Archives of Physical Medicine and Rehabilitation

ObjectiveTo compare healthcare utilization and cost in individuals with spine pain who undergo no physical therapy, standard physical therapy, or physical therapy in an integrated practice unit model. DesignA cost-effectiveness analysis SettingMulti-site outpatient physical therapy clinics within a single metropolitan region ParticipantsIndividuals with de-identified claims data from a single insurance provider under Medicare Advantage with a spine-pain related diagnosis from January 2019-December 2021. InterventionsPatients were categorized into three cohorts: No physical therapy (NoPT), standard physical therapy (SPT), and physical therapy within an integrated practice unit model (IPUPT) based on their physical therapy history during the data collection period. Main Outcome MeasuresNumber and percentage of patients reporting claims, number of claims/patient per year, paid amount, and number of RVUs were compared across groups using chi-square or one-way ANOVA with multiple comparisons corrections. ResultsData from 13,569 patients was included in this study. The number of patients with spine-related inpatient claims was highest in the SPT group (2.8%) compared to the IPUPT (1.5%) and NoPT (1.3%) groups (p=0.004). Outpatient care utilization was driven by radiology (54.7%) and laboratory (22.1%) claims and was lowest in the IPUPT group (N=1,096; 56.8%) compared to the SPT group (N=1,654; 68.3%) and NoPT group (N=9,150; 99.3%, p<0.001). The SPT group was most costly per person ($2,243.66(11,048.94)) followed by the NoPT ($1,352.01(6,419.2), p<0.001) and the IPUPT ($1,259.88(9,061.23), p<0.001) groups. The greatest contributor to cost was outpatient procedures, averaging $142.39(1,046.26) per person. ConclusionAn integrated multidisciplinary rehabilitation model may be a cost-effective method of multimodal care in individuals with spine pain.

BackgroundModerate- to high-intensity walking training (M-HIT) is an established intervention for improving walking capacity in chronic stroke. Musculoskeletal (MSK) adverse events commonly occur during M-HIT, yet tools to identify individuals at higher risk are limited. Baseline clinical characteristics may provide insight into susceptibility to training-related MSK adverse events during M-HIT. Thus, this study aimed to develop and internally validate a model for predicting MSK adverse events during a 12-week M-HIT program in chronic stroke using baseline clinical characteristics. MethodsParticipants (n=100) from HIT-Stroke Trials 1 and 2 were included. Baseline clinical characteristics included measures of orthopedic history, pre-existing pain, motor function, recent exercise history, demographics and health characteristics, stroke chronicity, and psychological health. Logistic regression models evaluated all possible combinations of baseline characteristics with up to three predictors. Leave-one-out cross-validation was used for internal validation to mitigate overfitting. Predictive performance was quantified using the C-statistic, and the candidate model with the highest cross-validated C-statistic was selected as the final model. ResultsMSK adverse events occurred in 32.0% of participants. The optimal three-variable model included prior orthopedic condition (Odds ratio [OR] 3.02 [95% CI 1.14-8.64]), Fugl-Meyer lower extremity motor score (OR 1.14 [95% CI 1.02-1.28]), and self-reported participation in regular walking exercise (OR 0.17 [95% CI 0.05-0.49]) at baseline. This model demonstrated moderate discrimination (cross-validated C-statistic = 0.74; apparent C-statistic = 0.78). ConclusionsParticipants reporting at least one pre-existing lower extremity or lumbar spine orthopedic condition and those with better lower-extremity motor function exhibited greater odds of experiencing MSK adverse events during M-HIT, while participants reporting participation in regular walking exercise had lower odds. These findings suggest that baseline clinical characteristics may help identify individuals at elevated risk for MSK adverse events during M-HIT who may warrant closer monitoring or risk-reduction strategies. Future studies are needed for external validation. Clinical Trial Registrationhttps://ClinicalTrials.gov; Unique identifiers: NCT03760016, NCT06268041

ImportanceMedicare-Medicaid dual eligible beneficiaries experience pronounced disparities in stroke recovery. However, it remains unclear whether inpatient rehabilitation services and outcomes are comparable between dual-eligible beneficiaries enrolled in Medicare fee-for-service (FFS) versus Medicare Advantage (MA) plans. ObjectiveTo compare rehabilitation therapy utilization and associated outcomes among dual-eligible beneficiaries enrolled in FFS versus MA plans with stroke. DesignRetrospective cohort study. SettingInpatient Rehabilitation Facilities (IRF). ParticipantsMedicare beneficiaries admitted to IRF with stroke (n=125,782) between 2017 and 2019. ExposureDual-eligible beneficiaries enrolled in FFS versus MA plans. Main Outcome MeasuresTotal number of minutes of physical and occupational therapy provided within the first 2 weeks of IRF stay, self-care and mobility change scores, and 30-day all-cause hospital readmission. ResultsFor the first 2 weeks of therapy utilization, we did not find significant differences between the four groups. Using the non-dual FFS beneficiaries and low category of change as a reference, we found significantly lower likelihood of achieving high change in self-care scores for the dual FFS (OR=0.73, 95% CI=0.69-0.76), and dual MA (OR=0.93, 95% CI=0.88-0.98). However, non-dual MA patients had a higher likelihood of changes in self-care scores (OR=1.17, 95% CI=1.13-1.22). Similar trends were found for the mobility change scores, compared to non-dual FFS: dual FFS (OR=0.72, 95% CI=0.68-0.75), and dual MA (OR=0.91, 95% CI=0.86-0.96) and non-dual MA (OR=1.16, 95% CI=1.12-1.20). For 30-day readmission risk, dual FFS showed a higher likelihood of readmission (OR=1.19, 95% CI=1.08-1.31), while non-dual MA had a significantly lower likelihood (OR=0.77, 95% CI=0.71-0.83). Conclusions and RelevanceAlthough no differences in rehabilitation therapy utilization for stroke among dual-eligible beneficiaries, they had poorer functional recovery and higher 30-day readmission risk irrespective of FFS vs MA. Whereas non-dual-eligible MA beneficiaries experienced favorable outcomes. These findings underscore the importance of addressing post-IRF discharge needs among disadvantaged populations.

