Archives of Physical Medicine and Rehabilitation

Objectives: Explore feasibility and acceptability of upskilling a workforce to deliver a co-developed intervention, based on Acceptance and Commitment Therapy (ACT), to support psychological adjustment post-stroke targeting underserved groups. Design: Multi-site, single-arm feasibility study with embedded mixed-methods process evaluation (ISRCTN17628580). Setting: Four NHS community stroke services across England. Participants: 1. Stroke survivors [≥]18 years of age, [≥]4 months post-stroke, reporting psychological difficulties adjusting to stroke, able to consent and access remote group sessions in English; 2. Group facilitators from NHS stroke services, not ACT specialists. Intervention: WAterS-2: an eight-session, remotely-delivered ACT-informed group intervention. Outcome measures: Recruitment, fidelity, safety, acceptability and perceived value were assessed using fidelity checklists, post-intervention surveys and semi-structured interviews with stroke survivors and facilitators. Clinical outcomes including mood (HADS), wellbeing (ONS4), psychological flexibility (AAQ-ABI), measured post-group and three-months later. Results: Nineteen stroke survivors recruited (mean 9.6 months post-stroke; n=5 (26%) minoritised ethnicities; n=10 (52%) with aphasia). Thirteen facilitators - including two peer support workers - delivered the intervention with fidelity following structured training across four services. Drop-out was low (2/19; 11%); with 15 (79%) attending [≥]5/8 sessions. Remote data collection was feasible (79% follow-up completion), with no adverse events recorded. Acceptability was high: survivors valued peer connection, grounding and mindfulness practices. ACT metaphors were helpful for some but challenging for others, including some with aphasia. Online delivery was suitable but limited informal connection. Facilitators reported increased capability, incorporating ACT skills into routine care. NHS workforce pressures and geographically-constrained referral pathways limited recruitment reach. Conclusions: WAterS-2 is feasible, safe, acceptable and inclusive. A mixed workforce, including NHS peer support workers, can be upskilled to deliver with fidelity. Inclusion of underserved groups is achievable but requires active strategies beyond standard NHS referral routes. Findings inform a provisional logic model and a future pragmatic trial.

Background: Post-stroke motor impairment is the leading contributor to long-term disability. Despite evidence that high dose, high intensity (HDHI) and virtual reality (VR) interventions are effective in reducing post-stroke motor impairment, access to such interventions is limited, especially in community-based models. The purpose of this study was to explore the effect of one community-based HDHI VR intervention, Next-Generation NeuroAnimation Therapy (NG-NAT), on motor impairment for community-dwelling stroke survivors. Methods: The study employed a retrospective pre-test post-test design of de-identified data sets of one cohort of stroke survivors who participated in an HDHI NG-NAT intervention at a community-based center from March to December 2025. The intervention consisted of three hours of daily therapy, five days a week, for three weeks. Two hours were allocated for NG-NAT gameplay, while one hour focused on non-VR activity. The NG-NAT was provided in a small studio with a large screen monitor and 12 motion caption cameras mapping client movements to play the game. The upper extremity Fugl Meyer Assessment was used to measure motor impairment at pre- and post-testing. Linear regressions were run to determine the relational strength between pre- and post-UEFMA scores. Wilcoxon Signed Rank Tests were run to calculate median differences in pre- and post-UEFMA scores and account for non-parametric data distributions at baseline and the small sample size. Effect size was explored using the Rank Biserial Correlation. Frequency of minimally clinically important differences (MCID), minimal detectable changes (MDC), recovery stage transition were calculated. Content analysis and co-review of documentation contextualized statistical findings. Results: Nineteen participants completed three weeks of intensive NG-NAT. All experienced positive UEFMA score improvements from pre- to post-testing with a median difference of 8 points. Fifteen achieved MDC and MCID; one experienced a ceiling effect. Eight participants transitioned into better recovery stages. There was a highly significant, positive relationship with narrow confidence intervals and pre-score predicted post-score (e.g., those with mild/moderate impairment improved better than those with severe impairment). Conclusion: This study provides evidence supporting the efficacy of NG-NAT as a community-based intervention to reduce motor impairment for individuals with stroke. Given its ability to deliver intense and engaging therapy, NG-NAT offers a promising adjunctive strategy to expand access for stroke survivors to improve clinically relevant health outcomes. These findings underscore the need for pragmatic trials evaluating effectiveness, implementation, and cost-effectiveness.

