Archives of Physical Medicine and Rehabilitation

Background: Aerobic exercise is recommended during stroke rehabilitation to improve cardiorespiratory fitness and support recovery; however, participation rates remain low. While institutional and system-level barriers have been widely examined, less is known about how individual patient factors influence engagement in aerobic exercise during rehabilitation. Objectives: We aimed to determine whether depressive symptoms, apathy, self-efficacy and outcome expectations for exercise, perceived barriers, or past exercise history were associated with aerobic exercise participation in stroke rehabilitation. Methods: In this prospective cohort sub-study, adults admitted to in- or out-patient stroke rehabilitation at three urban hospitals completed validated questionnaires assessing depressive symptoms, apathy, exercise self-efficacy, outcome expectations for exercise, perceived barriers to being active, and premorbid exercise history. Participants were separated into two groups for analysis: those who completed aerobic exercise during rehabilitation and those who did not. Equivalence testing and between-group comparisons were performed. Results: Sixty-two participants were enrolled; 16 participated in aerobic exercise and 46 did not. Groups were not equivalent on any individual-level factors. Compared to non-participants, those who performed aerobic exercise had significantly higher depressive symptom scores (p=0.0025) and lower self-efficacy for exercise (p=0.0087). Non-participants demonstrated significantly higher apathy (p=0.0007). No significant differences were found for outcome expectations, perceived barriers, or exercise history. Conclusion: Depressive symptoms and lower self-efficacy did not impede aerobic exercise participation during rehabilitation. Increased apathy, however, was associated with non-participation. Findings highlight the need for individually tailored aerobic exercise prescriptions that consider motivational and affective factors to optimize engagement during stroke rehabilitation.

Abstract Introduction: Cardiac rehabilitation (CR) is key for secondary prevention; however, participation remains low due to persistent barriers. Identifying strategies used by high-performing programs may inform approaches to improve patient engagement and outcomes. Purpose: To identify strategies associated with improved participation and adherence in CR programs from the perspective of leaders in high-performing sites. Methods: Semi-structured interviews were conducted with 10 CR leaders from urban, suburban, and rural programs ranked in the top 10% on at least two objective performance measures (e.g., participation and adherence rates) but moderate or low on others. Data were analyzed using thematic analysis to identify strategies associated with high performance. Results: Programs with high participation and adherence rates consistently implemented proactive, patient-centered strategies to address barriers. Individualized care approaches tailored to language, culture, health literacy, and age were commonly used to improve engagement among Hispanic, Black, and older adult populations. High-performing programs addressed structural barriers such as insurance and transportation through flexible scheduling, community partnerships, and targeted outreach. Strong coordination with referring providers and effective transitions from inpatient to outpatient care were associated with higher enrollment and sustained participation. Additional strategies included staff development through ongoing education, use of digital tools for patient tracking, and implementation of virtual and hybrid CR models. Integration of psychological support further enhanced patient engagement. Conclusion: High-performing CR programs employ coordinated, patient-centered, and system-level strategies associated with improved participation and adherence. These findings provide actionable approaches to enhance accessibility and improve programs and patients outcomes in CR across diverse settings. Keywords: Cardiac rehabilitation; participation; adherence; health disparities; implementation strategies

Background: Low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) over the contralesional primary motor cortex is widely used for post-stroke upper-limb rehabilitation, but treatment response varies substantially. This systematic review and meta-analysis aimed to quantify the efficacy of contralesional LF-rTMS and to examine whether baseline motor impairment severity and corticospinal tract (CST) integrity modify treatment effects. Methods: We searched seven databases from inception to July 2026 for randomized controlled trials of contralesional LF-rTMS ([≤]1 Hz) versus sham after stroke, with comparable rehabilitation in both arms. The primary outcome was the change in Fugl-Meyer Assessment for the upper extremity (FMA-UE) scores. Random-effects meta-analysis used restricted maximum likelihood estimation with Knapp-Hartung adjustment. Effect modification was examined through meta-regression and biomarker-stratified analyses, and neurophysiological outcomes were also synthesized. Results: Thirty trials (33 comparisons, 1,668 participants) were included. LF-rTMS produced greater FMA-UE improvement than sham (mean difference 4.11 points, 95% CI 2.83-5.39; Hedges g 0.64, 95% CI 0.45-0.84), with substantial heterogeneity. Baseline severity did not significantly modify the effect in continuous meta-regression. However, exploratory within-trial biomarker-stratified analyses suggested larger effects in participants with preserved CST integrity or positive motor-evoked potential (MEP) status. LF-rTMS also shortened MEP latency and central motor conduction time, but these measures could not be validated as surrogate endpoints. Conclusions: Contralesional LF-rTMS provides a statistically significant but modest improvement in post-stroke upper-limb motor recovery. Baseline clinical severity alone may not identify responders, whereas CST integrity is an exploratory, hypothesis-generating candidate biomarker. It requires confirmation in adequately powered biomarker-stratified trials before it can inform clinical decisions. Trial Registration The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD420261441561).

