Clinical Benefit of Rehabilitation Training in Spinal Cord Injury

A Systematic Review and Meta-Analysis

Ruimeng Duan, MS; Mingjia Qu, MS; Yashuai Yuan, MS; Miaoman Lin, MS; Tao Liu, MS; Wei Huang, MS; Junxiao Gao, MS; Meng Zhang, MS; Xiaobing Yu, MD


Spine. 2021;46(6):E398-E410. 

In This Article

Abstract and Introduction


Study Design: A systematic review and meta-analysis.

Objective: This study was performed to evaluate the effects of different rehabilitation interventions in spinal cord injury.

Summary of Background Data: Several activity-based interventions have been widely applied in spinal cord injury in the past, but the effects of these rehabilitation exercises are controversial.

Methods: Publications were searched from databases (PubMed, Embase, Cochrane, the database of the U.S. National Institutes of Health and World Health Organization International Clinical Trials Registry Platform) using the searching terms like spinal cord injury, transcranial magnetic stimulation, functional electrical stimulation, activity-based therapy, and robotic-assisted locomotor training. Randomized controlled trials and controlled trials were included. The primary outcomes included functional upper/lower extremity independence, walking capacity, spasticity, and life quality of individuals with spinal cord injury. Meta-analysis was performed using Revman 5.0 software.

Results: Thirty-one articles were included. Meta-analysis showed that transcranial magnetic stimulation improved walking speed (95% confidence interval [CI] 0.01, 0.16) and lower extremity function (95% CI 1.55, 7.27); functional electrical stimulation significantly increased upper extremity independence (95% CI 0.37, 5.48). Robotic-assisted treadmill training improved lower extremity function (95% CI 3.44, 6.56) compared with related controls.

Conclusion: Activity-based intervention like transcranial magnetic stimulation, functional electrical stimulation, and robotic-assisted treadmill training are effective in improving function in individuals with spinal cord injury.

Level of Evidence: 1


Spinal cord injury (SCI) is characterized by the lesion and dramatic loss in neurons in spinal cord. SCI suppresses axonal regeneration and synaptic connection, and finally develops into locomotor disability in majority patients.[1,2] The life quality and satisfaction of individuals with SCI are frequently influenced. The purposes of SCI interventions mainly focus on decreasing the secondary neuronal injuries and complications. The focuses of interventions in SCI have changed from compensatory strategies[3] to the motor functional recovery (including walking capacity and extremity function), functional neurorehabilitation, and improvement in life quality.[4–8] In addition to the conventional drug management, robotic-assisted locomotor training,[9,10] gait training strategies,[11,12] functional electrical stimulation (FES) devices,[3] and repetitive transcranial magnetic stimulation (rTMS) devices[13,14] are universally recommended to improve function in persons with SCI.

The promising efficacies of these specific treatments within rehabilitation have been systematically reviewed, but there are conflicting recommendations.[5,6,15,16] For instance, rTMS coupled with training could improve spasticity, motor function in patients with SCI.[13,14] Yang et al[17] and Varoqui et al[18] confirmed that activity-based therapy (ABT) like Robotic-assisted locomotor training improved walking speed and distance, while Dobkin et al[11] showed that ABT did not benefit to extremity function in patients with SCI. In addition, Niu et al[5] and Duffell et al[6] confirmed the efficacy of Robotic-assisted locomotor training on walking capacity or walking speed, however there was a conflict of walking endurance in patients with SCI. Accordingly, we speculated that a comprehensive comparison of these strategies might benefit clinicians for applying these specific treatments in the rehabilitation of individuals with SCI.

The background of this study was conducted under the AO Spine Clinical Practice guidelines,[19] which are already authoritative enough. However, some new rehabilitation methods have not been included in the guidelines. We performed this study to systematically compare the benefit of rTMS, FES, ABT, and Robotic-assisted locomotor training on the walking capacity and motor function in persons with SCI in rehabilitation stage. The efficacy of rehabilitation methods on the upper and lower extremity function, walking capacity, and motor function in SCI would be analyzed and compared. The results of this study may provide some hints for new methods of rehabilitation for patients with SCI.