client-centered practice and patients' lived experiences. This raises important questions regarding patients' awareness of their therapeutic goals and how clearly the link between training activities and those goals is communicated. However, exploring the underlying reasons for this discrepancy, such as therapists' clinical reasoning, contextual constraints, or communication processes, was beyond the scope of the present observational study. The primary aim of our study was to describe current motor training strategies, therapy dose dimensions, and motivation in subacute arm-hand rehabilitation, and how these evolve over a six-month period. Previous work from our group has demonstrated the effectiveness of skill training, alone or in combination with strength and endurance training, in improving arm-hand skilled performance, which was confirmed by experienced therapists during focus group discussions [2, 3]. The present findings highlight that the translation of this evidence into routine clinical practice remains limited. Indeed, therapists have emphasized the need for structured, evidence-based, and person-centered guidelines to support arm-hand rehabilitation in individuals with cervical spinal cord injury. In response, our research group has developed a validated framework to guide clinical practice [4]. We fully agree that future studies incorporating qualitative methods, such as interviews or reflective protocols, would provide valuable insights into therapists' decision-making processes during therapy sessions. THERAPY DOSE DIMENSIONS We concur that repetition count alone cannot be considered a sufficient or universal indicator of therapy dose, particularly in skill training, but also across other training modalities. For this reason, our study explicitly emphasized the importance of assessing multiple therapy dose dimensions within a session, including active time, repetition counts, subjective intensity, and subjective difficulty. Taken together, these parameters provide a more comprehensive representation of therapy dose than any single metric in isolation. These insights have been further integrated into the validated arm-hand rehabilitation framework developed by our research team [4]. INTERPRETATION OF MOTIVATION AND SUBJECTIVE DOSE DIMENSIONS As acknowledged in the methodological considerations, we are aware of the limitations associated with using a visual analogue scale (VAS) to assess constructs beyond pain, such as motivation, fatigue, and difficulty. This measure was selected for its practical feasibility in a clinical setting, as participants were required to report these parameters before and after each therapy session. The use of more extensive questionnaires was therefore not considered feasible within the context of routine care. We agree that multidimensional motivation measures and objective indicators, such as psychological or neuromuscular biomarkers, could provide deeper insights into motivational states and fatigue. However, given the exploratory nature and primary aim of the study, we sought to interfere as little as possible with usual care during the rehabilitation phase, in order to obtain an ecologically valid picture of current clinical practice using measures feasible for daily use. In conclusion, we appreciate the authors' engagement with our work and their valuable suggestions. We agree that future