Motor Skills

Virtual reality sitting training (v no intervention) on ability to sit in people with SCI

evidence: Weak For Recommendation

Virtual Reality sitting training may be provided to improve ability in sitting in people with SCI.

Feedback

	Virtual reality sitting training (v no intervention) on ability to sit in people with SCI
P	People with SCI	Evidence recommendation Weak for (95%)	Weak evidence recommendation FOR Virtual Reality sitting training may be provided to improve ability in sitting in people with SCI.
I	Virtual reality (VR) sitting training
C	No intervention	Consensus-based opinion statement No opinion statements
O	Ability to sit
	SUMMARY	1 RCT (see reference)	Mean difference (95% CI): Seated reach in mm 64 (38 to 89) Favours VR sitting training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision Serious	Indirectness Serious	Publication bias Serious

VIRTUAL REALITY SITTING TRAINING FOR FUNCTIONAL ABILITY TO SIT: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

VIRTUAL REALITY SITTING TRAINING FOR ABILITY TO SIT: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
TAK 2015	Game based virtual reality sitting training (plus usual care) V Usual care	6 weeks, 30 minutes ×3 sessions per week of Nintendo Wii- based VR balance training	AIS A or B SCI (cervical and thoracic)	13/13	Modified functional reach test (front)	Some concerns of Risk of Bias PEDro = 7/10

Manual wheelchair skills training (v no intervention) on wheelchair skills in people with SCI

evidence: Weak For Recommendation

Manual wheelchair skills training may be provided to improve manual wheelchair skills in people with SCI.

Feedback

	Manual wheelchair skills training (v no intervention) on wheelchair skills in people with SCI
P	People with SCI	Evidence recommendation Weak for (95%)	Weak evidence recommendation FOR Evidence recommendation: manual wheelchair skills training may be provided to improve manual wheelchair skills in people with SCI.
I	Manual wheelchair skills training
C	No intervention	Consensus-based opinion statement No opinion statements
O	Wheelchair skills
	SUMMARY	4 RCTs (see references)	Standardised Mean difference (95% CI): 0.8 (0.1 to 1.4) Favours wheelchair skills training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Very serious	Imprecision Very serious	Indirectness Serious	Publication bias Serious

MANUAL WHEELCHAIR TRAINING FOR WHEELCHAIR SKILLS: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

MANUAL WHEELCHAIR SKILLS TRAINING FOR WHEELCHAIR SKILLS: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
KIRBY 2016	Wheelchair skills training V Educational Control	Intervention: Five individual training sessions Control: Five education sessions	People with SCI living in community	47/49	Wheelchair skills test	Some concerns about Risk of Bias PEDro = 7/10
RICE 2013	Wheelchair skills training V No Intervention	3 visits of real time feedback from a Smart wheel while pushing	People with SCI living in community SCI<2 years	6/9	Stroke frequency	Some concerns about Risk of Bias PEDro = 4/10
WOROBEY 2016	Wheelchair skills training V Control	Between 2-8, 60–80-minute group training sessions	People with SCI living in community	36/43	Wheelchair skills test	High Risk of Bias PEDro = 7
YEO 2018	Wheelchair skills training V No Intervention	1 hour per day, 3 days/week for 8 weeks	People with tetraplegia living in community	13/11	Wheelchair skills test	Some concerns about Risk of Bias PEDro = 4

Stair training (v no intervention) on ability to climb stairs in people with SCI and motor function in the lower limbs

consensus: Strong For Recommendation

Stair training should be provided to improve the ability to climb stairs in people with SCI who can walk.

Feedback

	Stair training (v no intervention) on ability to climb stairs in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Stair training should be provided to improve the ability to climb stairs in people with SCI who can walk. Clinical note: This statement includes ascending and descending stairs for people with SCI (and upright mobility) that have sufficient muscle strength and/or appropriate assistive devices to actively participate in stair training.
I	Stair training
C	No intervention	Consensus-based opinion statement Strong for (85%)
O	Ability to climb stairs

Robotic Upper limb training (v no intervention) on upper limb function in people with tetraplegia

consensus: Strong For Recommendation

Robotic upper limb training should be provided to improve upper limb function in people with tetraplegia.