Background: Mobility recovery after stroke is highly variable, yet is typically described using average patterns that obscure meaningful differences between individuals. Identifying distinct recovery trajectories may improve prognostication and guide rehabilitation strategies. Methods: We conducted a retrospective cohort study of adults admitted for stroke to a large health system between 2016 and 2024. Mobility was assessed using Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility, which was collected during routine clinical care. Growth mixture modeling was used to identify subgroups with distinct mobility recovery trajectories during the first 180 days after stroke. Subgroups were then characterized with baseline personal and clinical characteristics. Results: Seven hundred and fifty individuals contributed 3,389 mobility observations (median 4 per person). A five-class solution was selected based on model fit and classification quality. Distinct trajectories were identified: low stable (n=127), low rapidly improving (n=29), mid declining (n=169), mid improving (n=365), and high stable (n=60). Subgroups differed in both baseline mobility and patterns of change over time, with some demonstrating improvement, others remaining stable, and one declining. Individuals in improving subgroups were generally younger, more likely to be independent before stroke, received physical therapy on a greater proportion of hospital days, and were more frequently discharged to inpatient rehabilitation. In contrast, those in low or declining trajectories had lower baseline function, longer hospital stays, and were more likely to be discharged to skilled nursing facilities. Conclusions: The distinct mobility recovery trajectories identified in this work reflect the heterogeneity present in routine clinical practice. Subgroups differed in both recovery patterns and characteristics. Early identification of trajectory membership may improve prognostication and inform more targeted rehabilitation strategies.

Abstract Background: Non-specific chronic low back pain (NSCLBP) is a major cause of disability worldwide and is associated with low-grade systemic inflammation. This study investigated the effects of aerobic exercise on inflammatory biomarkers, pain intensity, and quality of life among individuals with NSCLBP. Methods: In this parallel-group randomized controlled trial, 41 participants with NSCLBP were allocated to either an aerobic exercise plus health education group (n=21) or a health education-only control group (n=20). Participants in the intervention group completed supervised aerobic cycling three times weekly for 12 weeks. Outcome assessors and laboratory personnel were blinded to group allocation. Outcomes were measured at baseline, Week 8, and Week 12. Results: Interaction effects were observed for TNF- (p=0.046), IL-6 (p<0.001), hs-CRP (p<0.001), and pain intensity (p<0.001). Significant improvements were also observed across all WHOQOL-BREF quality-of-life domains (all p<0.05). After adjustment for baseline values and age, participants in the intervention group had significantly lower Week 12 IL-6 (p=0.013), hs-CRP (p<0.001), and pain intensity (p<0.001) than controls. No serious adverse events were reported. Conclusions: Aerobic exercise combined with health education produced greater improvements in inflammatory biomarkers, pain intensity, and quality of life than health education alone among individuals with NSCLBP. These findings support the integration of structured aerobic exercise into rehabilitation programmes for chronic low back pain. Keywords: Non-specific chronic low back pain; aerobic exercise; inflammation; IL-6; hs-CRP; pain intensity; quality of life; randomized controlled trial.

Background & Objective. Cardiac rehabilitation is an existing guideline-concordant intervention for heart failure that provides benefits but is grossly underutilized by both physicians and patients. We aimed to identify patient-reported barriers and facilitators of participation in cardiac rehabilitation. Design, participants, approach: Qualitative theory-guided in-depth interviews were conducted with adults with heart failure, recruited from ambulatory settings with oversampling of those with heart failure with preserved ejection fraction. Thematic analysis was applied to interview data. Depressive symptoms and perceived stress were assessed by Patient Health Questionnaire (PHQ-8) and Perceived Stress Scale (PSS), respectively. Key results: Twenty-two adults with heart failure, aged 27-85, completed the study; of them 59.1% were women, 68.2% - African American, 4.5% - Hispanic; 77.3% had public insurance or were self-pay; 68.2% had heart failure with preserved ejection fraction. Mean PHQ-8 score was 11.4 (SD= 2.9) and mean PSS score - 20.4 (SD=4.5). Patient-reported barriers to cardiac rehabilitation included unawareness of cardiac rehabilitation and its benefits, perceived inability to exercise, depression, and weight gain, specifically for heart failure with preserved ejection fraction. Perceived inability to exercise stemmed from uncontrolled heart failure symptom burden and exercise intolerance, medication side effects, non-cardiac pain, fear of exercise, and low motivation for exercise. Facilitators of participation included intrinsic and extrinsic motivating factors and specific features of programs, such as individualized and supervised interventions with moderate level of exercise. Conclusion: Participants reported multiple barriers to cardiac rehabilitation; some of them can be modified by providing counselling and referral to cardiac rehabilitation from primary care physicians and simultaneously addressing heart failure symptom burden, pain, stress and depression. Combining cardiac rehabilitation and weight management can benefit adults with heart failure with preserved ejection fraction specifically. Increasing insurance coverage for cardiac rehabilitation for heart failure is warranted.

