June, 2022

Keegan Kjargaard, BSc Kin Student, Abby Krzyzaniak, BKin Student, Nicolas Lavoie, BSc Kin Student, Miranda Maldaner, BKin Student, and Emily Massing, BKin Student

Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta

Take home message

  • Conventional therapy, which includes physiotherapy, occupational therapy, and/or task specific training, is the most researched and used tool for upper extremity rehabilitation for those with a cervical spinal cord injury (SCI).
  • Non-invasive exercise modalities such as functional electrical stimulation (FES), virtual reality, and brain stimulation modalities may improve upper extremity function when used alongside conventional training. However, many of the results are minimal or insignificant.
  • Further research is needed to determine the effectiveness and optimal training parameters of these exercise modalities for improving upper extremity function for individuals with cervical SCI.


  • Improvement of upper extremity function is ranked high for individuals experiencing cervical SCI, and minor improvements in hand function have been shown to increase independence and quality of life in this population.
  • Non-invasive training is one method used to improve upper extremity function in persons with cervical SCI. There are several types of non-invasive exercise training modalities available including FES, virtual reality, and brain stimulation (i.e. repetitive transcranial magnetic stimulation or transcranial direct current stimulation).
  • A previous systematic review conducted by Lu et al. (2015) summarized the research evidence from 1950-2013 on the effectiveness of exercise training in promoting recovery of upper extremity function after cervical SCI. Lu et al. (2015) concluded that non-invasive exercise modalities may improve upper extremity muscle strength and function, but called for further research on this topic, especially on newer technological innovations such as virtual reality and brain stimulation modalities.

How the study was done

  • The authors conducted a systematic literature review in which they replicated the search strategy used by Lu et al. (2015). Databases were searched for studies published from 2013-2020 which compared a group of participants with cervical SCI following a non-invasive training intervention to a control group where hand function or upper extremity function were measured as outcomes.
  • Studies involving repetitive transcranial magnetic stimulation, transcranial direct current stimulation, FES, task-oriented practice training, or virtual training interventions were included.
  • 247 articles were identified after the initial search. Of these, 6 studies were identified as fulfilling the inclusion criteria.
  • The size of control and experimental groups in these studies ranged from 8-70 participants, the neurological level of injury varied from C2-T1, and the ASIA classification, which assigns spinal cord injuries a grade from A-E based on severity, ranged from A-D.

What the researchers found

  • There was no significant difference in upper extremity function following FES intervention. These results challenge previously held assumptions about the effectiveness of conventional training combined with FES for individuals with cervical SCI (Harvey et al., 2016).
  • Evidence regarding the effectiveness of virtual reality on improvement in upper extremity function showed mixed results. However, the gaming aspect was reported to improve motivation of participants during conventional therapy (Dimbwadyo-Terrer et al., 2016; Lim et al., 2020).
  • Repetitive transcranial magnetic stimulation may be a valuable adjunct to conventional training of upper extremity function, as it has been shown to improve grip strength and dexterity when combined with conventional training. (Gomes-Osman et al., 2015; Choi et al. 2019).
  • Transcranial direct current stimulation may provide some advantage in improving the strength of hand muscles, but no benefits were reported on upper extremity function or improvement in activities of daily living (Potter-Baker et al., 2018).


  • This updated systematic review provides information about the effects of various exercise modalities on upper extremity function among individuals with cervical SCI. Mixed results were obtained regarding the effects of these exercise modalities on upper extremity function, muscle strength and activities of daily living. Further high quality, standardized research is needed to determine the effectiveness and optimal training parameters for each modality.


Choi, H., Seo, K. C., Kim, T. U., Lee, S. J., & Hyun, J. K. (2019). Repetitive transcranial magnetic stimulation enhances recovery in central cord syndrome patients. Annals of Rehabilitation Medicine, 43(1), 62-73. https://dx.doi.org/10.5535/arm.2019.43.1.62

Dimbwadyo-Terrer, I., Gil-Agudo, A., Segura-Fragoso, A., de los Reyes-Guzman, A., Trincado-Alonso, F., Piazza, S., & Polonio-Lopez, B. (2016). Effectiveness of the virtual reality system toyra on upper limb function in people with tetraplegia: A pilot randomized clinical trial. BioMed Research International. https://dx.doi.org/10.1155/2016/6397828

Gomes-Osman, J., & Field-Fote, E. C. (2015). Improvements in hand function in adults with chronic tetraplegia following a multiday 10-Hz repetitive transcranial magnetic stimulation intervention combined with repetitive task practice. Journal of Neurologic Physical Therapy, 39(1), 23-30. https://dx.doi.org/10.1097/NPT.0000000000000062

Harvey, L. A., Dunlop, S. A., Churilov, L., Galea, M. P., Hands, S. C. I. P. A. S., & On Trial Collaborators. (2016). Early intensive hand rehabilitation is not more effective than usual care plus one-to-one hand therapy in people with sub-acute spinal cord injury (‘Hands On’): a randomised trial. Journal of physiotherapy, 62(2), 88-95. https://doi.org/10.1016/j.jphys.2016.02.013

Lim, D. Y., Hwang, D. M., Cho, K. H., Moon, C. W., & Ahn, S. Y. (2020). A fully immersive virtual reality method for upper limb rehabilitation in spinal cord injury. Annals of Rehabilitation Medicine, 44(4), 311-319. https://dx.doi.org/10.5535/arm.19181

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

Potter-Baker, K., Janini, D. P., Lin, Y., Sankarasubramanian, V., Cunningham, D. A., Varnerin, N. M., Chabra, P., Kilgore, K. L., Richmond, M. A., Frost, F. S., & Plow, E. B. (2018). Transcranial direct current stimulation (tDCS) paired with massed practice training to promote adaptive plasticity and motor recovery in chronic incomplete tetraplegia: A pilot study. Journal of Spinal Cord Medicine, 41(5), 503-517. https://doi-org.login.ezproxy.library.ualberta.ca/10.1080/10790268.2017.1361562

This article is a summary of an article published in Applied Physiology, Nutrition & Metabolism. If you intend to cite any information in this article, please consult the original article and cite that source. This summary was written for the Canadian Society for Exercise Physiology and it has been reviewed by the CSEP Knowledge Translation Committee.