Feedback

	Robotic Upper limb training (v no intervention) on upper limb function in people with tetraplegia
P	People with tetraplegia	Evidence recommendation Reason: No RCTs	Strong opinion statement FOR Robotic upper limb training should be provided to improve upper limb function in people with tetraplegia.
I	Robotic upper limb training
C	No intervention	Consensus-based opinion statement Strong for (89%)
O	Upper limb function

Upper limb and hand function training (v no intervention) on upper limb and hand function in people with tetraplegia

consensus: Strong For Recommendation

Upper limb function training should be provided to improve hand function in people with tetraplegia.

Feedback

	Upper limb and hand function training (v no intervention) on upper limb and hand function in people with tetraplegia
P	People with tetraplegia	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Strong opinion statement FOR Upper limb function training should be provided to improve hand function in people with tetraplegia.
I	Upper limb function training
C	No intervention	Consensus-based opinion statement Strong for (92%)
O	Upper limb and hand function
	SUMMARY	1 RCT35	Mean difference (95% CI): Hand function in points on Jebsen Hand Function test 128 (60 to 196) Favours hand training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency Serious	Imprecision No serious	Indirectness Serious	Publication bias Serious

UPPER LIMB and HAND TRAINING ON UPPER LIMB and HAND FUNCTION: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

UPPER LIMB and HAND TRAINING ON UPPER LIMB and HAND FUNCTION: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
BEEKHUIZEN 2008	Hand training v No intervention	2 hours of massed practice hand training 5 x per week for 3 weeks	C4-C7 tetraplegia	6/6	Jebsen Hand Function test (points)	High Risk of Bias PEDro = 4/10

Standing training (v no intervention) on ability to stand in people with SCI and motor function in the lower limbs

consensus: Strong For Recommendation

Standing training should be provided to improve the ability to stand in people with SCI (who have motor function in the lower limbs).

Feedback

	Standing training (v no intervention) on ability to stand in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Standing training should be provided to improve the ability to stand in people with SCI (who have motor function in the lower limbs). Clinical note: This statement includes standing training for people with SCI that have sufficient muscle strength to actively participate in standing training.
I	Standing training
C	No intervention	Consensus-based opinion statement Strong for (95%)
O	Ability to stand

Sit to stand training (v no intervention) on ability to move from sit to stand in people with SCI and motor function in the lower limbs

consensus: Strong For Recommendation

Sit to stand training should be provided to improve the ability to move from sit to stand in people with SCI and motor function in the lower limbs.

Feedback

	Sit to stand training (v no intervention) on ability to move from sit to stand in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Sit to stand training should be provided to improve the ability to move from sit to stand in people with SCI and motor function in the lower limbs. Clinical note: This statement includes standing up from sitting for people with SCI that have sufficient muscle strength to actively participate in sit to stand training.
I	Sit to stand training
C	No intervention	Consensus-based opinion statement Strong for (89%)
O	Ability to move into standing

Vertical transfer training (v no intervention) on ability to vertically transfer in people with SCI who are wheelchair dependent

consensus: Strong For Recommendation

Vertical transfer training should be provided to improve the ability to vertically transfer in people with SCI who are wheelchair dependent.

Feedback

	Vertical transfer training (v no intervention) on ability to vertically transfer in people with SCI who are wheelchair dependent
P	People with SCI that are wheelchair dependent	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Vertical transfer training should be provided to improve the ability to vertically transfer in people with SCI who are wheelchair dependent. Clinical note: This statement includes floor to wheelchair and wheelchair to floor transfers for people with sufficient strength to participate in vertical transfer training.
I	Vertical transfer training
C	No intervention	Consensus-based opinion statement Strong for (81%)
O	Ability to transfer

Transfer training v no intervention on ability to transfer in people with SCI

consensus: Strong For Recommendation

Transfer training should be provided to improve the ability to transfer in people with SCI.