BACKGROUND: Older adults with cancer often struggle to achieve recommended levels of physical activity and dietary intake. Ecological momentary assessment combined with accelerometry can provide insights into the temporal dynamics of psychological and behavioral processes at the individual level, such as motivation towards health behaviors. OBJECTIVE: This N-of-1 study aims to improve physical activity and nutritional behaviors among older patients with cancer using an mHealth behavioral intervention. METHODS: A single-subject ABA' design will be employed among older patients with cancer ([&ge;] 70 years). A 2-week baseline phase (A) will be followed by an 8-week intervention phase (B) and a two-week withdrawal phase (A'). Throughout all these phases, participants will complete a daily data collection protocol combining ecological momentary assessment questionnaires and an ActiGraph wGT3X-BT accelerometer worn on the waist to measure physical activity. Ecological momentary assessment questionnaires will be delivered via a digital application to collect information on nutritional behavior, fatigue, and motivational constructs based on the Theory of Planned Behavior. The intervention (B) will consist of an mHealth intervention based on behavior change techniques, delivered via weekly calls, personalized messages, and a digital application. Data will be analyzed using piecewise and segmented regression models. In addition, a semi-structured interview will be conducted to assess patient experience. These qualitative data will help identify contextual factors, such as treatment-related side effects or variations in health status, that may have influenced behavior change and participation in data collection. CONCLUSION: This N-of-1 study explores intra-individual behavioral dynamics using intensive longitudinal data rather than testing a strictly reversible intervention effect. The mHealth intervention is based on behavior change techniques and tailored to each patient, with adjustments made based on repeated daily assessments in a real-world setting using a wGT3X-BT accelerometer and ecological momentary assessment questionnaires. The results will contribute to the evidence base for mHealth interventions designed to promote sustained physical activity and dietary intake among older adults with cancer.

Spinal cord injury (SCI) is a devastating neurological injury that results in the profound loss of voluntary motor function and marked reduction in quality of life. Rehabilitation remains as the standard of care for recovery after SCI; however, it often falls short in recovering meaningful motor function. Spinal cord stimulation (SCS) has emerged as a promising neurostimulation approach to fill this gap and recover lost voluntary motor function. Two main approaches of SCS have been designed and implemented for human use: epidural and transcutaneous SCS. Over the last two decades, several clinical studies have shown convincing evidence that both epidural and transcutaneous SCS can be used in conjunction with rehabilitation to improve motor function of individuals after SCI. Yet fundamental clinical questions remain unanswered: when should clinicians choose epidural or transcutaneous SCS, which technique provides the most durable outcomes, and for whom is each therapy best? Without these answers, widespread and meaningful adoption of either approach into clinical practice will remain limited. To address these questions, in this Review, we define the distinct therapeutic goals, intended use cases, clinical parameters, and responder profiles for both epidural and transcutaneous SCS to guide their eventual adoption into clinical practice. We found that indeed epidural and transcutaneous SCS serve distinct therapeutic roles. Epidural SCS is designed as an assistive therapy that can restore muscle activity and single joint movements immediately within one week of implantation, while transcutaneous SCS is designed as a long-term therapeutic device with cumulative functional gains observed over treatment periods of up to 18 weeks. Lastly, epidural SCS produced benefits for all participants (AIS A-D) despite the extent of their injury, while transcutaneous SCS only consistently benefits individuals with incomplete motor injuries (AIS C-D).

