ARTICLES

A Systematic Review of Upper Limb

Rehabilitation for Adults With Traumatic
Brain Injury
Natasha A. Lannin and Annie McCluskey
University of Sydney, Australia

bjective: To summarise the effect of upper limb rehabilitation interventions on

motor function in adults with traumatic brain injury. Data sources: Databases
were last searched on August 2, 2008. Sources included the Cochrane Central
Register of Controlled Trials (CENTRAL); Cochrane Database of Systematic
Reviews, the Database of Effectiveness Reviews; MEDLINE, EMBASE, CINAHL,
Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic
Evaluation of Evidence database (OTseeker); Google Scholar; and reference lists
of included studies. Review methods: Two reviewers determined whether retrieved
abstracts met the inclusion criteria: systematic reviews and randomised controlled
trials (RCTs); English language; adult participants; 50% of study participants
with a brain injury; interventions designed to improve upper limb motor function.
Included papers were appraised for: study design, participants, therapy approach,
therapy protocol (indications, contra-indications, intensity and duration), safety
and adverse events, and outcomes. The methodological quality of RCTs was rated
using the PEDro scale (110 highest). Methodology of systematic reviews was
rated using the QUOROM criteria. Results: Of the 333 references identified, six
were appraised: three systematic reviews and three RCTs. Methodological quality
was high for two RCTs, and moderate for one, based on the PEDro scale score.
Interventions included upper limb casting, electrical stimulation, and coordination
training using meal preparation tasks (making a sandwich and hot drink). In the
latter trial, practice of functional kitchen tasks improved fine motor coordination
speed on one of four Jebsen-Taylor hand function subtests by 9.38 seconds (95%
CI, 1.1 to 17.7). Remaining trials reported non-significant effects for hand function.
Small sample sizes and limited reporting of results reduce the interpretability of
two RCTs. Conclusion: No conclusive evidence was found on which to base upper
limb motor rehabilitation after brain injury, however, lack of evidence does not
equate to evidence of no effect.

Keywords: occupational therapy, motor training, upper extremity, arm

While many people with traumatic brain injury

(TBI) experience a good physical recovery, 14%
continue to have difficulty using their hands
functionally after 3 years (Tate et al., 2006).
Impaired upper limb function can reduce opportunities for work and school, in addition to social
and leisure activities.

Research on upper limb motor rehabilitation is

extensive, with several systematic reviews having
been conducted on exercise therapy (van der Lee
et al., 2001; van Peppen et al., 2004), constraint
inducted movement therapy (Hakkennes &
Keating, 2005), mental practice (Braun, Beurskens,
Borm, Schack, & Wade, 2006), intensity of practice

Address for correspondence: Natasha A. Lannin, Lecturer, Rehabilitation Studies Unit, University of Sydney, PO Box 6,
Ryde NSW 1680, Australia, E-mail: nlannin@mail.usyd.edu.au
BRAIN IMPAIRMENT
VOLUME

9 NUMBER 3 DECEMBER 2008 pp. 237246

237

NATASHA A. LANNIN AND ANNIE McCLUSKEY

(Kwakkel, 2006) and electrical stimulation

(Pomeroy, King, Pollock, Baily-Hallam, &
Langhorne, 2006). Yet all of these studies focus on
people with stroke. Trials conducted in stroke rehabilitation provide important foundation guidelines
for motor training after brain injury. However, the
more diverse patterns of motor dysfunction seen
following brain injury mean that research also
needs to be conducted with this population
(Marshall et al. 2007). Factors which complicate
motor rehabilitation after brain injury include the
presence of multiple trauma, resulting in orthopaedic or peripheral nerve impairments (Kushwaha
& Garland, 1998), vestibular impairments, and
deconditioning (Bateman, Culpan & Pickering,
2001), all of which influence motor rehabilitation
outcomes. Little is known about the effectiveness
of different upper limb rehabilitation interventions
for adults with TBI.
The aim of this systematic review was to identify, then summarise, evidence on upper limb
rehabilitation interventions for improving motor
function in adults with brain injury. Information
from such a review will help therapists to select
interventions that have evidence of effect, from
those which show no effect.

