Comparison of the effects of robotic rehabilitation, functional electrical stimulation, and occupational therapy on upper extremity and hand functions in tetraplegic patients with spinal cord injury

Introduction and Aim: In patients who develop tetraplegia following spinal cord injury (SCI), deficits in upper extremity and hand functions lead to significant loss of independence in activities of daily living, particularly in self-care activities, and markedly reduce quality of life. Rehabilitation of the upper extremity and hand should therefore be prioritized within a comprehensive rehabilitation program for these patients. In recent years, the utilization of advanced rehabilitation technologies targeting the upper extremity and hand in tetraplegic individuals has increased substantially. Studies investigating functional electrical stimulation (FES), robotic rehabilitation, virtual reality-based interventions, and mirror therapy have emerged rapidly in the literature over the past decade. However, there is a paucity of research directly comparing the relative efficacy of these rehabilitative modalities in tetraplegic populations. This scarcity of evidence poses challenges in clinical practice regarding the selection of the most appropriate rehabilitation technology. Additionally, the high costs and limited accessibility of these interventions may further restrict their optimal use. Therefore, the aim of our study was to compare the effects of robotic rehabilitation, FES, and occupational therapy on upper extremity and hand functions in tetraplegic patients, and to contribute to the existing body of literature on this subject. Although a limited number of studies have compared these rehabilitative approaches individually or in pairs, to our knowledge, no study to date has directly compared all three modalities simultaneously. Patients and Methods: The study was designed as an open-label, parallel-group, prospective randomized trial. A total of 30 patients diagnosed with tetraplegia following spinal cord injury (SCI) and admitted to an inpatient rehabilitation program were included. Patients were allocated in a 1:1:1 ratio to robotic rehabilitation, functional electrical stimulation (FES), or occupational therapy groups using block randomization according to their chronological order of admission.In addition to a conventional rehabilitation program applied five days per week, each group received their assigned intervention targeting the dominant upper extremity and hand three times per week for a total duration of four weeks. Assessments were conducted at baseline and following the intervention, utilizing the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination form, the ASIA Impairment Scale (AIS), the Modified Ashworth Scale (MAS), gross grasp strength, lateral pinch, three-jaw chuck pinch, and tip-to-tip pinch strengths, the Nine-Hole Peg Test (NHPT), the Jebsen-Taylor Hand Function Test (JTHFT), and the self-care subscale of the Spinal Cord Independence Measure-III (SCIM-III). Results: In the robotic rehabilitation group, a significant improvement was observed in the total Upper Extremity Motor Score (UEMS) and the total score of the Jebsen-Taylor Hand Function Test (JTHFT) (p < 0.05). In the FES group, significant improvements were detected in UEMS, finger flexor muscle strength, gross hand grasp and three-jaw chuck pinch strengths, the Nine-Hole Peg Test (NHPT), the JTHFT total score, JTHFT subtests of object lifting and full can transport, as well as in the total score of the self-care subscale of the Spinal Cord Independence Measure-III (SCIM-III) (p < 0.05). In the occupational therapy group, significant improvements were observed in UEMS, finger flexor muscle strength, gross hand grasp and lateral pinch strength, the NHPT, the JTHFT total score and certain subtests (writing, card turning, empty can transport), as well as in the total score of the SCIM-III self-care subscale and the subdomains of bathing–upper body and grooming (p < 0.05). No statistically significant differences were found between the groups (p > 0.05). High patient satisfaction rates were reported across all treatment modalities. Conclusion: In our study, the effects of robotic rehabilitation, functional electrical stimulation (FES), and occupational therapy on upper extremity and hand functions in patients with tetraplegia due to spinal cord injury (SCI) were comparatively evaluated. Although no statistically significant superiority was observed among the three treatment modalities, all groups demonstrated significant functional improvements in various parameters compared to baseline. This finding suggests that each intervention may contribute to recovery processes through distinct neurophysiological mechanisms. Robotic rehabilitation appears to be more beneficial in the early phase following SCI, particularly in facilitating recovery of proximal muscle groups. FES, on the other hand, may provide versatile contributions to motor control retraining due to its potential to activate both proximal and distal muscle groups, especially during later stages of recovery. Occupational therapy is considered effective across all stages of rehabilitation, targeting both gross and fine motor skills as well as proximal and distal musculature, thereby supporting functional independence. Moreover, occupational therapy stands out in clinical practice due to its cost-effectiveness, feasibility, and accessibility, as it does not require advanced technology. These findings highlight the importance of tailoring rehabilitation programs according to the patient's neurological injury level, time since injury, and individual needs. jj