Background: Cognitive rehabilitation (CR) is an established behavioral intervention that improves daily functioning for individuals with mild cognitive impairment (MCI) and early-stage dementia. Traditional models of in-person delivery limit access, particularly for individuals living in rural areas. This study evaluated the efficacy of a novel telephone-based virtual CR model combining speech-language pathologist (SLP)-led sessions with cognitive exercises delivered by an automated voice agent between visits. Methods: We conducted a retrospective observational analysis of 141 older adults who completed treatment to discharge (58% female; mean age 71.2, standard deviation 10.8 years; MCI diagnosis rate 61.7%, dementia diagnosis rate 29.1%; Montreal Cognitive Assessment mean score 20.8, standard deviation 4.3). Changes in four outcome measures from initiation of treatment to discharge were evaluated for statistical significance. The four outcomes studied were patient-reported quality of life and three therapist-rated Functional Communication Measures (FCMs): overall cognition, spoken language, and language comprehension. Changes were compared to FCM averages from the American Speech-Language-Hearing Association National Outcomes Measurement System (ASHA NOMS). Models were developed to predict changes in outcome measures based on patient demographics, clinical status, program engagement and treating therapist. Results: All four outcomes improved significantly over the course of treatment (p<0.05), with medium to very large effect sizes. Mean changes in the three FCM outcomes exceeded ASHA NOMS benchmarks for in-person outpatient care. A majority of patients saw an improvement in each clinical outcome measure. Models with meaningful predictive power were identified for changes in all outcome measures except the FCM for language comprehension. Baseline cognitive function was the most influential and negatively correlated predictor of an improvement in overall cognitive abilities and language expression. Baseline quality of life was the dominant and negatively correlated predictor of improvement in quality of life. Conclusions: Telephone-based virtual CR led by SLPs with automated exercises delivered by a voice agent produced clinically meaningful functional and quality of life gains relative to external benchmarks for in-person clinical practice. These results support the use of virtual CR within post-diagnostic care for older adults experiencing cognitive impairment, particularly for rural and underserved communities.

Background Gait training incorporating visual feedback or rhythmic auditory cueing has shown promising results in neurological conditions but has rarely been investigated in clinical rehabilitation for persons with Multiple Sclerosis (pwMS). Objective To evaluate the feasibility of treadmill training (TT) with visual feedback (VF) and TT with visual feedback plus rhythmic auditory cueing (VF+RAC) during clinical rehabilitation and explore its effects on gait parameters. Methods PwMS were randomly allocated 1:1 to perform ten 30-minute training sessions of TT with VF or VF+RAC during inpatient rehabilitation. The primary outcome was feasibility (adherence, compliance, safety, and acceptability). Secondary outcomes were session-by-session developments in spatiotemporal and qualitative gait parameters. Results Sixty of 68 randomized participants completed the intervention (VF: n=29; VF+RAC: n=31). Adherence and compliance rates were 93% and 86%, respectively, with no differences between groups. The most common adverse event in both groups was (leg) pain (21/38 total adverse events). One fall occurred in 629 sessions. Both interventions were greatly accepted and perceived as fun, motivating and helpful to achieve rehabilitation goals. Both groups increased in distance, gait speed, and average step length. Step length variability did not change in the VF-group, while the VF+RAC-group slightly improved. Step length difference was constantly low in the VF+RAC-group, while the VF-group differences were elevated. Conclusions VF and VF+RAC are feasible training options for pwMS in a rehabilitation setting and are greatly accepted by participants. Qualitative gait parameters should be investigated in studies powered to detect clinically relevant differences in the future.

Abstract Background: Transcranial direct current stimulation (tDCS) paired with behavioral language therapy can improve naming in persons with aphasia (PWA), yet naming errors persist. Little is known about how naming error patterns change after non-invasive brain stimulation is combined with language treatment. Aims: To examine whether right cerebellar tDCS plus computerized aphasia therapy changes the types of naming errors in people with chronic aphasia across timepoints, and to determine whether effects differ by cerebellar tDCS polarity (anode vs. cathode). Methods and Procedures: In a randomized, double-blind, sham-controlled, within-subject crossover study, we retrospectively analyzed behavioral data from 24 individuals with post-stroke aphasia. Each participant completed two 15-session intervention periods (3-5 sessions/week) with active cerebellar tDCS + computerized aphasia therapy and sham + computerized aphasia therapy, separated by a two-month washout. General linear models (GLMs) assessed longitudinal changes in six error types (semantic, phonological real word, phonological nonword, no response, mixed, unrelated) on an untrained picture naming task (Philadelphia Naming Test; PNT) and a trained task (Naming 80; N80). Additional GLMs evaluated polarity effects with 2 (Group: anode vs. cathode) x 2 (Treatment) interactions, and treatment-order effects with 2 (Group: tDCS-first vs. sham-first) x 2 (Treatment) interactions. Outcomes and Results: Active cerebellar tDCS did not significantly change error types for trained items (N80). For untrained items (PNT), active tDCS reduced several error types relative to sham, with the clearest and most durable reduction in phonological nonword errors; more moderate reductions occurred for phonological real word and unrelated errors. Mixed errors showed a marginally opposite pattern, tending to increase after tDCS and decrease after sham. Polarity analyses indicated broadly similar effects across anodal and cathodal stimulation overall, but only the anode group showed a reliable treatment effect for phonological nonword errors on the PNT. Treatment-order analyses revealed no significant order effects. Conclusions: Our results indicate a shift in naming error types, particularly after tDCS treatment for the untrained naming task (PNT). These findings may help guide the course of treatment approaches of those with aphasia and what error naming pattern types may show changes post stroke when combining non-invasive brain stimulation and computerized aphasia therapy. Clinical Trial Registration: Cerebellar Transcranial Direct Current Stimulation and Aphasia Treatment [NCT02901574] Keywords: aphasia, naming errors, non-invasive brain stimulation, cerebellar tDCS, computerized aphasia treatment