Selection Criteria
We included English language studies of the effects
of upper limb rehabilitation that fulfilled the following criteria:

Methods
Search Strategy
Search strategies developed by the Cochrane
Injuries Group were used. The literature search
was limited to published studies, available in fulltext in English. The following electronic databases
were searched by one person on August 2 2008:
the Cochrane Central Register of Controlled
Trials (CENTRAL); The Cochrane Database of
Systematic Reviews (Issue 3, 2008), the Database
of Effectiveness Reviews (DARE), MEDLINE
(1956 to August 2008), EMBASE (1974 to
August 2008), CINAHL (1983 to August 2008),
the Physiotherapy Evidence Database (PEDro),
Occupational Therapy Systematic Evaluation of
Effectiveness database (OTseeker); and Google
Scholar. Reference lists of retrieved studies and
review articles were also hand searched to identify
additional studies. Unpublished, nonpeer-reviewed
sources such as theses were not included.
Keywords were mapped to MeSH/subject
headings and included: brain injury, craniocerebral trauma, head injury, hemiplegia, hemiparesis,
upper extremity, arm, rehabilitation, therapy, exercise therapy, physical therapy, physiotherapy and
occupational therapy (full search strategy available upon request). Selection of articles was based
on the title and abstract content.

238

Study designs. Studies which generated systematic reviews or randomised controlled trials
(RCTs) (i.e., Level Ia & Ib evidence of the
Oxford Centre for Evidence-based Medicine
levels of evidence (Phillips, Ball, Sackett,
Badenoch, Straus, & Haynes, 2000).
Interventions. Studies concerning any intervention aimed at improving motor function of a
hemiparetic/hemiplegic arm in adults after
TBI. The range of interventions includes exercise therapies such as physiotherapy, occupational therapy, neurodevelopmental therapy and
motor retraining strategies; sensorimotor strategies; biofeedback and/or electrical stimulation;
peripheral splinting and casting; imagery; and
surgery to improve upper limb function or correct deformity. Focal or generalised pharmacotherapy interventions (e.g. botulinum
toxin-A) were excluded.
Participants. Studies that explicitly involved
humans in which 50% or more of the sample
were adults who had experienced a TBI, or
studies where the data pertaining to adults who
had experienced a TBI were able to be separated from the remaining data.
Outcome measures. Outcomes which measure
changes in participants Impairments, Activity
Limitations and Participation Restrictions
(WHO, 2001).

Studies were excluded for the following reasons:

(1) not an intervention study, (2) less than 50% of
the intervention was targeted at remediating the
upper limb (e.g., rehabilitation of the lower limb),
(3) no separate upper limb analyses (such that outcomes from upper limb therapy could not be differentiated from the outcomes of other therapies
which were provided simultaneously to the participants), and (4) a second publication of the same
study presented the same results. Two reviewers
applied these predetermined criteria by reading
abstracts of all retrieved studies and independently
listing studies for inclusion. There was only one
disagreement on inclusion decisions; a third person
appraised this paper and agreement on inclusion/exclusion was reached following discussion.
Authors were not contacted for additional data.

Organisation of Evidence
Data extraction. Data extracted from eligible
studies included authors and date of study, study

Not stated
Not stated
(1970s
onwards)
Not stated
Unclear

72
19662004
1
26

19802005
2

Watson, 2001

van Dijk et al., 2005

To investigate the efficacy of treatment strategies

used to manage motor impairments following
acquired brain injury (upper & lower limbs)
Assessment of the available evidence regarding
the effect of augmented feedback on motor
function of the upper extremity in rehabilitation
patients
To identify the effectiveness of physiotherapy for
physical problems after traumatic brain injury
Marshall et al., 2007