Feedback

	Transfer training v no intervention on ability to transfer in people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No RCTs	Strong opinion statement FOR Transfer training should be provided to improve the ability to transfer in people with SCI. Clinical note: This statement includes transfers for people with SCI that have sufficient muscle strength to actively participate in transfer training. The method of transfer will depend on muscle strength.
I	Transfer training
C	No intervention	Consensus-based opinion statement Strong for (100%)
O	Ability to transfer

Sitting training (v no intervention) on ability to sit in people with SCI and paralysis of the lower limbs/trunk

consensus: Strong For Recommendation

Sitting balance training should be provided to improve the ability to sit in people with SCI and paralysis of the lower limbs/trunk.

Feedback

	Sitting training (v no intervention) to improve the ability to sit in people with SCI and paralysis of the lower limbs/trunk
P	People with SCI and paralysis of the lower limbs/trunk.	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Strong opinion statement FOR Sitting balance training should be provided to improve the ability to sit in people with SCI and paralysis of the lower limbs/trunk
I	Sitting balance training
C	No intervention	Consensus-based opinion statement Strong for (82%)
O	Ability to sit
	SUMMARY	2 RCTS33-34	Mean difference (95% CI): Reach distance in mm 22 (-60 to 104) Favours sitting training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias No serious	Inconsistency Very serious	Imprecision Very serious	Indirectness Serious	Publication bias Serious

SITTING TRAINING ON ABILITY TO SIT: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

SITTING TRAINING ON ABILITY TO SIT: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
BOSWELL-RUYS 2010	Sitting training V No intervention	1 hour of training, 3 x per week for 6 weeks	T1-T12 with chronic SCI	15/15	Maximal balance range test (mm)	Some concerns of Risk of Bias PEDro = 8/10
HARVEY 2011	Sitting training (plus usual care) V Usual care	3 additional 30- minute sessions per week of motor retraining for sitting	Acute paraplegia	16/16	Maximal lean test (mm)	Some concerns of Risk of Bias PEDro = 8/10

Sitting training (v no intervention) on ability to sit in people with SCI and motor function in the lower limbs

consensus: Strong For Recommendation

Sitting balance training should be provided to improve the ability to sit in people with SCI and motor function in the lower limbs.

Feedback

	Sitting training (v no intervention) to improve the ability to sit in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation Reason: No RCTs	Strong opinion statement FOR Sitting balance training should be provided to improve the ability to sit in people with SCI and motor function in the lower limbs.
I	People with SCI and motor function in the lower limbs
C	No intervention	Consensus-based opinion statement Strong for (78%)
O	Ability to sit

Bed mobility (v no intervention) on ability to move in bed in people with SCI

consensus: Strong For Recommendation

Bed mobility training should be provided to improve the ability to move in bed in people with SCI.

Feedback

	Bed mobility (v no intervention) on ability to move in bed in people with SCI
P	People with SCI	Evidence recommendation Reason: No RCTs	Strong opinion statement FOR Bed mobility training should be provided to improve the ability to move in bed in people with SCI. Clinical note: This statement includes rolling and moving from supine to sitting for people with SCI that have sufficient muscle strength to actively participate in bed mobility training.
I	Bed mobility training
C	No intervention	Consensus-based opinion statement Strong for (100%)
O	Ability to move in bed

Power wheelchair skills training (v no intervention) on power wheelchair skills in people with SCI who are dependent on a power wheelchair for mobility

consensus: Strong For Recommendation

Power wheelchair skills training should be provided to improve ability to use a power wheelchair in people with SCI who are dependent on a power wheelchair for mobility.

Feedback

	Power wheelchair skills training (v no intervention) on power wheelchair skills in people with SCI who are dependent on a power wheelchair for mobility
P	People with SCI who are dependent on a power wheelchair for mobility	Evidence recommendation Reason: No RCTs	Strong opinion statement FOR Power wheelchair skills training should be provided to improve ability to use a power wheelchair in people with SCI who are dependent on a power wheelchair for mobility.
I	Power wheelchair skills training
C	No intervention	Consensus-based opinion statement Strong for (100%)
O	Power wheelchair mobility

Conventional therapy (package of interventions including gait training) vs treadmill gait training (with or without body weight support) to improve walking in people with SCI and motor function in the lower limbs

consensus: Strong For Recommendation

Conventional therapy (package of interventions that includes gait training) should be provided (in favour of treadmill gait training with or without body weight support) to improve walking in people with SCI.

