Effectiveness of respiratory rehabilitation in cervicothoracic spinal cord injury: A systematic review and network meta-analysis

Zhixiang Liu¹Jiejun Tan¹Xiaodong Song¹Ziyi Zhang²Yajie Wang³Yating Tao¹Simeng Chen¹Fanxing Zhuo¹Zhuang Wu¹Zerong Zhang¹Hongpeng Li^2*

• ¹The Third The People's Hospital of Bengbu, Bengbu, China
• ²Beijing Sport University, Beijing, China
• ³Universiti Kebangsaan Malaysia, Bangi, Malaysia

Objective: Respiratory dysfunction is a major contributor to morbidity and mortality in patients with cervicothoracic spinal cord injury (SCI). This dysfunction primarily arises from diaphragmatic paralysis, impaired neural control of respiratory muscles, and autonomic dysregulation, leading to reduced ventilatory capacity and compromised respiratory performance. Although various respiratory rehabilitation strategies are widely used, their comparative effectiveness remains unclear. This study aimed to evaluate and rank non-pharmacological respiratory rehabilitation interventions for improving pulmonary function, respiratory muscle strength, and dyspnea in individuals with cervicothoracic SCI. Review Methods: A systematic review and Bayesian network meta-analysis were conducted in accordance with PRISMA 2020 guidelines. Eight databases were searched from inception to July 2025 for randomized controlled trials (RCTs) evaluating non-pharmacological respiratory rehabilitation interventions in cervicothoracic SCI. Primary outcomes included forced vital capacity (FVC, L), forced expiratory volume in one second (FEV₁, L), maximal inspiratory pressure (MIP, cmH₂O), and Borg dyspnea score. Network meta-analyses were performed using the gemtc and multinma packages in R. Results: Forty RCTs involving 1,878 participants were included. Liuzijue demonstrated the greatest improvement in FVC (MD = 0.97, 95% CrI 0.57–1.37), abdominal compression training showed the largest effect on FEV₁ (MD = 0.68, 95% CrI 0.36–1.00), progressive resistance breathing training achieved the highest gain in MIP (MD = 13.95, 95% CrI 9.08–18.82), and normocapnic hyperpnoea produced the greatest reduction in dyspnea severity (MD = −3.00, 95% CrI −4.50 to −1.50). No significant inconsistency or publication bias was detected across the outcome networks. Conclusion: Distinct respiratory rehabilitation modalities confer domain-specific benefits in patients with cervicothoracic SCI. Liuzijue and abdominal compression training primarily improve ventilatory function, progressive resistance breathing training enhances inspiratory muscle strength, and normocapnic hyperpnoea effectively alleviates dyspnea. These findings support a multimodal, individualized rehabilitation approach tailored to specific respiratory deficits in clinical practice.