Total number of
studies included
in the review
Objective of review

The search retrieved 333 papers. Six studies met

the inclusion criteria and were obtained and
appraised. Three studies were systematic reviews
(Marshall et al., 2007; van Dijk, Jannink, &
Hermens, 2005; Watson, 2001), and three were
randomised trials (Moseley et al., 2008;
Neistadt, 1994; Peri et al., 2001). The systematic
reviews are summarised in Table 1. RCTs are
summarised in Table 2.
Of the 333 papers retrieved papers, 327 were
excluded for the following reasons: less than 50%
of the study population had a traumatic brain
injury, or data from participants with a brain injury
could not be separated from remaining participants
(n = 215; 66%); participants were not adults (n =
8; 2%); effectiveness of upper limb rehabilitation
intervention was not investigated (n = 84; 26%) or
could not be differentiated from other interventions because outcomes were merged (n = 9; 3%);

Review

Results

TABLE 1
Characteristics of Published Systematic Reviews (n = 3) Included in the Current Review

Rating of trial quality. The methodological quality

of included trials was assessed independently by
two raters using the PEDro scale. The PEDro scale
has established reliability and provides a score out
of 10 (Maher, Sherrington, Herbert, Moseley, &
Elkins, 2003). Studies which attain a PEDro score
of 7 or greater are considered high quality, those
with a PEDro score of 5 or 6 are considered
moderate quality and those with a PEDro score
of 4 or less are considered poor quality in terms
of study methods and susceptibility to bias
(Harvey, Herbert, & Crosbie, 2002). Adequacy of
concealment was additionally rated using the procedure outlined by Schulz (Schulz, 1995).

Total number of RCTs

(UL functional
outcomes) included
in the review

Rating of systematic review quality. The included

reviews were assessed independently by two
raters to determine if they met the requirements of
the QUOROM statement checklist (Moher, Cook,
Eastwood, Olkin, Rennie, & Stroup, 1999). The
QUOROM statement identifies 18 criteria; it has
been used to provide an indication of the quality
of systematic reviews in other published reviews.

36

Range of years of
studies included
in review

The total number

of adults with TBI
included in the
review

design, setting, number of participants, diagnosis,

intervention (including therapy protocol where
described), outcomes, and a summary description
of findings. Data extracted from each study were
tabulated. We planned to conduct a meta-analysis
if there was sufficient clinical and statistical
homogeneity. The level of evidence was determined for each study. Any safety issues and/or
adverse events reported in randomised trials were
recorded (Keech, Wonders, Cook, & Gebski,
2004), as were therapy protocols.

1,180

UPPER LIMB REHABILITATION

239

240

Passive stretching 1
hour per day

Sham stimulation,
8 hours/day while
in coma for up to
14 days; sham
machine had no
discernable
difference from the
genuine stimulation
machine

Serial elbow casts

Electrical
stimulation of the
median nerve of
the dominant hand
(intermittent pulse
at 40 hz, 1520
mA); 8 hours/day
while in coma for
up to 14 days

Meal preparation
tasks, completed as
part of a group
session, for 30
mins x 3 times
weekly for 6 weeks
(9 hours total)

Moseley
et al.,
2008

Peri
et al.,
2001

Neistadt,
1994
45 TBI (41 closed,
1 open), 3 anoxia;
Mean age 33.2 years
(SD 9.1);
Mean time post-injury
7.9 years (SD 6.6)

10 TBI (7 post-MVA, 2
falls, 1 struck by a
beam);
Mean age of 40 (range
19 66);
ES was started a mean
of 62 hours postinjury
(range 48 72 hours).

Brain injury, adults

Participants
Diagnosis, age, length
of time post-injury

45

10

26

Total
n

JTHFT Subtests
Simulated page
turning and picking up
small object; Line
Bisection Test;
Parquetry Block Test,
RKE-R and WAIS-R
Measured at baseline
and after 6 weeks

GCS; GOS, FIM/FAM;

measured at baseline
and after 3 months

Torque-controlled
passive elbow
extension; Maximum
seated forward reach;
TEMPA

Outcome Measures

Hand Function (subtests of JTHFT): change scores in

seconds. Negative scores represent an improved
performance (faster speed).
Simulated page turning
Dominant hand: 1.13 (95% CI -3.9 to 6.2)
Nondominant hand: 8.56 (95% CI -4.2 to 21.3)
Picking up small objects
Dominant hand: -9.38 (95% CI -17.7 to-1.1)
Nondominant hand: 8.24 (95% CI -6.5 to 23.0)

Hand Function (FIM/FAM score) including Motor

Function subscore:
Mean FIM/FAM score for ES 114, Mean score for
control 64.5*
Mean difference between groups 49.5 FIM/FAM points
but with high variability in response; these differences
were not statistically significant.