Background: Heatwrap is recommended for acute low back pain (ALBP), and previous research found heatwrap plus exercise more effective than each intervention alone. While recommended by clinical guidelines, their impact on mechanistic outcomes is unknown. This trial aimed to (i) assess immediate and short-term effects of heatwrap alone or combined with exercise, compared with a sham heatwrap, on pain sensitivity, lumbar muscle activity, current pain intensity, and trunk flexion range of motion, and (ii) explore whether changes in pain sensitivity and lumbar muscle activity are associated with changes in clinical symptoms from baseline to 1-week follow-up. Methods: A randomised controlled trial took place at a single research center. Of 315 individuals screened for eligibility, 99 adults with ALBP were recruited and assigned to one of three intervention groups: heatwrap plus exercise (n=34), heatwrap alone (n=33) or sham heatwrap (n=32). Interventions were applied for one hour at the first visit, and immediate effects were measured. Then, interventions were applied for 7 days, and short-term effects were measured at 1-week follow-up. Outcomes included pressure pain threshold, temporal summation of pain, flexion-relaxation ratio, trunk range of motion and current pain intensity. Results: Heatwrap and exercise did not produce greater effects over time than heatwrap alone or a sham heatwrap on all outcomes, and changes in sensorimotor outcomes at one week were not associated with changes in symptoms. Conclusions: Heatwrap and/or exercises did not influence specifically the potential sensorimotor mechanisms tested in individuals with ALBP. Trial registration: ClinicalTrials.gov; registration number: NCT03986047

Purpose: To explore how 12-weeks of robotic walking impacts physical function and sequelae of inactivity for individuals with pediatric-onset neuromotor impairments. Methods: A single-arm mixed-methods interventional study examined robotic walking for 12-weeks in home and community settings, with 12-week follow-up. Outcomes included family goals (Goal Attainment Scale (GAS)) and perspectives (Interviews), postural control (Early Clinical Assessment of Balance), physical activity (Actigraphy, Habitual Activity Estimation Scale, Patient Reported Outcome Measurement Information System (PROMIS) Physical Activity) and sequelae of inactivity (PROMIS Sleep Disturbances, Bowel Function Diary). GAS was collected pre-training, post-training, and 12-week follow-up. All other quantitative outcomes were collected every 4-weeks. Quantitative data are described with median (25th-75thpercentile) and analyzed using a Skillings-Mack test with post-hoc Wilcoxon Signed-Rank. Qualitative interviews were conducted before and after training and analyzed thematically. Results: 15 participants aged 4-23 completed this study. Participants had cerebral palsy (10/15) or rare genetic conditions (5/15), and most used a wheelchair in community settings. Postural control improved (test-statistic = 23.0, p<0.001) after 8 weeks (change=5.0(0.0-21.4), p=0.016) and was maintained through 12-week follow-up (change=13.7(3.1-23.7), p=0.008). Over half of the participants achieved goals (t-score > 50) after training. Exploratory analyses suggest improvements in sleep disturbance immediately after training (p=0.025) and 4-weeks after (p=0.047). All measures of physical activity did not improve. Parents reported improvements in walking, activities of daily living, and sequelae of inactivity (i.e., bowel function, appetite, and sleep). Conclusions: Improvements were seen across a range of measures and notably postural control improvements were maintained at the follow-up. Parents perceived improvements in physical function and activities of daily living. Future research is warranted to further understand the impacts of robotic walking for children and small adults with mobility impairments.