BackgroundAfter discharged from the hospital for acute stroke, individuals typically receive rehabilitation in one of three settings: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home with community services (i.e., home health or outpatient clinics). The initial setting of post-acute care (i.e., discharge location) is related to mortality and hospital readmission; however, the impact of this setting on the change in functional mobility at 90-days after discharge is still poorly understood. The purpose of this work was to examine the impact of discharge location on the change in functional mobility between hospital discharge and 90-days post-discharge. MethodsIn this retrospective cohort study, we used the electronic health record to identify individuals admitted to Johns Hopkins Medicine with an acute stroke and who had measurements of mobility [Activity Measure for Post Acute Care Basic Mobility (AM-PAC BM)] at discharge from the acute hospital and 90-days post-discharge. Individuals were grouped by discharge location (IRF=190 [40%], SNF=103 [22%], Home with community services=182 [(38%]). We compared the change in mobility from time of discharge to 90-days post-discharge in each group using a difference-in-differences analysis and controlling for demographics, clinical characteristics, and social determinants of health. ResultsWe included 475 individuals (age 64.4 [14.8] years; female: 248 [52.2%]). After adjusting for covariates, individuals who were discharged to an IRF had a significantly greater improvement in AM-PAC BM from time of discharge to 90-days post-discharge compared to individuals discharged to a SNF or home with community services ({beta}=-3.5 (1.4), p=0.01 and {beta}=-8.2 (1.3), p=<0.001, respectively). ConclusionsThese findings suggest that the initial post-acute rehabilitation setting impacts the magnitude of functional recovery at 90-days after discharge from the acute hospital. These findings support the need for high-intensity rehabilitation and for policies that facilitate the delivery of high-intensity rehabilitation after stroke.

IntroductionPost-stroke fatigue (PSF) affects nearly half of all stroke survivors and significantly hinders rehabilitation and daily functioning. There is no established treatment. Low cardiorespiratory fitness may contribute to PSF, suggesting aerobic training as a potential intervention. MethodsIn this two-center, randomized, open-label, blinded-endpoint trial, we evaluated a home-based supervised cardiorespiratory interval training program (HS-CITP) in individuals with PSF (Swedish Fatigue Assessment Scale [S-FAS] [&ge;]28) 1-7 months post-stroke. Participants were randomized (1:1) to either HS-CITP or usual care with self-directed activity following early supported discharge. The intervention included three weekly cycling sessions at 70%-80% of maximum heart rate over eight weeks. The primary outcome was self-reported fatigue (S-FAS); the secondary outcome was peak oxygen uptake (VO2peak, mL/kg/min) post-intervention. ResultsForty-five participants were randomized; 43 completed follow-up (HS-CITP: n=22; control: n=21). Adherence to HS-CITP was 92%, with no adverse events. Compared with the control group, HS-CITP significantly reduced fatigue (mean between-group difference -5.35 S-FAS points; 95% CI -9.03 to -3.67; p<.001) and improved cardiorespiratory fitness (+4.48 VO2peak mL/kg/min; 95% CI 3.41-5.54; p<.001). ConclusionSupervised home-based interval training significantly reduced PSF and improved fitness, with high adherence and no safety concerns. These findings support integrating structured aerobic exercise into stroke rehabilitation. Larger, longer-term trials are needed to confirm the durability of this benefit. RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT03458884

Introduction: Reduced or lost sensation and movement after a spinal cord injury (SCI) impairs the brain s ability to accurately localize paralyzed body parts, causing deficits in its internal body map, or mental body representations (MBR). These deficits hinder functional recovery and contribute to neuropathic pain. Medications for neuropathic pain are often ineffective and carry side effects. Our pilot trials found that in-person Cognitive Multisensory Rehabilitation (CMR), a physical therapy restoring MBR, led to prolonged pain reduction, improved sensorimotor function, and enhanced brain function, to greater extent than adaptive fitness. To explore more accessible interventions for those in rural areas or with transportation challenges, we examined whether 12 weeks of remotely delivered CMR or exercise would (1) improve function and reduce pain; (2) increase brain activity and connectivity related to sensorimotor function and MBR in adults with SCI. Methods: Of 19 adults with SCI who consented, 15 (51+/-15 years old, 8+/-10 years post-SCI) were randomized to 12 weeks of remotely delivered CMR or exercise (45min, 3x/week). Eight reported neuropathic pain equal or greater than 3/10. The Numeric Pain Rating Scale (NPRS), ASIA Impairment Scale (AIS), and Neuromuscular Recovery Scale (NRS) assessed pain and sensorimotor function at baseline, post-intervention, and 6-month follow-up. Functional MRI included resting-state and four tasks: imagining feeling the left leg, imagining moving the left leg, whole-body movement imagery, and a sensation task. Results: After CMR (n=8), participants improved on AIS (large effect sizes: touch: d=1.30; pinprick: d=1.21; lower limb motor function: d=1.83). Exercise (n=7) produced smaller improvements (touch: d=0.35; pinprick: d=0.36; lower limb motor function: d=0.80). CMR showed greater NRS effect sizes (core: d=1.48; upper limb: d=0.69; lower limb: d=1.25) than exercise (core: d=0.31; upper limb: d=0.74; lower limb: d=0.83). Benefits persisted at follow-up for both AIS and NRS, especially in the CMR group. Highest neuropathic pain intensity decreased in both groups post-intervention (CMR: d=-0.61; exercise: d=-0.73) and at 6-month follow-up (CMR: d=-0.55; exercise: d=-0.55). Unlike previous studies, group effects for CMR were not found due to high heterogeneity. Increased task-based activation, including in the lateral occipital cortex involved in visual body perception and spatial awareness, was seen for the exercise group (n=5). Discussion: These preliminary results support the potential of remotely delivered CMR and exercise to improve function and reduce neuropathic pain in adults with SCI, highlighting the need for larger trials. Clinicaltrial.gov: NCT05870189

