Tele-rehabilitation using transcranial direct current stimulation combined with exercise in people with spinal cord injury: a randomized controlled trial.

The sample size was small (30 participants), which limits the power to detect differences in secondary outcomes and prevents subgroup analysis by injury severity. Many participants had motor complete injuries (AIS A or B), which inherently limits potential for motor recovery, particularly in the lower limbs. Lower limb exercises could not be performed independently by most participants, and no participants received functional or transfer training via the tele-rehabilitation model, explaining the null results in these areas. H-reflex data, used to assess spasticity, was only available for a subset of participants (19 out of 30) because the reflex was absent in others. Participants were allowed to continue other rehabilitation during the follow-up period, which could have influenced the long-term results. The study applied a Bonferroni correction for multiple comparisons, but the authors acknowledge the risk of Type I error remains due to the number of outcomes measured.

The authors declared no conflicts of interest. The research was funded by the Faculty of Physical Therapy, Mahidol University, and the National Science, Research and Innovation Fund (NSRF).

Do not assume this intervention improves overall physical function or independence. The benefit was isolated to upper limb motor scores; lower limb function, sensation, strength, and daily living activities showed no improvement over sham treatment.