Mean ROM
1 day post-cast removal: 11(95% CI 0 to 21)
4 weeks post-cast removal: 2(95% CI 13 to 17)
Maximum reach
Post-cast removal: 0cm (95% CI 18 to 47)
4 weeks post-cast removal: 11cm (95% CI 34 to 52)
TEMPA (hand function)
Post-cast removal: 1(95% CI 5 to 2)
4 weeks post-cast removal: 0(95% CI 7 to 6)

Results (effect size)

Note: * Change scores were used in the calculation of 95% confidence intervals around mean treatment difference.
Standard deviations were not reported in the original publication, precluding calculation of 95% confidence intervals around mean treatment difference.
ROM: range of elbow extension movement; TEMPA: Test valuant la Performance des Membres Suprieurs des Personnes ges; JTHFT: Jebsen-Taylor Hand Function Test; RKE-R:
Rabideau Kitence Evaluation Revised; WAIS-R: Weschler Adult Intelligence Scale Revised; GCS: Glasgow Coma Scale; GOS: Glasgow Outcome Scale; FIM/FAM: Functional
Independence Measure/Functional Assessment Measure

Parquetry block
puzzle assembly
group, for 30 mins
x 3 times weekly
for 6 weeks (9
hours total)

Control Intervention

Therapy
Intervention

Study

TABLE 2
Summary of Included Randomised Controlled Trials (n = 3): Participants, Interventions, Outcome Measures and Main Results

NATASHA A. LANNIN AND ANNIE McCLUSKEY

Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
N
N
Y
N
Marshall et al., 2007
van Dijk et al., 2005
Watson, 2001

Note: Explanation of score items: The QUOROM Statement checklist items are: (1) title identifies the report as a meta-analysis [or systematic review] of RCTs; (2) abstract uses a structured format;
(3) abstract objective states the clinical question explicitly; (4) abstract outlines the data sources; (5) abstract outlines the review methods; (6) abstract identifies the characteristics of the RCTs
included and excluded; qualitative and quantitative findings and subgroup analyses; (6) abstract conclusion includes the main results; (7) introduction states the explicit clinical problem,
biological rationale for the intervention, and rationale for review; (8) methods outlines the information sources, in detail and any restrictions; (9) methods states the inclusion and exclusion
criteria; (10) methods outlines the criteria and process used for assessment of study validity; (11) methods outlines the process or processes used for data abstraction; (12) methods outlines
how study characteristics were assessed; (13) methods outlines the procedure for quantitative data synthesis; (14) results provide a meta-analysis profile summarising trial flow; (15)
results present descriptive data for each trial; (16) results present quantitative data synthesis where appropriate; (17) Discussion summarises key findings; discuss clinical inferences
based on internal and external validity; interpret the results in light of the totality of available evidence; describe potential biases in the review process; and suggest a future research
agenda. N = absent, or not clearly present; Y= present.

N
Y
N
N
N
N
Y
Y
N
N
N
N
Y
Y
N
Y
Y
N
Y
Y
Y

Y
Y
N

12
5
4
3
2
1
Review

TABLE 3
Assessment of Included Reviews using the QUOROM Statement Checklist

QUOROM Statement Checklist Items

7
8
9
10
11

13

14

15

16

17

UPPER LIMB REHABILITATION

or the study design was not an RCT or systematic

review (n = 11; 3%) [references to excluded papers
are available upon request].
The three systematic reviews evaluated the
effect of augmented feedback (van Dijk et al.,
2005), physiotherapy interventions (Watson,
2001), and physical and/or pharmacological interventions on motor function following brain
impairment or injury (Marshall et al., 2007).
Included reviews were assessed using the
QUOROM statement checklist. The results of this
assessment are presented in Table 3. No data from
these reviews could be extracted for meta-analysis. No new trials were identified for inclusion and
appraisal from these systematic reviews.
RCTs were rated for methodological quality.
Table 4 presents the PEDro scores for each criteria for the three RCTs. PEDro scores were 8/10
(Moseley et al., 2008), 7/10 (Peri et al., 2001), and
5/10 (Neistadt, 1994). All trials used blinded
assessors and random allocation, however, only
the trial of upper limb casting conducted by
Moseley and colleagues (2008) reported intention
to treat analysis and concealed allocation.