BackgroundPost-stroke recovery trials pose distinct recruitment and retention challenges, and understanding the financial requirements of conducting randomized controlled trials is crucial to ensure sufficient resources for successful study execution. The purpose of this analysis was to quantify the costs at a single site with a large catchment area of the Moderate-Intensity Exercise Versus High-Intensity Interval Training to Recover Walking Post-Stroke, HIT Stroke Trial. MethodsTo determine cost, study expense reports were gathered and divided into four categories: oversight, recruitment, retention, and outcome assessments. Categories were then further divided into chronological order for initial contact and prescreening, consenting, initial screening, and baseline testing. The 12-week intervention was divided into 4-week blocks: intervention block 1, post 4-week outcome testing, intervention block 2, post 8-week outcome testing, intervention block 3, and post 12-week outcome testing. ResultsTotal direct cost for site execution was $539,768 with cost per participant approximated as $35,984. Oversight costs accounted for 65.8% of the budget at $355,661. To achieve goals related to inclusive participant recruitment ($21,923) and retention ($28,009), our site costs totaled $49,932. Direct study-related costs included screening assessments ($5,905), baseline assessments ($15,028), intervention ($76,952), and outcome assessments ($36,288). ConclusionClinical trials on walking rehabilitation and exercise, especially those involving multiple assessment visits, require intensive oversight. This cost analysis provides important and critical insight into the expenses required to successfully execute an exercise-based walking rehabilitation trial in the United States.

BackgroundPeople with chronic stroke have significant impairments in their walking capacity. Minimal clinically important differences (MCIDs) can be used to interpret changes in patient outcomes following interventions. There is significant variability in the response to moderate-to-high walking interventions in people with chronic stroke. One reason for this response variability could be the lack of understanding of the threshold exercise dose needed to achieve an MCID. The purpose of this analysis was to determine the threshold of exercise training speed most predictive of a small (> 20m) or moderate (> 50m) clinically important difference in 6MWT in people with chronic stroke. Materials and MethodsParticipants with chronic stroke with a walking speed of 0.3-1.0m/s were randomized into a 12-week (1) fast-walking training or (2) fast-walking training and step-activity monitoring intervention. This analysis included participants (n = 129; age: 63.1 {+/-} 12.5, 46% female) with complete pre- and post-intervention data. Exercise intensity was quantified as average training speed. ResultsReceiver operating characteristic curves analyzed whether training speed is predictive of attaining a clinically important difference in the 6MWT. Training speed had poor, non-significant accuracy of predicting a small (AUC [95% CI] = 0.584 [0.475 - 0.693], p = 0.131) or moderate (AUC [95% CI] = 0.597 [0.498 - 0.696], p = 0.056) change in 6MWT. DiscussionThe average walking training speed during this high-intensity walking intervention did not accurately predict which people with chronic stroke would attain a small or moderate clinically meaningful change in 6MWT distance.

Introduction: Adults with spinal cord injury (SCI) often experience reduced or lost sensation and movement, impairing the ability of the brain to locate paralyzed body parts, which, in turn, compromises sensorimotor recovery. This disruption of the internal body map of the brain, or mental body representations (MBR), also contributes to neuropathic pain in about 69% of adults with SCI. Medications for neuropathic pain are often ineffective and can cause adverse reactions. Our previous pilot clinical trial showed that Cognitive Multisensory Rehabilitation (CMR), a physical therapy that restores MBR, produced significant, lasting reductions in neuropathic pain, improved sensorimotor function, and enhanced brain function. Building on these results, we examined whether 8 weeks of CMR or adaptive fitness (1) improved sensorimotor function and reduced pain; (2) greater brain activity and connectivity related to sensorimotor function and MBR in adults with SCI. Methods: Sixteen participants (52+/-8 years old, 13+/-10 years post-SCI) were randomized to 8 weeks of CMR or adaptive fitness (45 min, 3x/week). Ten participants had neuropathic pain of 3/10 or greater. Pain and sensorimotor function were assessed at baseline, post-intervention, and 3-month follow-up using the Numeric Pain Rating Scale (NPRS), ASIA Impairment Scale (AIS), and Neuromuscular Recovery Scale (NRS). Functional MRI included resting-state and 4 tasks: imagining feeling the left leg, imagining moving the left leg, whole-body movement imagery, and a sensation task. Results: After CMR, participants improved on AIS with large effect sizes (touch: d=1.54; pinprick: d=1.83; lower limb motor function: d=1.32), while adaptive fitness had small/moderate effects (touch: d=0.49; pinprick: d=0.53; lower limb motor function: d=0.74). CMR also showed larger effect sizes for NRS (core: d=2.19; upper limb: d=0.69; lower limb: d=0.74) than fitness (core: d=0.73; upper limb: d=0.34; lower limb: d=0.00). Benefits persisted at follow-up. Highest neuropathic pain intensity reduced post-CMR and at 3-month follow-up (d=0.48; d=0.63). Pain increased slightly after fitness (n=6; d=-0.19; d=-0.41). CMR increased brain connectivity and activation during the leg imagery task. Increased activation during whole-body imagery was greater after CMR than fitness. Discussion: These preliminary results support the potential of CMR to improve function and reduce neuropathic pain in adults with SCI, warranting larger confirmatory trials. Clinicaltrial.gov: NCT05167032

