Multimodal Interventions for Upper-Limb Recovery After Cervical Spinal Cord Injury: A Systematic Review and Quantitative Synthesis
Cervical spinal cord injury (CSCI) leads to severe impairment of the upper limb, which leads to tetraplegia and decreased independence in aspects of self-care and grasping. Conventional rehabilitation provides limited recovery, particularly in the case of complete American Spinal Injury Association (ASIA) Impairment Scale (AIS) A–B injuries, and there is a growing interest in multimodal rehabilitation strategies. This systematic review summarized evidence from 38 studies including pilot studies, preclinical investigations, and randomized controlled trials published between 2016 and 2026. Interventions were systematically classified and data extracted for the primary upper-limb outcomes, the Action Research Arm Test, grip strength, Graded Redefined Assessment of Strength, Sensibility and Prehension, Upper Extremity Motor Score, and Spinal Cord Independence Measure. About three-quarters of the studies reported improvements in at least one upper-limb outcome and almost half the studies had clinically meaningful improvements. However, 44% of studies were judged to have a high or critical risk of bias due to small sample sizes and limited controls; more than 90% reported no major safety concerns. Orthotic and robotic interventions maintained functional improvements, whereas hybrid neuromodulation approaches led to the largest gains in grip strength. Pharmacological therapies were of little benefit. In conclusion, multimodal non-invasive rehabilitation strategies might be promising for the improvement of upper-limb recovery after CSCI, but larger, high-quality clinical trials are needed. Received: 24 March 2026 | Revised: 18 June 2026 | Accepted: 11 August 2026 Conflict of Interest The authors declare that they have no conflicts of interest to this work. Data Availability Statement Data sharing is not applicable to this article as no new data were created or analyzed in this study. Author Contribution Statement Krishnakumar Sankar: Conceptualization, Methodology, Validation, Investigation, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision, Project administration. Yazhini Arulselvam: Conceptualization, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization. Supriya Harikrishna: Conceptualization, Investigation, Data curation, Writing – original draft, Writing – review & editing, Visualization.