Feedback

	Conventional therapy (package of interventions including gait training) vs treadmill gait training (with or without body weight support) to improve walking in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Strong opinion statement FOR Conventional therapy (package of interventions that includes gait training) should be provided (in favour of treadmill gait training with or without body weight support) to improve walking in people with SCI.
I	Conventional therapy (package of interventions that includes gait training)
C	Treadmill gait training (with or without body weight support)	Consensus-based opinion statement Strong for (96%)
O	Walking ability
	SUMMARY	4 RCTS	Mean difference (95% CI): Walking speed in m/s 0.08 (-0.12 to 0.27) Favours conventional therapy (package of therapies including gait training)
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency No serious	Imprecision Serious	Indirectness No serious	Publication bias Serious

CONVENTIONAL THERAPY V TREADMILL ON ABILITY TO WALK: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

CONVENTIONAL THERAPY V TREADMILL ON ABILITY TO WALK: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
ALEXEEVA 2011	Conventional therapy V Body weight support treadmill training (BWSTT)	BWSTT: 30% BWS 60 mins of training, 3 x per week for 13 weeks	AIS C and D SCI	9/12	Walking speed m/s	Some Concerns of Risk of Bias PEDro = 7/10
LUCARELI 2011	Conventional therapy V BWSTT	BWSTT: 30 mins of training, 2 x per week for 4 months (total 30 sessions)	AIS C and D SCI	12/12	Walking speed m/s	Some Concerns of Risk of Bias PEDro = 6/10
PIIRA 2019	Conventional therapy V BWSTT	BWSTT: 2 daily sessions, 90 minutes per day, 5 days per week over 12 weeks	AIS C and D SCI	7/7	Walking speed m/s	Some Concerns of Risk of Bias PEDro = 7/10
SADEGHI 2015	Conventional therapy V BWSTT	BWSTT: 60 min per session, 4 x per week for 12 weeks	AIS B and C SCI	10/7	Walking speed m/s	High Risk of Bias PEDro = 6/10

Walking training (v no intervention) on ability to walk in people who have lower limb motor function

consensus: Strong For Recommendation

Walking training should be provided to people with SCI who have lower limb motor function.

Walking training can include:

Overground gait training
Treadmill gait training (with and without body weight support)
Treadmill gait training with electrical stimulation (+/- body weight support)
Overground gait training and electrical stimulation
Robotic overground gait training
Robotic treadmill gait training
Conventional therapy (package of interventions including gait training)
Gait training with orthotics

Feedback

	Walking training (v no intervention) on ability to walk in people who have lower limb motor function
P	People with SCI who have lower limb motor function	Evidence recommendation Reason: No RCTs	Strong opinion statement FOR Walking training should be provided to people with SCI who have lower limb motor function. Walking training can include: • Overground gait training (100%) • Treadmill gait training (with and without body weight support) (100%) • Treadmill gait training with electrical stimulation (+/- body weight support) (100%) • Overground gait training and electrical stimulation (100%) • Robotic overground gait training (92%) • Robotic treadmill gait training (75%) • Conventional therapy (package of interventions including gait training) (85%) • Gait training with orthotics (100%)
I	Walking training
C	No intervention	Consensus-based opinion statement Strong for (75% - 100%)
O	Walking ability

Upper limb and hand function training and FES (v no intervention) on hand function in people with tetraplegia

consensus: Weak For Recommendation

Upper limb and hand function training and FES may be provided to improve hand function in people with tetraplegia

Feedback

	Upper limb and hand function training and FES (v no intervention) on hand function in people with tetraplegia
P	People with tetraplegia	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Upper limb and hand function training and FES may be provided to improve hand function in people with tetraplegia.
I	Upper limb and hand function training and FES
C	No intervention	Consensus-based opinion statement Weak for (96%)
O	Upper limb and hand function
	SUMMARY	2 RCTs36-37	Standardised mean difference (95% CI) 0.2 (-0.3 to 0.8) Favours hand training with FES
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency No serious	Imprecision Very serious	Indirectness No serious	Publication bias Serious

UPPER LIMB AND HAND FUNCTION TRAINING PLUS FES ON UPPER LIMB AND HAND FUNCTION: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