BackgroundSedentary behavior is highly prevalent following traumatic brain injury (TBI) and compounds existing risks for cardiovascular, neurodegenerative, and affective disorders. The cognitive and behavioral sequelae of TBI, including impaired decision-making, blunted reward processing, and cognitive fatigue, create particular barriers to adopting and maintaining an active lifestyle. Despite this, effective behavior change interventions targeting physical activity in community-dwelling TBI survivors remain scarce. Here, we evaluated the feasibility, compliance, and preliminary efficacy of a 12-week remotely delivered walking intervention combining planning, behavioral reminders, and monetary micro-incentives. MethodsFifty-six adults aged 40-80 years with a mild-to-moderate TBI diagnosed between 3 months and 15 years prior were randomized to either a planning, reminders, and micro-incentives intervention (n=23) or a health advice control condition (n=25). Participants wore a Fitbit Inspire 3 continuously throughout the study. Intervention participants completed weekly phone calls to plan five 30-minute walks for the following week, received daily text message or email reminders on planned walk days, and earned small monetary incentives upon walk completion. Control participants received weekly health education calls. Feasibility was assessed through recruitment, retention, and adverse event rates. Compliance was assessed via phone call completion rates and Fitbit wear time. Efficacy outcomes included weekly walk counts, walking duration, and step counts, modeled using Poisson generalized linear mixed models and linear mixed-effects models over 12 weeks. ResultsForty-eight participants completed the study (retention rate: 84.2%), with high phone call compliance in both groups (intervention: 98.4%; control: 98.1%). Intervention participants completed significantly more walks than controls from week 1 onward (aIRR = 5.33, 95% CI: 2.27-12.5, p < 0.001), with the group difference growing over time (interaction aIRR = 1.09 per week, 95% CI: 1.01-1.17, p = 0.029). Estimated marginal means indicated that intervention participants completed 5.5 times more walks than controls at week 1, increasing to 15.5 times more by week 12. The intervention group also walked significantly longer at week 1 (b = 62.14 min, 95% CI: 1.05-123.23, p = .046), with the advantage growing over time; by week 12, intervention participants walked 5.3 times longer than controls. Similarly, the intervention group accumulated significantly more steps during walks at week 1 (b = 4,779 steps, 95% CI: 45.50-9,513.00, p = .048), accumulating 3.1 times more steps than controls by week 12. ConclusionsA remotely delivered, multicomponent walking intervention targeting planning, behavioral reminders, and micro-incentives was feasible, well-tolerated, and produced meaningful increases in walking activity in community-dwelling adults with TBI. With high retention and compliance, and consistent effects on walk counts, duration, and steps across the intervention period, these findings provide compelling support for a larger, fully powered trial.

BackgroundCurrent practice guidelines recommend moderate to vigorous intensity locomotor training to improve walking outcomes in chronic stroke. However, these intensities span a wide range, and the lack of specificity may lead to under-dosing or over-dosing of training intensity. Recent evidence indicates that vigorous intensity locomotor training improves walking outcomes significantly more than moderate intensity. Although, previous studies have not been powered to rule out the possibility of meaningful risk increases or negligible benefit with vigorous versus moderate intensity, nor have they been designed to compare sustained effects after training ends. In addition, small subgroup analyses have suggested that individuals with severe walking limitations (speed <0.4 m/s) may require vigorous training intensity to have meaningful benefit, but this has not been prospectively tested with a sufficient sample. The results of this study are expected to provide more specific guidance for optimizing locomotor training intensity and walking outcomes in chronic stroke. MethodsIn this single-blind, 3-site, randomized trial, 156 chronic (>6 months) stroke survivors will be allocated to 36 sessions (3 times a week for 12 weeks) of either high intensity interval or moderate intensity continuous locomotor training. Eligible participants have residual walking limitations from stroke and can walk without continuous physical assistance from another person. At least 52 participants will have severe baseline walking speed limitations. Outcomes are assessed at baseline, after 4 weeks, 8 weeks, 12 weeks (POST), and 3 months after completing training. The primary outcome is walking capacity (6-minute walk distance). Secondary outcomes include comfortable and fast gait speed, aerobic capacity, fatigue, balance confidence, quality of life, and motivation for exercise. Statistical analyses will compare outcome changes and adverse events between treatment groups, and will include subgrouping by walking limitation severity. DiscussionThis study will provide important new information to guide greater specificity and individualization of locomotor training intensity in chronic stroke. Trial RegistrationClinicalTrials.gov NCT06268041; Registration Date: 2024-02-12