Effectiveness of Upper Limb Rehabilitation

Although three RCTs were included in the systematic review, meta-analysis was precluded due
to their heterogeneity. These trials differed in
design (interventions, time post-injury, outcomes
and outcome measures, and study periods different across studies see Table 2).
The recently completed study of Moseley and
colleagues (2008) received a high PEDro score for
methodological quality. In this study, the effects of
elbow casting were compared to a one hour stretch
in adults with brain injury. A mean improvement
in muscle extensibility of 11 (95% confidence
interval 0 to 21) favouring the casting group was
found one day after cast removal, but that any
effect from cast-wear had almost completely disappeared by the follow-up 4 weeks post (mean
difference 2, 95% CI 13 to 17). Upper limb
function results showed no between-group differences, with very small effect sizes and statistically
non-significant results as measured by maximum
reach (in cm) and scores on the Test valuant
la Performance des Membres Suprieurs des
Personnes ges (TEMPA, see Table 2).
A second RCT with high methodological
quality (PEDro score 7/10) was inconclusive
about whether electrical stimulation improved
upper limb motor function when administered
during coma (Peri et al., 2001). Upper limb motor
function was not specifically measured. The only
measure that tested upper limb performance did so

241

NATASHA A. LANNIN AND ANNIE McCLUSKEY

TABLE 4
Methodological Quality of Included Randomised Controlled Trials (n = 3)
Study
Moseley et al., 2008
Neistadt, 1994
Peri et al., 2001

1#

Y#
N#
Y#

Y
Y
Y

Y
N
N

Y
Y
Y

N
N
Y

PEDro criterion score

6
7
8
N
N
N

Y
Y
Y

Y
N
Y

10

11

TOTAL

Y
N
N

Y
Y
Y

Y
Y
Y

8
5
7

Note: Explanation of score items: The PEDro scale criteria are: (1) specification of eligibility criteria (# Not included in the
PEDro score); (2) random allocation; (3) concealed allocation; (4) prognostic similarity at baseline; (5) subject blinding; (6) therapist blinding; (7) assessor blinding; (8) > 85% follow-up of at least one key outcome; (9) intention-to-treat
analysis; (10) between group statistical comparison for at least one key outcome; and (11) point estimates of variability provided for at least one key outcome. Only items 211 are summed to provide total score. N = absent or not
clearly present, Y = present.

indirectly, using a combined FIM/FAM total

score, with length of coma being the primary outcome measure. Mean difference between groups
was 49.5 FIM/FAM points however this difference was not statistically significant according
to the authors, with wide variability in responses.
No measures of variability were reported, precluding calculation of 95% confidence intervals.
The third RCT was of moderate methodological quality (PEDro score 5/10), and concluded
that functional training through involvement in
meal preparation tasks (making a cold sandwich
with two fillings and a hot instant drink) may
improve fine motor coordination more than practising tabletop, puzzle tasks (Neistadt, 1994).
Scores for picking up small objects using the
dominant hand showed a mean difference between
groups of 9.38 seconds (95% CI, 1.1 to 17.7) on
the Jebsen-Taylor hand function small objects
subtest, in favour of the meal preparation group.
However, all other reported results were inconclusive, with very small effect sizes, wide confidence
intervals and statistically nonsignificant results
(see Table 2).