Background and Purpose: Walking after stroke is often characterized by persistent biomechanical impairments and reduced walking capacity. While visual biofeedback can improve gait mechanics and fast walking can enhance capacity, it is unclear whether individuals post-stroke can effectively use biofeedback at higher walking speeds to address both deficits simultaneously. This study examined the effects of walking speed on the ability of participants with chronic stroke to reduce step length (SL) errors using visual biofeedback. Methods: Sixteen individuals with chronic stroke walked on a treadmill at slow, self-selected, and fast speeds with and without visual SL biofeedback. Absolute SL error relative to individualized targets was calculated for paretic and non-paretic limbs. Linear mixed-effects models with piecewise linear splines assessed the effects of speed, limb, and feedback condition. Post hoc comparisons were performed for significant interactions. Results: At lower speeds, increasing speed reduced SL error in both limbs (p < 0.001). At higher speeds, the effects of speed were dependent on limb and condition (p < 0.001). Paretic SL error increased with speed without feedback but remained stable with feedback (p < 0.001). Non-paretic SL error decreased with speed regardless of condition. SL error was greater in the paretic limb overall (p < 0.001). Discussion and Conclusions: Fast walking alone did not reduce paretic SL errors. Participants with chronic stroke can effectively use visual biofeedback to reduce paretic SL errors at higher speeds, supporting its integration into high-intensity gait training to simultaneously treat biomechanical impairments and walking capacity deficits after stroke.

Spinal cord injury (SCI) causes rapid and severe bone loss in the paralysed lower limbs, particularly at the distal femur and proximal tibia, where fragility fracture risk is high. In vitro nanoscale vibration at 1 kHz has been shown to promote osteogenic differentiation and inhibit osteoclastogenesis, suggesting potential as a targeted mechanical intervention. This study aimed to develop and evaluate a wearable device for delivering and monitoring localised nanovibration at the distal femur in individuals with SCI. The device delivered continuous sinusoidal nanoscale stimulation at 1 kHz via a bone-conduction transducer, with an opposing accelerometer used to monitor transmitted vibration in real time. Design and target-site selection were refined through two healthy-volunteer investigations comparing the distal femur, proximal tibia, and distal tibia. Bovine femur experiments characterised vibration transmission under controlled benchtop conditions. Preliminary repeated-use feasibility was assessed in one individual with motor-complete SCI. Healthy volunteer testing showed that although the ankle initially produced the highest transmitted amplitudes, these were highly variable, and positioning was inconsistent. Within the knee region, the distal femur provided the most practical and repeatable site for a wearable application. In bovine femur experiments, scanning laser vibrometry demonstrated measurable vibration on the condylar surface opposite the transducer, and depth-resolved measurements confirmed that nanoscale vibration remained detectable within bone. A gel interface layer reduced the transmitted amplitude. In the feasibility evaluation, 61 sessions were completed over 14 weeks, with logged accelerometry confirming repeated nanoscale vibration transmission. These findings establish feasibility and support further device optimisation and translational studies.