BackgroundNeck pain (NP) clinical practice guidelines (CPG) generally emphasize natural history, self-care, and non-pharmaceutical therapies. For non-pharmaceutical therapies provided for NP, like chiropractic manipulative treatment (CMT), active care (AC), manual therapy (MT), or acupuncture, little is known about the dose/response relationship with use of other services and total cost. The purpose of this retrospective cohort study of individuals with NP was to examine the dose response association between the number of visits of CMT, AC, MT, or acupuncture, the exposure to pharmaceutical, imaging, and interventional services, and total episode cost. MethodsEpisode of care was used to analyze a national sample of individuals 18 years and older with a single episode of non-surgical NP occurring in 2017-2019 and initially contacting a chiropractor (DC), physical therapist (PT), or licensed acupuncturist (LAc). The number of visits of CMT, AC, MT, or acupuncture were the primary independent variables. Rate and timing of use of 13 types of health care services and total episode cost were the primary dependent measures. ResultsA total of 91,805 continuously insured individuals initially contacted a DC, PT, or LAc for a single episode of non-surgical NP. These individuals initially contacted 19,387 different DCs, 1,828 PTs and 1,153 LAcs. There were $39,150,944 in total expenditures. The most common number of visits was 1 to 3 for CMT (47.8% of episodes), AC (31.8%), and MT (35.0%), and 4 to 6 for acupuncture (27.5%). Different levels of utilization intensity of CMT, AC, MT, and acupuncture were generally not associated with statistically or clinically meaningful differences in exposure to pharmaceutical, imaging, or interventional services. Total episode cost increased with higher numbers of visits of CMT, AC, MT, and acupuncture with CMT associated with the lowest median total episode code at each level of visit utilization. ConclusionsFor individuals with non-surgical NP initially contacting a DC, PT or LAc, 1 to 3 visits of CMT, AC, or MT, and 4 to 6 visits of acupuncture were the most common levels of utilization. A higher number of visits of CMT, AC, MT or acupuncture was associated with significantly higher total cost, without clinically or statistically meaningful differences in exposure to pharmaceutical, imaging, or interventional services. CMT was associated with the lowest total episode cost at each level of utilization. Higher visit counts of CMT, AC, MT, or acupuncture may have been associated with unmeasured clinical benefits and warrants further study.

BackgroundFor individuals with low back pain (LBP), in the absence of serious pathology clinical practice guidelines (CPG) recommend a stepped approach to management with first-line emphasis on natural history, self-care, and non-pharmaceutical therapies. For individuals with non-surgical LBP initially contacting a chiropractor (DC), physical therapist (PT), or licensed acupuncturist (LAc), the purpose of this retrospective cohort study was to examine the dose response association between the number of visits of chiropractic manipulative therapy (CMT), active care (AC), manual therapy (MT), or acupuncture, exposure to second- and third-line services, and total episode cost. MethodsA national sample of individuals with a single episode of non-surgical LBP occurring in 2017-2019 was analyzed using episode of care as the unit of analysis. The primary independent variables were initial contact with either a DC, PT, or LAc, and the number of visits of CMT, AC, MT, or acupuncture. Dependent measures included rate and timing of use of 13 types of health care services and total episode cost. Results132,199 continuously insured individuals aged 18 years and older initially contacted 21,336 different DCs, 2,734 PTs and 1,339 LAcs for a single episode of non-surgical LBP. These individuals were associated with $62,185,930 in expenditures. The most common number of visits was 1 to 3 - CMT (48.2% of episodes), AC (29.7%), MT (32.1%), and acupuncture (27.0%). For each service, 1 to 3 visits was associated with the lowest rate of exposure to second- and third-line services although rate differences between visit dose categories were generally not significant or clinically. Episode total cost and duration increased significantly with increasing number of visits. CMT was associated with lowest median total episode cost at each level of visit utilization. ConclusionsFor non-surgical LBP episodes initially contacting a DC, PT or LAc, 1 to 3 visits of CMT, AC, MT, or acupuncture was the most common level of utilization, associated with the lowest exposure to second- and third-line services and lowest total episode cost. Among, CMT, AC, MT, and acupuncture, CMT was associated with the lowest total episode cost at each level of utilization. A higher number of visits of CMT, AC, MT or acupuncture was associated with significantly higher total cost, without meaningful impact on exposure to second- or third-line services. Unmeasured clinical benefits may be associated with higher visit counts and warrants further study.

Background: Lumbar spinal stenosis (LSS) can cause pain and severe walking limitation. Although surgery aims to improve walking, many patients do not achieve clinically meaningful gains. Rehabilitation can improve outcomes, yet existing programmes lack robust evidence and theoretical underpinning. This study aimed to (1) co-design a theory-informed rehabilitation programme to improve walking after LSS surgery, and (2) evaluate feasibility of conducting a future trial and acceptability of the intervention. Methods: A multi-methods study included intervention co-design followed by a single-arm feasibility study. Co-design used an adapted Experience-Based Co-Design approach with patients, carers, and healthcare professionals (n=39), integrating the Behaviour Change Wheel. This resulted in STructured Rehabilitation and InDividualised Exercise and Education (STRIDE), delivered over 12-week pre- and 12-weeks post-surgery, targeting knowledge, expectations, perceived control, physical capability, and fears. Adults aged [&ge;]50 years awaiting LSS surgery were recruited to a before-after feasibility study. Feasibility outcomes included recruitment and retention. Acceptability was assessed using the Theoretical Framework of Acceptability questionnaire (0-5 (high acceptability)) and focus groups. Clinical outcomes measured at baseline, post-prehabilitation, and post-rehabilitation included 6-minute walk distance (6MWD) and mean daily step count over 7 days. Results: Fifteen of 31 eligible participants were recruited (48%; mean age 70 years), with 80% retained to study end (2 decided against surgery, 1 unable to complete final assessment). Acceptability was high (median 5/5, IQR 0). Participants valued the personalised, supportive approach and reported improved motivation and preparation for surgery, though travel was burdensome. Small pre-operative and moderate-to-large post-operative improvements were observed in 6MWD (+49.9 m and +81.6 m) and daily step count (+868 and +1405 steps/day). Conclusions: This co-designed, physiotherapy-led, behaviour-change rehabilitation programme was acceptable to participants, with encouraging recruitment, retention, and signals of improved walking following LSS surgery. The findings support progression to a future trial.