Adverse Events and Safety

Two trials explicitly made adverse event statements relating to the interventions of casting
(Moseley et al., 2008) and electrical stimulation
(Peri et al., 2001). While Peri and colleagues.
reported that: There were no adverse events relating to ES [electrical stimulation] (2001; p.905),
Moseley and colleagues reported the odds ratios
for adverse events associated with casting to be
14.7 (95% confidence interval 1.5 to 147.0) as
reported by treating physiotherapists and 4.3
(95% confidence interval of 0.4 to 47.6) as
reported by participants. This means that the odds
or probability of an adverse event occurring was
14 times greater for participants that received

242

serial elbow casting, compared to no cast. The

numbers of participants who experienced adverse
events from upper limb casting as reported by
physiotherapists were: none (6/14); skin irritation
(1/14); skin breakdown (1/14); pain (1/14);
swelling (3/14); triggered dysautonomia (0/14);
and two or more adverse events (2/14). The numbers of participants who experienced adverse
events from upper limb casting as reported by participants were: unable to be assessed (2/14); none
(7/14); skin irritation (1/14); pain (2/14); swelling
(1/14); numbness (0/14); inconvenience (1/14);
and two or more adverse events (0/14) (Moseley
et al., 2008). No details relating to adverse events
were reported in the trial by Neistadt (1994).

Contraindications
Exclusion criteria reported in the studies were
considered potential clinical contraindications to
the upper limb rehabilitation interventions. Only
one study (Peri et al., 2001) reported exclusion
criteria relating to the study intervention (electrical stimulation). These included: participants with
implanted pacemakers or defibrillators, spinal
cord injury, or who were pregnant, to avoid possible negative interactions with the electrical stimulation. Careful review of the inclusion criteria of
the casting trial (Moseley et al., 2008, p. 407) suggests that orthopaedic or other injuries which
would preclude serial casting of the elbow, and
active heterotopic bone growth were contraindications to upper limb serial casting.

Therapy Protocol
Trials were not homogenous, therefore therapy
protocols will be discussed separately. The casting
protocol described by Moseley and colleagues
(2008) applied long arm synthetic casts for two
weeks to the elbow in a stretched position of

UPPER LIMB REHABILITATION

extension. The elbow position was determined by

either the participants perception of a strong
stretch or the physiotherapists perception of significant passive tension in the elbow flexor muscles. Casts were changed after 7 days to progress
the stretch, with the total cast-wear period being 2
weeks. At the same time, participants received an
individually designed therapy programme for 15
minutes/day, 5 days/week (serial casting and control groups). These exercises were designed to
elicit activity of paralysed muscles and improve
voluntary control of the upper limb muscles.
The electrical stimulation (ES) protocol
described by Peri and colleagues (2001) involved
ES for 8 hours a day, every day the participant
remained in a coma (GCS < 9), for up to 14 days.
ES was applied to the volar (or palmar) surface of
the right forearm for people who were righthanded, in order to stimulate the right median
nerve (one participant was left-handed, therefore,
ES was applied on the persons left arm and
median nerve). Stimulation was applied in 300 ms
pulses at 40 Hz, and 15 20 mA given intermittently (20 seconds on, 40 seconds off).
The protocol for the meal preparation group,
also designed to target fine-motor coordination
(Neistadt, 1994) was delivered 3 times a week for
6 weeks, and involved 30-minute treatment sessions (total treatment time 9 hours). Participants
made a sandwich with two fillings and a hot instant
drink. While the authors report a prompting protocol for participants with problem solving difficulties, no details are provided of the number of
repetitions/amount of practice per session/week.

Discussion
This systematic literature review of upper limb
rehabilitation for adults after brain injury found
little evidence to inform clinical decision-making.
Only three randomised controlled trials were
located and appraised. While a greater number of
clinical trials were located which included participants who had experienced a TBI, the proportion of
participants was commonly less than 50% (it was
not possible to discern the TBI-only data from the
results of located studies which was disappointing).
Included RCTs all studied different interventions. Heterogeneity of the included studies,
including study design, time postinjury and outcomes, prevented pooling of the data across the
trials. Ultimately, included trials reported mixed
findings on upper limb outcomes, with clinically
significant findings being reported for range of
movement following upper limb casting (Moseley
et al., 2008) and statistically significant findings