Background Cervical rotatory manipulation is commonly used for neck-related symptoms and is often accompanied by a cracking sound. This sound is frequently regarded as a sign of successful manipulation, but whether it contributes substantially to the immediate relaxation response remains unclear. Objective This study examined whether short-term relaxation after cervical rotatory manipulation is more closely related to manipulation-associated sensory input than to the cracking sound cue alone. Methods In this single-session, three-arm, parallel randomized controlled study, 54 healthy volunteers were allocated to cervical rotatory manipulation, sham manipulation, or sham manipulation plus simulated cracking sound. Subjective outcomes were assessed before and after intervention, including positive affect, negative affect, comfort, and satisfaction. Eyes-closed resting-state electroencephalography was recorded before and after intervention. Prespecified neural outcomes included frontal alpha power, frontal alpha/beta ratio, occipital individual alpha frequency, and alpha-band fronto-parietal and fronto-temporal functional connectivity. Results Cervical rotatory manipulation produced greater improvements in positive affect, comfort, and satisfaction than sham manipulation or sham manipulation plus simulated cracking sound, whereas negative affect remained generally stable across groups. These subjective responses were accompanied by short-term electroencephalography changes, particularly in frontal alpha/beta and alpha-band fronto-parietal and fronto-temporal functional connectivity. Changes in frontal alpha/beta ratio were positively associated with changes in positive affect. In contrast, simulated cracking sound alone did not reproduce the full subjective or electroencephalography response observed after real manipulation. Conclusions The immediate relaxation response after cervical rotatory manipulation appears to be more closely related to manipulation-associated sensory input than to the cracking sound cue alone. These findings provide preliminary neurophysiological evidence for distinguishing real manipulation effects from sound-related contextual cues.

Shoulder impingement syndrome (SIS), including subacromial impingement and rotator cuff tendinitis, is commonly caused by repetitive swimming movements and associated shoulder joint dysfunction. Despite numerous available treatment options, no consensus exists on the most effective treatment option. Therefore, this systematic review and network meta-analysis aimed to investigate treatment methods for SIS in swimmers. Using a frequentist framework and Cochrane PICOS principles, we compared SIS treatments, constructed network evidence diagrams, and assessed heterogeneity. A total of 45 studies were included in the qualitative synthesis, and 42 contributed to the network meta-analysis, comprising 1752 participants, 9 treatment categories, and outcome measures. For pain outcomes, some adjunctive interventions combined with exercise showed favorable ranking probabilities, although several estimates were accompanied by wide confidence intervals. For shoulder range-of-motion outcomes, taping, acupuncture, manual therapy, and sport-specific training showed favorable effects in selected comparisons, particularly for external and internal rotation. According to surface under the cumulative ranking curve (SUCRA) rankings, exercise combined with medium-frequency therapy ranked highly for pain reduction, whereas exercise combined with acupuncture or extracorporeal shock wave therapy ranked highly for shoulder flexion. Exercise combined with taping ranked highly for external rotation, and exercise combined with manual therapy ranked highly for internal rotation. However, the interpretation of ranking results should remain cautious because uncertainty and inconsistency were present in some comparisons. Exercise-based rehabilitation appears to remain central to the management of SIS in swimmers. Several adjunctive interventions showed favorable findings for selected outcomes, especially pain relief and shoulder rotational function. However, the available evidence was affected by heterogeneity, inconsistency, and imprecision across some treatment comparisons. More rigorously designed swimmer-specific randomized controlled trials are needed before firm treatment hierarchies can be established. Trial registration: The protocol for this systematic review is registered with PROSPERO (www.crd.york.ac.uk/PROSPERO; registration number: CRD42024498851). The first submission of PROSPERO was on January 15, 2024, and it was revised and updated on March 25, 2026.

Quantitative gait analysis could enhance personalized treatment for many movement-related conditions; however, it is not routinely integrated into clinical care. Advances in mobile sensing, such as smartphone-based motion capture, enable rapid clinical gait assessment, but extracting actionable insights remains challenging. Although machine learning models can support clinical decisions from gait data, they typically require costly task- and condition-specific datasets, which limits progress across various gait-related conditions. Here we present a generative foundation model of walking kinematics that enables various downstream clinical tasks across diverse patient populations using clinically accessible smartphone video-based gait analysis. We aggregated eight gait datasets comprising 657 individuals across seven unique pathologies. Using weakly-supervised learning, we trained a variational autoencoder to distill high-dimensional gait kinematics into a 16-dimensional learned latent representation. We demonstrate generalizability across four downstream clinical tasks spanning pathologies both seen and unseen during training, with and without model fine-tuning, including: 1) classification of neuromuscular disorders unseen during training, 2) predicting clinical severity scores for individuals with Parkinson's disease, 3) tracking of subacute recovery post-stroke, and 4) generating patient-specific kinematic changes following total hip arthroplasty. Our model also computes a deviation from mean unimpaired (DMU) score, an interpretable scalar metric that captures an individual's deviation from typical unimpaired gait, providing rapid, holistic quantification of impairment. This generalizable model provides a foundation for clinically actionable tools that translate mobile sensing-derived gait data into precise biomechanical insights for clinical research and decision-making. The open-source model is deployed in the cloud for automated smartphone video-based gait analysis on our freely available OpenCap platform.