BackgroundAdapted dance is a promising rehabilitation intervention for physical and psychosocial impairments in people with chronic stroke. However, in-person attendance is hindered by limited community ambulation, transportation, and schedule conflicts. At-home participation with a live-streamed dance program could address these issues, but psychosocial benefits may be diminished because of reduced social interactions. The primary objective of this study was to assess the feasibility and safety of a live-streamed dance program for chronic stroke. Secondary objectives were to characterize participants who choose live-stream vs in-person options and quantify pre-post changes in balance, gait and social connection. MethodPeople with chronic stroke were given the choice of attending a live-streamed adapted dance program either in-person or at home twice a week for 4 weeks. A priori feasibility criteria were tracked, and participants were characterized with self-report (Center for Epidemiologic Studies Depression Scale; CES-D) and performance-based measures (e.g., Montreal Cognitive Assessment, Chedoke McMaster Assessment) at baseline. Pre-post measures of secondary outcomes included gait speed, Mini Balance Evaluation Systems Test (Mini-BESTest), Activities of Balance Confidence Scale (ABC), and Inclusion of Community in Self scale (ICS). Unpaired median/mean differences in baseline clinical presentation were used to compare in-person and live-stream participants. Paired median/mean differences were used to examine change in secondary outcomes with dance. ResultsInterest and enrollment rates for both groups combined were 87% and 38% respectively. Of the 13 people who enrolled, 8 chose in-person and 5 chose live-stream. In-person and live-stream attendance rates were 83% and 89% respectively, and retention rates were 80% and 75% respectively. At baseline, the in-person group had greater depressive symptoms (CES-D score, median [IQR] difference: 11.5 [-21.5, -5]), and faster mean gait speed (-25.8cm/s [-50.98, 0.006]) than the live-stream group. There were no pre-post changes in secondary outcome measures. ConclusionsA live-streamed dance intervention featuring in-class and at-home participation is safe and feasible for people with chronic stroke. These results will inform a future randomized controlled trial to investigate the effects of a live-stream dance program with a longer duration while considering how factors such as gait function and mood may relate to the choice between in-person and at-home attendance.

BackgroundPhysical rehabilitation interventions can enhance functional capacity after stroke, but improved ability doesnt always lead to better real-world performance. Understanding this gap is key to optimizing post-stroke recovery strategies. ObjectivesThis research aimed to evaluate the effectiveness of physical rehabilitation interventions specifically exercise, behavior change techniques (BCTs), or their combination on real-world walking measured using wearable sensors and capacity (gait speed and walking endurance) outcomes in stroke survivors. MethodsThis systematic review and meta-analysis followed PRISMA guidelines. Comprehensive searches were conducted in Medline, Embase, CINAHL, and Scopus up to January 2025. Randomized controlled trials involving stroke survivors receiving physical rehabilitation interventions--exercise, BCTs, or both--compared to exercise-only or usual care were included. Outcomes assessed were daily steps, gait speed (comfortable and fastest), and endurance (6-minute walk test). Meta-analyses using random-effects models (STATA 18) reported standardized mean differences (SMDs) and 95% confidence intervals (CIs). Heterogeneity was evaluated using I{superscript 2} statistics. ResultsOf 1,782 references screened, 28 studies met the inclusion criteria, and 23 were included in meta-analyses comprising 2,327 participants. Exercise-only interventions produced a small but significant improvement in daily steps (SMD = 0.23; 95% CI: 0.03 to 0.44; I2 = 36.6%; moderate certainty), and moderate improvements in both comfortable gait speed (SMD = 0.38; 95% CI: 0.19 to 0.57; I2 = 35.5%; moderate certainty) and endurance (SMD = 0.39; 95% CI: 0.26 to 0.52; I2 = 0%; moderate certainty). BCT-only interventions demonstrated a larger effect on daily steps (SMD = 0.41; 95% CI: 0.19 to 0.63; I2 = 0%; moderate certainty). In contrast, combined exercise and BCT interventions did not yield significant improvements in any outcomes and were supported by very low to low certainty of evidence. ConclusionExercise-only interventions improve gait speed and endurance after stroke, with small gains in daily steps. BCT-only interventions yield greater improvements in daily walking activity. Combined interventions show limited added benefit. Protocol registrationThis study has been registered in PROSPERO (No. CRD42023411679)

