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Research paper 
FOI 24/25-0223 
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Therapy for chronic incomplete cervical spinal 
cord injury 
The content of this document is OFFICIAL. 
Please note: 
The research and literature reviews collated by our TAB Research Team are not to be shared 
external to the Branch. These are for internal TAB use only and are intended to assist our 
advisors with their reasonable and necessary decision-making. 
Delegates have access to a wide variety of comprehensive guidance material. If Delegates 
require further information on access or planning matters, they are to call the TAPS line for 
advice. 
The Research Team are unable to ensure that the information listed below provides an 
accurate & up-to-date snapshot of these matters 
Research question: For adults living with a high-level Spinal Cord Injury at least 5+ years 
post-injury, how does the provision of a high level of physiotherapy and/or occupational 
therapy hours for the purpose of restoring upper limb function, compared to reduced therapy 
hours and a delegated model of care, impact functional upper limb outcomes? 
Date: 13/6/24 
Requestor:  s47F - personal privacy 
Endorsed by: Helen Bs47F - personal privacy 
Researcher: Aaron Hs47F - personal priva 
Cleared by: Aaron Hs47F - personal priva 
1. Contents
Therapy for chronic incomplete cervical spinal cord injury ......................................................... 1 
1. Contents .......................................................................................................................... 1 
2. Summary ......................................................................................................................... 2 
3. Improving function for chronic spinal cord injury.............................................................. 2 
4. Therapy targeting upper limb function ............................................................................. 2 
5. References ...................................................................................................................... 5 
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2. Summary
There is some evidence that therapy continues to be effective in improving upper limb function 
and strength for people in the chronic stage of cervical spinal cord injury. Conventional 
physiotherapy or occupational therapy focussing on hand and arm function is possibly effective 
in this cohort and participants may be benefited by conventional training combined with robot-
assisted upper limb training and/or electrical stimulation. It may be more likely that benefit 
could be achieved for people with incomplete rather than complete injury. 
However, the level of evidence reviewed is generally low to very low certainty. Insufficient 
evidence was found to determine optimal frequency or timing to achieve the possible benefits 
for upper limb function and strength. Insufficient evidence was found to determine whether 
gains were likely to be achieved after 5 years. 
No studies were found investigating the efficacy of a delegated model of care for the people 
with chronic cervical spinal cord injury. 
3. Improving function for chronic spinal cord injury
The chronic phase of spinal cord injury is usually defined as starting from 12 months post-
injury and represents a period during which the neurological function of the person stabilises. 
Some sources indicate that functional gains can stil  be made up to 2 years post-injury and 
possibly longer in the case of incomplete injury (Spinal Cord Injury Guidelines, 2022; Willig et 
al, 2022; Kalsi-Ryan et al, 2021). Therapy and management during this phase wil  often focus 
on adaptive skil -building and preventing secondary complications (contracture, pressure 
sores, inactivity, weight gain, decline in strength and fitness) (Spinal Cord Injury Guidelines, 
2022; Kalsi-Ryan et al, 2021). 
Some evidence shows that functional outcomes may be improved during the chronic stage of 
spinal cord injury. Chiou et al (2022) found moderate quality evidence that arm-crank exercise 
could improve cardiorespiratory fitness in people with chronic spinal cord injury. However, the 
study does not differentiate effect for higher and lower levels of injury. A review from Figoni et 
al (2021) that looks specifically at those with higher level injuries found inconclusive evidence 
aerobic exercise could improve fitness for people with tetraplegia.  
4. Therapy targeting upper limb function
Reviews analysing evidence into the effectiveness of therapies for improvement of upper limb 
function for people with people with chronic spinal cord injury have generally showed positive 
results from very low certainty evidence. One review found exercise interventions were able to 
improve upper extremity motor control and functional ability in people with chronic cervical 
spinal cord injury (Kloosterman et al, 2009). The authors noted good methodological quality in 
the included studies. However, later reviews tend to find positive results from very low certainty 
evidence. Lu et al (2014) found evidence that improvements in upper limb function and 
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strength was possible for people in the chronic stage of spinal cord injury. While they note that 
the internal validity of the studies was fair to good, the external validity was generally poor. 
The Australian and New Zealand Clinical Practice Guidelines for the physiotherapy 
management of people with Spinal Cord Injury evaluate the evidence and clinical consensus 
surrounding physiotherapy management strategies for people with spinal cord injury (Glinsky 
et al, 2022). As of 2022, none of the management strategies that the authors identified were 
supported by good quality evidence, though many achieved high levels of clinical endorsement 
(refer to Table 1). 
A more recent meta-analysis of variables associated with improved function hand-arm training 
programs for people with cervical spinal cord injury notes: 
analysis of 8 training programmes showed that training programmes using only skil  
training or combined with strength and endurance training exhibited a moderate effect 
on [arm-hand skil ed performance]. Training programmes that integrate the task-oriented 
training components: functional movements, clear functional goals, real-life object 
manipulation, multiple movement planes, total skil  practice, context-specific 
environment, exercise variety, and bimanual practice demonstrated a moderate effect 
on [arm-hand skil ed performance] (Bertels et al, 2023, p.9). 
The authors also compared effect sizes for participants with complete and incomplete injuries, 
and for sub-acute and chronic stages. While the authors suggest that the results were no 
different for each group, they also note that the meta-analysis was not reported due to an 
insufficient number of studies. 
Bertels et al (2022) also note that a minimum of 8 weeks seems to be required to achieve 
moderate effect size. However, they also note that dosage parametres are not reported 
consistently and were unable to identify optimal frequency or intensity of therapy to achieve 
clinically meaningful results. 
Bertels et al (2022) note very low certainty evidence around robotic assisted therapy for upper 
limb function. They provide a strong consensus recommendation in favour of the therapy. 
More recent evidence provides inconsistent support for this recommendation. Ho et al (2023) 
reviewed seven studies looking into the effectiveness of robotic-assisted upper limb 
rehabilitation to improve upper limb function after cervical spinal cord injuries. Four of the 
studies showed statistically significant improvements in upper limb function and strength. The 
studies showing significant results in favour of the intervention (4 out of 7) were all small 
sample case-series or observational studies. The only randomised control trial included in the 
review did not produce a statistically significant effect. 
Other recent studies have produced suggestive evidence. A 2023 observational study of 6 
patients with chronic C5-7 level injury investigated the effects of the functional hand protocol. 
The participants were between 30 and 90 years old. Two participants were <2 years post-
injury. The other four participants had sustained spinal cord injury between 13 and 35 years 
prior (Ciardi et al, 2023). The functional hand protocol is described as: 
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combined with 
strength 
training 
Electrical 
Voluntary 
Very low 
- 
Weak - 
stimulation 
strength 
Shoulder 
Pain 
Very low 
81% 
Strong + 
exercises 
 