UPPER LIMB AND HAND FUNCTION TRAINING PLUS FES ON UPPER LIMB AND HAND FUNCTION: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
HARVEY 2017	Hand training plus FES (plus usual care) V Usual care	1 hour per day, 5 days per week for 8 weeks.	C2-T1 tetraplegia	35/31	Action Research Arm Test (ARAT)	Low Risk of Bias PEDro = 8/10
HOFFMAN 2013	Hand training plus FES V No intervention	5 x per week, 2 hours per day, for 3 weeks.	Chronic tetraplegia	10/9	Jebsen Hand function test	High Risk of Bias PEDro = 3/10

Upper limb virtual reality (v no intervention) on upper limb function in people with tetraplegia

consensus: Weak For Recommendation

Upper limb virtual reality training may be provided to improve UL function in people with tetraplegia.

Feedback

	Upper limb virtual reality (v no intervention) on upper limb function in people with tetraplegia
P	People with tetraplegia	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Upper limb virtual reality training may be provided to improve UL function in people with tetraplegia.
I	Upper limb virtual reality training may be provided to improve UL function in people with tetraplegia.
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Upper limb function
	SUMMARY	3 RCTs (see references)	Standardised mean difference (95% CI) 0.7 (-1.6 to 0.2) Favours no intervention
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency Serious	Imprecision Very serious	Indirectness No serious	Publication bias Serious

UPPER LIMB VIRTUAL REALITY TRAINING ON UPPER LIMB FUNCTION: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

UPPER LIMB VIRTUAL REALITY TRAINING ON UPPER LIMB FUNCTION: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
DIMBWADYO-TERRER 2016	Virtual reality UL training (plus usual care) V Usual care	15 sessions with Toyra(®) virtual reality system for 5 30 minutes per day, 3 days/week for 5 weeks	Complete tetraplegia	15/16	SCIM (self-care sub-score)	Some Concerns of Risk Bias PEDro = 6/10
LIM 2020	Virtual reality (plus usual care) V Usual care	30 minutes of VR training and 30 minutes of conventional therapy per day, 4 x per week for 4 weeks	C4-C6 tetraplegia	10/10	SCIM	High Risk of Bias PEDro = 5/10
PRASAD 2018	Virtual reality UL training (plus usual care) V Usual care	3 x per week for 4 weeks	tetraplegia	11/9	Box and block test	High Risk of Bias PEDro = 6/10

Overground gait training v Robotic gait training to improve walking in people with SCI and motor function in the lower limbs

consensus: Weak For Recommendation

Overground gait training may be provided (in favour of robotic gait training) to improve walking in people with SCI.

Feedback

	Overground gait training v Robotic gait training to improve walking in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Overground gait training may be provided (in favour of robotic gait training)to improve walking in people with SCI. Clinical note: Robotic gait training includes the use of devices such as the Lokomat (with and without electrical stimulation) and exoskeletons.
I	Overground gait training
C	Robotic gait training	Consensus-based opinion statement Weak for (85%)
O	Ability to walk
	SUMMARY	3 RCTs (see references)	Mean difference (95% CI): Walking ability: WISCI points 3 (-1 to 7) Favours robotic gait training
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Very serious	Imprecision Serious	Indirectness No serious	Publication bias Serious

OVERGROUND GAIT TRAINING V ROBOTIC GAIT TRAINING ON WALKING: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours Robotic training	Favours the I	Don't know
RESOURCES REQUIRED	Large costs Robotic training	Moderate costs	Negligible costs and savings of overground walking training	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact for overground walking training	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes for overground walking training		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes for overground walking training		Don't know