AbstractO_ST_ABSObjectiveC_ST_ABSTo identify race/ethnic disparities in rehabilitation services after stroke and characterize the independent associations of each of race/ethnicity and rehabilitation to functional recovery post-stroke. MethodsThe Transitions of Care Stroke Disparities Study (TCSD-S) is a prospective cohort study designed to reduce disparities and to optimize the transitions of care for stroke survivors throughout the state of Florida. Participant characteristics were extracted from the American Heart Associations Get-With-The-Guidelines-Stroke dataset. Rehabilitation services, and modified Rankin Scale were recorded via follow up phone calls at 30- and 90-days after hospital discharge. Logistic regression models adjusted for potential confounders were used to determine: 1) race/ethnic differences in rehabilitation services received; 2) race/ethnic differences in functional change from discharge to 30- and 90-days, respectively; and 3) the influence of rehabilitation on functional change from discharge to 30- and 90-days. ResultsOf 1,083 individuals, 43% were female, 52% were Non-Hispanic White (NHW), 22% were Non-Hispanic Black (NHB), and were 22% Hispanic. Individuals who engaged in rehabilitation were more likely to show improvements [aOR=1.820, 95%CI (1.301,2.545)] at 90-days from hospital discharge. Irrespective of rehabilitation services, there were no differences in functional change between NHW and NHB individuals, yet Hispanic individuals were less likely to improve [aOR=0.647, 95%CI (0.425,0.983)] compared to NHW. Additionally, Hispanic individuals were significantly less likely to receive any rehabilitation services [aOR=0.626, 95%CI (0.442,0.886)] and were half as likely to receive outpatient services [aOR=0.543, 95%CI (0.368,0.800)] as compared to NHW. ConclusionsRehabilitation is key to functional improvement after stroke. We are making strides in health equity between NHW and NHB individuals, yet there remain disparities in functional outcomes and in rehabilitation services particularly for Hispanic individuals after stroke.

BackgroundPost-stroke disability contributes substantially to long-term functional limitation, yet access to rehabilitation remains inequitable in low and middle-income countries (LMICs), where workforce and service delivery constraints are pronounced. Global priorities, including WHOs Rehabilitation 2030 agenda, emphasize integrating scalable rehabilitation into health systems and decentralizing services beyond tertiary-centers. Evidence supports home and community-oriented approaches, including caregiver-mediated exercise, that can achieve gains comparable to centre-based therapy when dose is matched. The Karnataka Brain Health Initiative (KaBHI) is a public-sector model strengthening neurological care pathways through district Brain Health Clinics (BHCs). ObjectiveTo evaluate short-term changes in balance, mobility, and global disability among community-dwelling stroke survivors completing the KaBHI physiotherapy programme. MethodsThis prospective, single-group pre-post evaluation included adults aged 18-90 years enrolled at KaBHI BHCs (April-December 2024). Participants received a structured six-week balance and mobility programme prescribed by physiotherapists and implemented with caregiver support and follow-up within routine-care. Outcomes assessed at baseline (day 0) and post-intervention (day 45) were the Berg Balance Scale (BBS), Timed Up and Go (TUG), and Modified Rankin Scale (mRS). ResultsAmong 199 participants (mean age 54.9 {+/-} 14.5 years; 71% male), BBS improved from 28.9 to 37.2 (p < 0.001), TUG improved from 22.7 s to 19.8 s (p < 0.001), and mRS decreased from 3.30 to 2.45 (p < 0.001). Clinically meaningful improvement was common: 51% achieved [&ge;]7-point gains on BBS, and 70% improved by [&ge;]1 mRS grade. No programme-related serious adverse events were reported. ConclusionsIn a real-world public health setting, a physiotherapist-led, caregiver-supported KaBHI rehabilitation model delivered through district BHCs demonstrated significant short-term improvements in balance, mobility, and disability. These findings align with evidence supporting decentralized, home-/community-oriented, caregiver-mediated rehabilitation and support KaBHI as a potentially scalable strategy to strengthen stroke rehabilitation capacity in resource-constrained settings; controlled and longer-term evaluations are warranted.