5.  References 
Bertels, N., Seelen, H., Dembele, J., & Spooren, A. (2023). Essential training variables of arm-
hand training in people with cervical spinal cord injury: a systematic review. Journal of 
rehabilitation medicine, 55, jrm7147. https://doi.org/10.2340/jrm.v55.7147 
Chiou, S. Y., Clarke, E., Lam, C., Harvey, T., & Nightingale, T. E. (2022). Effects of Arm-Crank 
Exercise on Fitness and Health in Adults With Chronic Spinal Cord Injury: A Systematic 
Review. Frontiers in physiology, 13, 831372. https://doi.org/10.3389/fphys.2022.831372 
Ciardi, G., Lamberti, G., & Avanzi, M. (2023). Using "functional hand" protocol to improve hand 
function following a spinal cord injury: an explorative study. Acta bio-medica : Atenei 
Parmensis, 94(5), e2023255. https://doi.org/10.23750/abm.v94i5.14408 
Ho, J. S., Ko, K. S., Law, S. W., & Man, G. C. (2023). The effectiveness of robotic-assisted 
upper limb rehabilitation to improve upper limb function in patients with cervical spinal 
cord injuries: a systematic literature review. Frontiers in neurology, 14, 1126755. 
https://doi.org/10.3389/fneur.2023.1126755 
Figoni, S. F., Dolbow, D. R., Crawford, E. C., White, M. L., & Pattanaik, S. (2021). Does 
aerobic exercise benefit persons with tetraplegia from spinal cord injury? A systematic 
review. The journal of spinal cord medicine, 44(5), 690–703. 
https://doi.org/10.1080/10790268.2020.1722935 
Glinsky J.V., Harvey L.A. and the Australian and New Zealand Physiotherapy Clinical Practice 
Guidelines consortium. (2022). Australian and New Zealand Clinical Practice Guideline 
for the physiotherapy management of people with spinal cord injury. 
https://sciptguide.com/about-guidelines/documents/ 
Kalsi-Ryan, S., Kapadia, N., Gagnon, D. H., Verrier, M. C., Holmes, J., (NA), Flett, H., 
Farahani, F., Alavinia, S. M., Omidvar, M., Wiest, M. J., & Craven, B. C. (2021). 
Development of Reaching, Grasping & Manipulation indicators to advance the quality of 
spinal cord injury rehabilitation: SCI-High Project. The journal of spinal cord medicine, 
44(sup1), S134–S146. https://doi.org/10.1080/10790268.2021.1961052 
 
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Kloosterman, M. G., Snoek, G. J., & Jannink, M. J. (2009). Systematic review of the effects of 
exercise therapy on the upper extremity of patients with spinal-cord injury. Spinal cord, 
47(3), 196–203. https://doi.org/10.1038/sc.2008.113 
Lu, X., Battistuzzo, C. R., Zoghi, M., & Galea, M. P. (2015). Effects of training on upper limb 
function after cervical spinal cord injury: a systematic review. Clinical rehabilitation, 
29(1), 3–13. https://doi.org/10.1177/0269215514536411 
Spinal Cord Injury Clinical Guidelines. (2022). Physiopedia. https://www.physio-
pedia.com/Spinal_Cord_Injury_Clinical_Guidelines 
Wil ig RM, Garcia I, da Silva NSL, Corredeira R, Carvalho J. The effectiveness of community-
based upper body exercise programs in persons with chronic paraplegia and manual 
wheelchair users: A systematic review. J Spinal Cord Med. 2022 Jan;45(1):24-32. doi: 
10.1080/10790268.2020.1782608. Epub 2020 Jul 9. PMID: 32644024; PMCID: 
PMC8890546. 
 
 
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