Sensorimotor adaptation is a motor learning process that contributes to movement flexibility and is thought to arise from the interaction of fast and slow adaptive processes. Evidence suggests that declarative memory contributes to adaptation through its influence on the fast process. Although adaptation deficits are common following stroke, the mechanisms underlying these deficits remain unclear. This study investigated differences in locomotor adaptation rate and forgetting between individuals with chronic stroke and age-matched controls and examined how these measures were associated with immediate declarative memory performance. Individuals with chronic stroke (n = 23) and age- and education-matched controls (n = 21) completed four 4-minute bouts of split-belt treadmill adaptation separated by rest breaks. Adaptation rate, adaptation magnitude, and forgetting were quantified from exponential fits to normalized step-length asymmetry data. Immediate declarative memory was quantified using the Repeatable Battery for the Assessment of Neuropsychological Status, and associations between adaptation measures and immediate declarative memory were evaluated using robust linear regression. Participants with stroke adapted less (p = 0.001) and more slowly (p = 0.039) than controls during early adaptation and forgot less of the adapted behavior during the first rest break (p = 0.024). Notably, poorer immediate declarative memory performance was associated with reduced forgetting during the initial rest break, irrespective of group assignment (p = 0.035). This relationship supports the hypothesis that declarative memory contributes to adaptation through a cognitively mediated fast process. These findings suggest that cognitive impairment contributes to altered adaptation following stroke and highlight the importance of considering cognitive factors when investigating motor learning mechanisms and rehabilitation outcomes in neurological populations.

Background: Chronic pain is a multidimensional condition that often persists despite conventional treatment and adversely affects multiple domains of daily life. Music listening has emerged as a promising non-pharmacological intervention, with accumulating evidence supporting its beneficial effects on pain and associated psychological outcomes. However, despite growing evidence of efficacy, the translation of music listening into routine clinical practice remains limited, partly because intervention reporting has received comparatively little attention. Objective: To evaluate the effectiveness of music listening interventions for chronic pain and systematically assess the methodological quality and completeness of intervention reporting to identify barriers to reproducibility and clinical implementation. Methods: Systematic searches were conducted in PubMed, Cochrane Library, CINAHL, and Web of Science through June 2025, with no date restrictions on publication. Randomized controlled trials involving adults with chronic pain receiving music listening interventions were included. Two independent reviewers screened studies, extracted data, and assessed risk of bias. Intervention reporting was evaluated using the TIDieR checklist, and a random-effects meta-analysis was performed for pain intensity outcomes. Results: Ten RCTs involving 538 participants were included. Music listening interventions varied substantially in delivery, duration, and music selection procedures, reflecting considerable heterogeneity in intervention design. Most studies reported significant improvements in pain and psychological outcomes. Meta-analysis of eight trials (10 effect estimates), demonstrated a moderate reduction in pain intensity (SMD = -0.53, 95% CI: -0.96 to -0.11, p = 0.014; I2 = 76.2%). Although intervention rationale and procedures were generally well described, reporting of intervention modifications, treatment fidelity, and adherence was frequently incomplete. These reporting deficiencies may compromise reproducibility and limit translation into clinical practice. Conclusions: Music listening appears to be a safe, accessible, and scalable non-pharmacological intervention for chronic pain management, with benefits extending beyond pain reduction to psychological wellbeing, quality of life, and functioning. However, incomplete reporting of key intervention components may limit reproducibility and hinder clinical implementation. Future trials should adopt standardized and transparent reporting standards to facilitate implementation into clinical practice.

