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

Objective: This study explored the effects of home-based transcranial direct current stimulation combined with exercise on motor and sensory function, spasticity, functional and transfer performance, and quality of life.

Design: A prospective, double-blind, randomized, sham-controlled trial.

Subjects and methods: Thirty individuals with SCI were allocated to receive either active transcranial direct current stimulation or sham transcranial direct current stimulation, followed by the same tele-rehabilitation programme, for 12 sessions over 4 weeks (3 sessions/week). Each session included 20 min of transcranial direct current stimulation followed by 1 h of tele-supervised exercise. Primary outcome was the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Secondary outcomes included (i) the upper limb muscle strength evaluated by hand-held dynamometer, (ii) spasticity evaluated by H reflex and modified-Modified Ashworth Scale, (iii) functional performance assessed by the spinal cord independence measure III, (iv) transfer performance assessed by the transfer assessment instrument, and (v) quality of life assessed by WHOQOL-BREF. Outcomes were assessed at baseline, post-intervention, and 1-month follow-up.

Results: Two-way mixed ANOVA revealed an interaction effects between group and time (F(1,18)=4.49, p=0.043) and main effects of time (F(1,18)=7.82, p=0.009). Bonferroni post-hoc analysis showed a significant improvement only within the active group at 1-month follow-up (p=0.002) for the upper extremity motor scores (UEMS). No significant differences were observed for any of the secondary outcomes.

Conclusion: The effect of 12 sessions of home-based transcranial direct current stimulation combined with exercise was limited to improved upper limb motor recovery, with after-effect at 1-month post-intervention as compared with exercise alone. No improvements were found in sensory function, spasticity, functional and transfer performance, and quality of life. However, this intervention appeared to be feasible, safe, and well-adhered to and provides insight into the use of transcranial direct current stimulation as a tool for tele-rehabilitation in a spinal cord injury outpatient population.