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


This is a comprehensive study exploring the efficacy of rTMS, FES, ABT, and Robotic-assisted locomotor training on the functional rehabilitation post SCI. Our results suggested the efficacy of rTMS, FES, and Robotic-assisted locomotor training in functional recovery. ABT had no efficacy in SCI.

Effectiveness of rTMS Intervention in SCI

The responses to rTMS therapy depend on the frequency and degree in subjects with SCI.[13,14,24,25] It has been reported that a 5-day session of rTMS-induced spasticity amelioration could last for 7 days.[14] In addition, high-frequency rTMS (5 Hz) at subthreshold intensity could regulate regional glucose metabolism, improve insulin resistance, and control overweight or obesity.[43,44] These indications suggested the benefit of rTMS in the metabolism and behavior in subjects with SCI.

Our present meta-analysis showed that rTMs had significant benefit in walking speed (10MWT; 95% CI [0.01, 0.16]) and lower extremity function (ASIA LEMS; 95% CI [1.55, 7.27]), but not in spasticity (MAS score; 95% CI [–1.13, 0.14]) and walking capacity (WISCI II; 95% CI [–3.34, 0.40]). These differences indicated the potential value and research ability of high-frequency rTMS-mediated benefit in nerve and functional rehabilitation post SCI. This was consistent with the review performed by Lu et al.[45]

Effectiveness of FES Intervention Therapy

FES mainly used to improve the upper limb function in chronic and subacute (<6 months post injury) SCI subjects.[26,28] During the past 40 years, the reliance on FES for achieving muscle contraction has been reduced.[28] Our present study included six articles reporting the effectiveness of FES intervention on voluntary walking function following chronic[27–29] and subacute SCI.[26,30,31] We confirmed that FES only benefited to functional upper extremity independence significantly (95% CI 0.37, 5.48), with unobvious efficacy in upper extremity function (95% CI –2.23, 12.56), lower extremity independence (95% CI –1.18, 1.15), and the life quality of individuals with SCI (95% CI –0.04, 0.18). The insignificant difference in upper extremity function might due to the mixture of studies with chronic[27] and subacute SCI,[26,30,31] while the others might due to the less literature included.

Intervention of Exercise or Treadmill Training With and Without Robotic Assistance Therapy

The efficacy of robot-assisted gait training (Lokomat) in improving walking function and activity had been reported.[16] Our present meta-analysis indicated that robotic assistance significantly improved ASIA LEMS (95% CI 3.44, 6.56) and upper extremity (95% CI 2.53, 4.92) independence in SCI subjects compared with treadmill training alone, although no difference in walking capacity (10MWT and 6MWT). These results suggested that robotic assistance improved the therapeutic effectiveness of treadmill training on nerve and functional rehabilitation in SCI subjects relative to massed practice. However, depending on the individual's disease situation, the application of treadmill training may not be extensive. Treadmill is useful for SCI patients with mild paralysis, but not for severe cases.

In addition, we found that treadmill training with and without robotic assistance had no influence on the walking capacity in participants with SCI, although the efficacy of robot-assisted training in physical and functional recovery had been reported patients with SCI.[46] We blamed this insignificance to the various durations, strategies, and intervention courses used in these included studies.[3,11,12,17,32–35,42] Even so, robotic assistance improved the benefits of device configuration, including body-weight supporting system, driven-gait orthosis device, and symmetric lightweight robotic actuators in patients with SCI in comparison with massed practice and treadmill training alone.[10,18]