reported for fine motor coordination after functional training in meal preparation tasks (Neistadt,
1994). Remaining outcomes were not significant.
The use of less than optimal methods for measuring these outcomes, however, may have contributed to these results. Since function and
quality of life are what matter to our patients, outcome measures at the level of activities are understandably important. However, generic measures
of basic activities of daily living (e.g., FIM + FAM
as used in the trial by Peri et al., 2001) are likely
to suffer from both ceiling and floor effects,
decreasing the potential to show a difference
between groups in outcome and significantly
reducing the power of the study. Consequently,
researchers must consider recovery beyond ADL
where the clinical rationale for treatment is to
improve functional movement and, ultimately,
participation. Measures that assess a higher level
of activity may be more sensitive to differences
between groups.
Three previous systematic reviews were
appraised, which included studies of the effectiveness of upper limb rehabilitation after brain injury
(Marshall et al., 2007; van Dijk et al., 2005;
Watson, 2001). The review by Watson (2001)
reported on research studies (including n-of-1
designs) that evaluated the outcomes of physiotherapy for adults with TBI. Each study was categorised under one of nine types of intervention,
three addressing functional upper limb rehabilitation (Underlying approaches to therapy,
Functional skills training and Casting, splinting
and associated therapies). The review did not
report the number of studies located or reviewed.
Watson (2001) did not include the trial by Neistadt
(1994) that had been published at the time.
Although not stated, it is possible that the trial by
Neistadt (1994) was excluded because the upper
limb motor training intervention was described as
an occupational therapy, and not a physiotherapy,
intervention. No explanation for the reasons for
non-inclusion of the Neistadt trial, in addition to
the low QUOROM rating, contribute to the low
methodological quality of Watsons (2001) review.
A second systematic review of 26 randomised
controlled trials evaluated the effect of augmented
feedback on motor function, and was published by
van Dijk and colleagues (2005). Unlike the
reviews by Watson (2001) and Marshall and colleagues (2007), van Dijk and colleagues included
a range of rehabilitation populations and was not
limited to TBI. The varied diagnoses and populations included by van Dijk and colleagues (2005)
resulted in one study only in common with the
present review the RCT by Peri and colleagues

243

NATASHA A. LANNIN AND ANNIE McCLUSKEY

(2001). Van Dijk and colleagues (2005) found that

nine studies reported a positive effect of augmented feedback on arm function. However, they
concluded overall that there was no firm evidence on the effectiveness of augmented feedback for improving upper limb motor function.
Finally, the most recent systematic review
(Marshall et al., 2007) investigated the efficacy of
interventions used to manage motor impairments
following acquired brain injury. Like Watson
(2001), Marshall and colleagues included lower
levels of evidence (nonrandomised trials, case series,
before and after studies and retrospective chart
reviews), with a subsequent reduction in review
quality based on the QUORUM checklist. Similar to
van Dijk and colleagues (2005), Marshall and colleagues included studies where less than 50% of participants had a TBI, making it difficult to generalise
review findings to persons with TBI. By including
lower level studies, as well as studies where the
majority of participants had diagnoses other than
TBI, Marshall and colleagues were able to include a
higher number of trials in their review, in comparison to the present review. A total of 36 studies were
included in the review by Marshall and colleagues;
however, only one of these was eligible for inclusion
in the present review.
Each of the previous systematic reviews had
limitations, making the present review unique and
necessary. First, none of the previous reviews
included all three RCTs included in this review. For
some reason, possibly their exclusion criteria, key
studies investigating the effect of upper limb motor
training (e.g., Neidstadt, 1994), were either missed
or excluded. Second, both reviews included lower
levels of evidence, which limits review quality. A
third limitation of these two more recent reviews is
the inclusion of studies involving other rehabilitation and non-TBI populations, making it impossible for clinicians to determine the average effect of
intervention on a person with TBI. Consistent with
the findings of the present review, two of the previous reviews (Marshall et al., 2007; van Dijk et al.,
2005) concluded that, at best, only limited evidence
exists on the effectiveness of interventions to
improve upper limb motor function of the upper
limb. Another benefit of the current systematic
review is the inclusion of more recent evidence
(Moseley et al., 2008).
Strengths of the present review include the
clear research question, adherence to an explicit
research protocol developed prior to the analysis,
the comprehensive nature of the data search
(employing both computer databases and manual
bibliography searches), and reaching consensus
between reviewers about data elements prior to