Introduction Chronic musculoskeletal pain (CMSKP) in adolescence is associated with physical, psychological, social, and academic impairment and increased risk for chronic pain in adulthood. Although physical activity interventions are an evidence-based approach for managing pediatric chronic pain, many adolescents with CMSKP avoid physical activity due to fear of increased pain, low confidence in physical functioning, and other pain-avoidance behaviors. Resilience-focused interventions targeting self-efficacy, motivation, and mental flexibility may improve engagement in valued activities despite pain. This study describes the design and protocol of the Pain REsilience Promotion for Youth (PREP-Y) intervention, a resilience-focused physical activity intervention for adolescents with CMSKP. Methods and analysis This single-site, pilot phase 2, single-group, non-randomized clinical trial will enroll 40 adolescents aged 12-17 years with CMSKP from Nationwide Childrens Hospital in Columbus, Ohio, USA. Participants complete questionnaires, objective physical functioning assessments, and physical activity monitoring using activPAL devices as baseline measures. Participants then complete 4 virtual resilience-focused intervention sessions targeting pain resilience, self-efficacy, motivation, and adaptive coping related to physical activity. Garmin watches are used to track activity during the intervention period. Follow-up assessments occur post-intervention and at 3 months post-intervention. Primary outcomes include feasibility and acceptability, assessed through recruitment, retention, attendance, intervention fidelity, and completion of study measures. Exploratory outcomes include physical activity, sedentary behavior, pain-related functioning, pain catastrophizing, kinesiophobia, self-efficacy, and resilience-related constructs. Ethics and dissemination The study was approved by the Nationwide Childrens Hospital Institutional Review Board. Findings will inform a future randomized clinical trial. This manuscript reflects protocol version 5.0 dated 23 March 2026. Trial registration ClinicalTrials.gov: NCT06923891.

Introduction: Stair walking challenges balance and coordination in older people. Bench-stepping training improves stair climbing speed in healthy older women. This study assessed whether bench-stepping also improves dynamic balance and movement complexity during stair walking. Methods: Stair walking data were obtained from a previous study involving 45 healthy older women (69y+/-4) that assessed the effects of a 12-week bench-stepping intervention with non-training controls. Centre-of-mass acceleration was measured during stair ascent and descent. Linear dynamics included time, acceleration magnitude, and harmonic ratios (HR; indicating symmetry). Movement complexity was quantified using nonlinear dynamics including sample entropy (SE), recurrence quantification analysis (RQA), and fractal dimension (FD). Results: For stair ascent, increased speed (p =0.018, R2partial =0.093,) was accompanied by proportional increases in acceleration magnitudes (p=<0.039, R2partial =0.078-0.101). SE decreased more in the intervention group (p=<0.012, R2partial =0.049-0.101), indicating more predictable dynamics. In contrast, for stair descent, no changes in speed or acceleration magnitudes were observed. However, SE (p =0.001, R2partial =0.082) and maximum RQA line length (p= 0.008, R2partial =0.057) of vertical acceleration increased significantly compared to controls, indicating lower predictability and more persistent recurring patterns. No significant changes were found for other outcomes. Exploratory factor analysis revealed distinct differences in motor behaviour between stair ascent and descent. Conclusion: Bench-stepping training induced measurable changes in stair walking dynamics. Specifically, sample entropy shows potential as a sensitive marker of altered motor complexity, particularly of vertical accelerations. Interestingly, the direction of changes in unpredictability differed between stair ascent and descent, suggesting different underlying control strategies.

Background: Transition timing to post-acute rehabilitation after ischemic stroke is heavily influenced by non-clinical factors, introducing potential systemic disparities in care access. We evaluated the association between insurance payor status and acute hospital length of stay (LOS) prior to inpatient rehabilitation discharge among critically ill stroke patients. Methods: Using the MIMIC-IV database, we identified ICU-admitted adults with ischemic stroke discharged to inpatient rehabilitation (n=1,285). The primary outcome was hospital LOS prior to rehab transfer. Multivariable log-transformed linear regression evaluated the association with insurance payor (Medicare, private, other/unknown; reference: Medicaid), adjusting for demographics, diagnostic-code counts (medical complexity), and ICU LOS (acute illness severity). Results: Median hospital LOS before rehab discharge was longest for Medicaid patients (13.2 days) compared with private insurance (11.0 days) and Medicare (9.5 days). In the adjusted model, Medicare insurance was associated with a significantly shorter transition time to inpatient rehabilitation, corresponding to a 13.5% shorter acute hospital stay (adjusted LOS ratio 0.87; 95% CI: 0.79-0.96; p=0.005) relative to Medicaid. Private insurance demonstrated a descriptive trend toward shorter LOS that did not achieve statistical significance (adjusted LOS ratio 0.93; 95% CI: 0.84-1.02; p=0.122). Other and unknown payor categories showed no significant differences. Conclusions: Insurance payor status serves as an independent predictor of acute care transition timing for stroke patients requiring inpatient rehabilitation. The prolonged acute stays observed among Medicaid beneficiaries suggest significant non-clinical, administrative bottlenecks in post-acute placement, underscoring the critical need for standardized, streamlined insurance approval pathways to ensure equitable neurological recovery.