BackgroundNeuropathic pain after spinal cord injury (SCI) is notoriously hard to treat. Mechanisms of neuropathic pain are unclear, which makes finding effective treatments challenging. Prior studies have shown that adults with SCI have body awareness deficits. Recent imaging studies, including ours, point to the parietal operculum and insula as key areas for both pain perception and body awareness. Cognitive multisensory rehabilitation (CMR) is a physical therapy approach that helps improve body awareness for pain reduction and sensorimotor recovery. Based on our prior brain imaging work in CMR in stroke, we hypothesized that improving body awareness through restoring parietal operculum network connectivity leads to neuropathic pain relief and improved sensorimotor and daily life function in adults with SCI. Thus, the objectives of this study were to (1) determine baseline differences in resting-state and task-based functional magnetic resonance imaging (fMRI) brain function in adults with SCI compared to healthy controls and (2) identify changes in brain function and behavioral pain and pain-associated outcomes in adults with SCI after CMR. MethodsHealthy adults underwent a one-time MRI scan and completed questionnaires. We recruited community-dwelling adults with SCI-related neuropathic pain, with complete or incomplete SCI >3 months, and highest neuropathic pain intensity level of >3 on the Numeric Pain Rating Scale (NPRS). Participants with SCI were randomized into two groups, according to a delayed treatment arm phase I randomized controlled trial (RCT): Group A immediately received CMR intervention, 3x/week, 45 min/session, followed by a 6-week and 1-year follow-up. Group B started with a 6-week observation period, then 6 weeks of CMR, and a 1-year follow-up. Highest, average, and lowest neuropathic pain intensity levels were assessed weekly with the NPRS as primary outcome. Other primary outcomes (fMRI resting-state and functional tasks; sensory and motor function with the INSCI AIS exam), as well as secondary outcomes (mood, function, spasms, and other SCI secondary conditions), were assessed at baseline, after the first and second 6-week period. The INSCI AIS exam and questionnaires were repeated at the 1-year follow-up. FindingsThirty-six healthy adults and 28 adults with SCI were recruited between September 2020 and August 2021, and of those, 31 healthy adults and 26 adults with SCI were enrolled in the study. All 26 participants with SCI completed the intervention and pre-post assessments. There were no study-related adverse events. Participants were 52{+/-}15 years of age, and 1-56 years post-SCI. During the observation period, group B did not show any reductions in neuropathic pain and did not have any changes in sensation or motor function (INSCI ASIA exam). However, both groups experienced a significant reduction in neuropathic pain after the 6-week CMR intervention. Their highest level of neuropathic pain of 7.81{+/-}1.33 on the NPRS at baseline was reduced to 2.88{+/-}2.92 after 6 weeks of CMR. Their change scores were 4.92{+/-}2.92 (large effect size Cohens d=1.68) for highest neuropathic pain, 4.12{+/-}2.23 (d=1.85) for average neuropathic pain, and 2.31{+/-}2.07 (d=1.00) for lowest neuropathic pain. Nine participants out of 26 were pain-free after the intervention (34.62%). The results of the INSCI AIS testing also showed significant improvements in sensation, muscle strength, and function after 6 weeks of CMR. Their INSCI AIS exam increased by 8.81{+/-}5.37 points (d=1.64) for touch sensation, 7.50{+/-}4.89 points (d=1.53) for pin prick sensation, and 3.87{+/-}2.81 (d=1.38) for lower limb muscle strength. Functional improvements after the intervention included improvements in balance for 17 out of 18 participants with balance problems at baseline; improved transfers for all of them and a returned ability to stand upright with minimal assistance in 12 out of 20 participants who were unable to stand at baseline. Those improvements were maintained at the 1-year follow-up. With regard to brain imaging, we confirmed that the resting-state parietal operculum and insula networks had weaker connections in adults with SCI-related neuropathic pain (n=20) compared to healthy adults (n=28). After CMR, stronger resting-state parietal operculum network connectivity was found in adults with SCI. Also, at baseline, as expected, right toe sensory stimulation elicited less brain activation in adults with SCI (n=22) compared to healthy adults (n=26). However, after CMR, there was increased brain activation in relevant sensorimotor and parietal areas related to pain and mental body representations (i.e., body awareness and visuospatial body maps) during the toe stimulation fMRI task. These brain function improvements aligned with the AIS results of improved touch sensation, including in the feet. InterpretationAdults with chronic SCI had significant neuropathic pain relief and functional improvements, attributed to the recovery of sensation and movement after CMR. The results indicate the preliminary efficacy of CMR for restoring function in adults with chronic SCI. CMR is easily implementable in current physical therapy practice. These encouraging impressive results pave the way for larger randomized clinical trials aimed at testing the efficacy of CMR to alleviate neuropathic pain in adults with SCI. Clinical Trial registrationClinicalTrials.gov Identifier: NCT04706208 FundingAIRP2-IND-30: Academic Investment Research Program (AIRP) University of Minnesota School of Medicine. National Center for Advancing Translational Sciences of the National Institutes of Health Award Number UL1TR002494; the Biotechnology Research Center: P41EB015894, the National Institute of Neurological Disorders & Stroke Institutional Center Core Grants to Support Neuroscience Research: P30 NS076408; and theHigh-Performancee Connectome Upgrade for Human 3T MR Scanner: 1S10OD017974.

IntroductionColorectal cancer (CRC) is a leading global malignancy, and surgery is frequently followed by complications, functional decline, and reduced quality of life. Multimodal prehabilitation and rehabilitation can improve physical recovery and psychosocial outcomes, but uptake is often limited by logistical and mobility barriers. Asynchronous telerehabilitation provides a flexible, patient-centred and scalable solution, yet its effectiveness across the perioperative CRC pathway has not been rigorously evaluated. This trial will test a multimodal asynchronous programme, delivered in prehabilitation and postoperative phases, against a standard leaflet-based approach. MethodsThis single-blind, parallel-group randomized controlled trial comparing an asynchronous, multimodal telerehabilitation program with a leaflet-based standard program in adults scheduled for elective CRC resection. Fifty-six participants will be randomized 1:1 to telerehabilitation (HEFORA platform) or control. The intervention spans a 2-week prehabilitation phase and a 4-week postoperative phase. Assessments occur at five time points: baseline (pre-prehabilitation), post-prehabilitation (pre-surgery), post-surgery (pre-rehabilitation), post-rehabilitation, and 3-month follow-up. OutcomesThe primary outcome is functional capacity (Six-Minute Walk Test distance). Secondary outcomes include muscle strength, body composition, pulmonary function, physical activity, sleep quality, psychosocial measures, health-related quality of life, treatment expectancy, usability, satisfaction, and adherence. Analyses will follow the intention-to-treat principle with appropriate models for repeated measures and sensitivity analyses for missing data and adherence. ConclusionsThis study will provide essential evidence on the role of asynchronous telerehabilitation in perioperative colorectal cancer management. Positive results could inform clinical guidelines, promote wider adoption of digital rehabilitation strategies, and drive a more accessible, patient-centered, and cost-effective approach to oncologic recovery. Trial registrationClinicalTrials.gov identifier: NCT06593678 Ethics approvalAragon Clinical Research Ethics Committee (PI23/557).