244

entry into the database. There are, however, limitations to this review. We only included studies
published in English and thus acknowledge a language bias, and review conclusions have been
based on only three RCTs. Having only three
RCTs included in this review, and with those trials
having mixed findings on functional outcomes
(less than 50% of studies reporting significant
findings), it is not possible to draw conclusions
about the effectiveness of upper limb rehabilitation for adults after traumatic brain injury.
The scarcity of high-level research evidence is
neither unexpected nor surprising. RCTs that evaluate upper limb rehabilitation with the TBI population pose unique challenges. Trials need to cope
with variability in functional levels of people
with TBI, and accommodate different levels of
outcome (for example, impairments such as range
of movement versus hand function). The complex
range of pathologies, variable levels of motor
function, and typically small populations compared to stroke, make the conduct of RCTs particularly challenging (Maas, Marmarou, Murray,
Teasdale, & Steyerbergm, 2007). Operationalisation and description of interventions is also difficult because each participants rehabilitation
frequently needs to be individualised. Nonetheless, adequate description is important, so that
replication is possible in future trials.
Despite difficulties in conducting RCTs with a
TBI population, there remains a need for highlevel evidence about the effectiveness of upper
limb rehabilitation after TBI. Research is needed
to determine with confidence not only whether
specific interventions are helpful but also what
intensity is required to effect change, and how feasible it is to deliver interventions to samples of
people with TBI. Similar questions have been
raised, and are being addressed in stroke rehabilitation. For example, systematic reviews involving
people with stroke indicate that the following
interventions may improve motor recovery: use of
mental practice or imagery (Braun et al., 2006),
electrical stimulation alone, or combined with
biofeedback (de Kroon, Ijzerman, Chae,
Lankhorst, & Zilvold, 2005); restraining the noninvolved arm (Hakkennes & Keating, 2005); and
engaging people in repetitive, novel tasks assisted
by robotics (Barreca, Wolf, Fasoli & Bohannon,
2003; de Kroon et al., 2005; Prange, Jannick,
Groothuis-Oudshoom, Hermens, & Ijzerman,
2006). Researchers and clinicians can use this
existing research to guide their selection of upper
limb treatment techniques in future TBI research
and practice. Ultimately, however, research still
needs to be conducted with a TBI population.

UPPER LIMB REHABILITATION

Reviewers Conclusions
There is still insufficient evidence to either support or refute the effectiveness of any one specific
rehabilitation intervention to improve upper limb
motor function in adults following TBI. There is a
need for studies which investigate the effect of
motor training interventions on upper limb outcomes in a TBI-only population. Adequately powered RCTs are needed such as that reported by
Moseley and colleagues (2008) but that also
use consistent therapy protocols and outcome
measures. Such trials should include a no-therapy
condition or group (i.e., a true control group) so
that interventions not involving motor training do
not confound results. Future trials also need an
adequate sample size to avoid type-II errors, that
is, where small numbers do not detect a positive
treatment effect when this exists (Domholdt,
2000). In the present review, caution is needed
when interpreting results that were not statistically
significant, which was the case for some outcomes
in each of the three trials (see Table 1). These nonsignificant results may be due to a lack of adequate power rather than lack of significant effect.
It is difficult to determine if this was the case in
the included trials as power calculations were not
reported for two of the trials (Neistadt, 1994; Peri
et al., 2001). In the casting trial (Moseley et al.,
2008), the outcome of interest (upper limb function) was a secondary outcome, and so again, findings must be interpreted with caution. Finally,
while there is a need for further research, it is
important to make the distinction between a lack
of evidence, versus evidence of lack of effect.
There is still a lack of robust evidence due to the
limited number of studies to guide clinicians with
regard to upper limb motor rehabilitation for
adults with TBI.

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