OVERGROUND GAIT TRAINING V ROBOTIC GAIT TRAINING ON WALKING: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
ALCOBENDAS-MAESTRO 2012	Overground gait training V Robotic Gait training	Intervention: 40 sessions of overground gait training Comparison: 40 sessions of lokomat	C2 to T12 AIS C and D SCI	37/38	Walking Index for SCI	Some Concerns of Risk of Bias PEDro = 8/10
ESCLARIN-RUZ 2014	Overground gait training V Robotic Gait training	Intervention: Overground training 60 minute, 5 days/week for 8 weeks Comparison: Lokomat 60 minutes 5 days/week for 8 weeks	AIS C or D SCI	41/42	Walking Index For SCI	Some Concerns of Risk of Bias PEDro = 8/10
HORNBY 2005	Overground gait training V Robotic Gait training	Intervention: Overground gait training 3 x 30mins per week for 8 weeks Comparison: Robotic gait training 3 x 30 mins per week for 8 weeks	T10 to L4 AIS B,C,D SCI	10/10	Walking index for SCI	Some Concerns of Risk of Bias PEDro = 3/10

Overground gait training vs Treadmill gait training (with or without body weight support) to improve walking in people with SCI and motor function in the lower limbs

consensus: Weak For Recommendation

Overground gait training may be provided (in favour of treadmill gait training with or without body weight support) to improve walking in people with SCI.

Feedback

	Overground gait training vs Treadmill gait training (with or without body weight support) to improve walking in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Overground gait training may be provided (in favour of treadmill gait training with or without body weight support) to improve walking in people with SCI.
I	Overground gait training
C	Treadmill gait training (with and without body weight support)	Consensus-based opinion statement Weak for (79%)
O	Ability to walk
	SUMMARY	4 RCTs (see references)	Standardised Mean Difference (95% CI) 0 (-0.3 to 0.4)
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision Very serious	Indirectness Serious	Publication bias Serious

OVERGROUND GAIT TRAINING V TREADMILL GAIT TRAINING ON WALKING: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact for overground walking training	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes for overground walking training		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes for overground walking training		Don't know

OVERGROUND GAIT TRAINING V TREADMILL GAIT TRAINING ON WALKING: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
DOBKIN 2006	Overground gait training V Treadmill gait training	Intervention: Mobility training one hour per day, 5 x per week for 12 weeks Comparison: Treadmill training plus mobility training one hour per day, 5 x per week for 12 weeks	People with SCI	35/33	Walking speed m/s	High Risk of Bias PEDro = 7/10
HORNBY 2005	Overground gait training V Treadmill gait training	Intervention: Overground gait training 3 x 30mins per week for 8 weeks Comparison: BWSTT 3 x 30 mins per week for 8 weeks	T10 to L4 AIS B,C,D SCI	10/10	Walking Index for SCI	Some Concerns of Risk of Bias PEDro = 3/10
SENTHILVELKUMAR 2015	Overground gait training V Body weight support treadmill gait training	Intervention: Body weight support overground training, 30 mins 5 x per week for 8 weeks Comparison: treadmill training, 30 mins 5 x per week for 8 weeks	People with SCI	7/7	Walking Index for SCI	Some Concerns of Risk of Bias PEDro = 7/10
YANG 2014	Overground gait training V Treadmill gait training	Intervention: Overground training one hour per day, 5 x per week for 2 months Comparison: BWSTT one hour per day, 5 times x week for 2 months	People with SCI	10/10	Walking speed m/s	High Risk of Bias PEDro = 6/10

Treadmill gait training (with or without body weight support) vs Robotic gait training to improve walking in people with SCI and motor function in the lower limbs

consensus: Weak For Recommendation

Treadmill gait training with or without body weight support may be provided (in favour of robotic gait training) to improve walking in people with SCI.

Feedback

	Treadmill gait training (with or without body weight support) vs Robotic gait training to improve walking in people with SCI and motor function in the lower limbs
P	People with SCI and motor function in the lower limbs	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Treadmill gait training with or without body weight support may be provided (in favour of robotic gait training) to improve walking in people with SCI.
I	Treadmill gait training (with and without body weight support)
C	Robotic gait training	Consensus-based opinion statement Weak for (89%)
O	Ability to walk
	SUMMARY	2 RCTs (see references)	Standardised Mean Difference (95% CI) -0.2 (-0.8 to 0.4) Favours treadmill gait training (with or without body weight support)
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Serious	Inconsistency Serious	Imprecision Very serious	Indirectness Serious	Publication bias Very serious

TREADMILL GAIT TRAINING V ROBOTIC GAIT TRAINING ON WALKING: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours treadmill gait training	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs for both	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes for treadmill gait training		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes for treadmill gait training		Don't know

TREADMILL GAIT TRAINING V ROBOTIC GAIT TRAINING ON WALKING: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
FIELD-FOTE 2011	Treadmill gait training V Robotic gait training	Intervention: BWSTT with manual assistance 5 days per week for 12 weeks Comparison: Robotic gait training 5 days per week for 12 weeks	Chronic SCI	14/17	Speed m/s	High Risk of Bias PEDro = 6/10
HORNBY 2005	Treadmill gait training V Robotic gait training	Intervention: BWSTT 3 x 30mins per week for 8 weeks Comparison: Robotic BWSTT 3 x 30mins per week for 8 weeks	T10 to L4 AIS B,C,D SCI	10/10	Walking index for SCI	Some Concerns of Risk of Bias PEDro = 3/10

Hydrotherapy as an adjunct to land therapy to improve function for people with SCI

consensus: Weak For Recommendation

Hydrotherapy may be provided as an adjunct to land based therapy (in favour of no intervention) to improve function in people with SCI.

Feedback

	Hydrotherapy as an adjunct to land therapy to improve mobility for people with SCI
P	People with SCI	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Weak opinion statement FOR Hydrotherapy may be provided as an adjunct to land based therapy (in favour of no intervention) ) to improve function in people with SCI.
I	Land therapy
C	Hydrotherapy	Consensus-based opinion statement Weak for (95%)
O	Mobility

Tenodesis splinting (v no intervention) on a tenodesis grip in people with C6 or C7 tetraplegia

consensus: Weak For Recommendation

Tenodesis splinting may be provided to improve a tenodesis grip in people with C6 and C7 tetraplegia.

Feedback

	Tenodesis splinting (v no intervention) on a tenodesis grip in people with C6 or C7 tetraplegia
P	People with C6 and C7 tetraplegia	Evidence recommendation Reason: No RCTs	Strong opinion statement FOR Tenodesis splinting may be provided to improve a tenodesis grip in people with C6 and C7 tetraplegia.
I	Tenodesis splinting
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Tenodesis grip

Gait training (BWS or robotics) (v no intervention) on functional walking for people with no motor function in the lower limbs

consensus: Strong Against Recommendation

Gait training (BWS or robotics) should not be provided to improve functional walking in people with SCI that have no motor function in the lower limbs.

Feedback

	Gait training (BWS or robotics) (v no intervention) on functional walking ability in people with no motor function in the lower limbs
P	People with SCI that have no motor function in the lower limbs.	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Strong opinion statement AGAINST Gait training (BWS or robotics) should not be provided to improve functional walking in people with SCI that have no motor function in the lower limbs.
I	Gait training
C	No intervention	Consensus-based opinion statement Strong Against (100%)
O	Ability to walk

Gait training (orthotics) vs no intervention to improve functional walking in people with SCI that have no motor function in the lower limbs

consensus: Strong Against Recommendation

Gait training (orthotics) should not be provided to improve functional walking in people with SCI that have no motor function in the lower limbs.

Feedback

	Gait training (Orthotics) (v no intervention) on functional walking ability in people with no motor function in the lower limbs
P	People with SCI that have no motor function in the lower limbs.	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.	Strong opinion statement AGAINST Gait training (orthotics) should not be provided to improve functional walking in people with SCI that have no motor function in the lower limbs.
I	Gait training
C	No intervention	Consensus-based opinion statement Strong Against (89%)
O	Ability to walk

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The Australian and New Zealand Physiotherapy Guidelines for people with SCI was funded by icare NSW, National Injury Insurance Scheme Queensland, Transport Accident Commission Victoria, and Lifetime Support Authority South Australia.

Acknowledgement of Country – The Australian and New Zealand Clinical Practice Guidelines team acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respect to their Elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

Honouring Te Tiriti – Ethical approval, including Māori consultation through University of Otago, Christchurch, Te Komiti Whakarite (Canterbury District Health Board), and through Māori consultation (Counties Manukau District Health Board) was obtained for Phase 1 of the study. In developing these guidelines, we were committed to meeting our obligations under Te Tiriti and reflect the principles of tino rangatiratanga, equity, active protection, options, and partnership.