Background Mirror therapy (MT)-specifically paradigms using mirror visual feedback (MVF)-is widely used in neurorehabilitation; however, mechanistic implementations vary substantially in movement content, rhythmicity and attentional demands. This protocol describes an acute mechanistic, within-participant fNIRS screening study designed to compare three prespecified upper-limb mirror-therapy task paradigms and to quantify associated subjective experience after each condition in healthy adults during a single visit. Methods and analysis This is a single-centre, within-participant, randomised crossover study conducted at Wuhan Wuchang Hospital (Wuhan, China). Healthy adults aged 18-35 years will complete three task conditions once each in a counterbalanced order using a 3*3 Latin-square scheme: UMT1 (task-oriented rhythmic functional movement), UMT2 (open-ended free movement with auditory control), and UMT3 (non-functional rhythmic movement). fNIRS will be acquired using the NirSmart-6000A system during a standardised block design. The primary outcome is ROI-level HbO activation quantified as GLM-derived {beta} estimates within the prespecified primary ROIs (bilateral SM1/M1 and bilateral PMC). Secondary outcomes include ROI-level windowed {Delta}HbO (5-20 s post-onset relative to the immediately preceding rest; descriptive only), ROI-level {Delta}HbR, and post-condition subjective ratings (illusion, immersion, confusion and fatigue; 1-7 Likert). Condition effects will be analysed using linear mixed-effects models with fixed effects for condition and period and prespecified multiplicity-adjusted pairwise contrasts. Ethics and dissemination Ethics approval was obtained from the Ethics Committee of Wuchang Hospital Affiliated to Wuhan University of Science and Technology (Approval No.: 2025-112-01; approved on 2025-08-21). The study is expected to be minimal risk. Findings will be disseminated through publication of this protocol manuscript and subsequent results manuscripts and conference presentations. Trial registration number Chinese Clinical Trial Registry (ChiCTR2600116634). This study is conducted as a prespecified mechanistic sub-study under the overarching registered project.

Objective: To describe cardiovascular and autonomic responses to body weight-supported treadmill training (BWSTT) combined with active or sham transcutaneous spinal cord stimulation (TSCS) in individuals with chronic, motor-complete spinal cord injury (SCI). Design and setting: Exploratory case series from randomized, sham-controlled clinical trial in a tertiary Rehabilitation Centre in Vancouver, Canada. Participants: Eight adults with chronic ([&ge;]1 year post-injury) traumatic, motor-complete (American Spinal Injury Association Impairment Scale A-B) SCI at or above T6 Interventions: Participants were randomized to 12 weeks of BWSTT plus lumbosacral TSCS or BWSTT plus sham stimulation, delivered 3 sessions/week. TSCS was delivered at T11-L1 using 30 Hz stimulation with a 10 kHz carrier frequency. Five participants completed the intervention, and four completed full cardiovascular testing (TSCS n=2; sham n=2). Outcome measures: Ambulatory blood pressure (BP) monitoring, participant-reported symptoms of AD and OH (via ADFSCI questionnaire), BP variability, orthostatic hemodynamics, echocardiography, electrocardiography (ECG)- and heart rate variability (HRV)-derived indices, and baroreflex function. Results: Among complete cases, several cardiovascular indices changed over time, including reduced daytime hypotensive burden in TSCS participants, preserved nocturnal dipping, and small changes in stroke volume and ECG-derived variability indices; however, responses were heterogeneous and overlapped with Sham. Both TSCS and Sham participants showed reduced autonomic symptom scores, while low-frequency blood pressure variability responses during orthostatic stress were heterogeneous and did not indicate a pattern that was specific to a cohort. Conclusion: Although preliminary, this exploratory complete-case analysis suggests that cardiovascular responses to BWSTT with active or sham TSCS are measurable but highly individualized after chronic motor-complete SCI. Given the small sample and overlapping Sham responses, findings are exploratory and larger trials are needed to determine whether TSCS augments cardiovascular autonomic adaptations to locomotor training.

Objective: To investigate the clinical validity of finger-worn accelerometers for providing a comprehensive assessment of upper-limb motor performance in stroke survivors in real-world environments, compared to wrist-worn accelerometers, and to examine how the clinimetric properties of wearable-based motor performance measures vary with the duration of patient data collection. Design: Cross-sectional observational design. Setting: Research laboratory and free-living environments. Participants: Twenty-seven stroke survivors aged 18-80 years with ischemic or hemorrhagic stroke at least six months prior to enrollment and mild-to-moderate upper-limb impairment without severe range-of-motion restrictions were enrolled. Three participants were ineligible and four withdrew, resulting in a final cohort of 20 participants (N = 20). Interventions: Not applicable. Main Outcome Measures: Wearable-based motor performance measures derived from fine-hand movements, gross-arm movements, and the combination of fine-hand and gross-arm movements captured by finger-worn and wrist-worn accelerometers in naturalistic settings for 6.4 {+/-} 1.8 days. Results: Wearable-based motor performance measures from fine-hand movements demonstrated the strongest convergent validity, known-group validity, and test-retest reliability, followed by those from combined and gross-arm movements. Convergent validity and test-retest reliability of wearable-based motor performance measures improved with longer monitoring durations, with four days being sufficient to obtain accurate and reliable upper-limb measures. Conclusions: Wearable-based motor performance measures from finger-worn accelerometers provide a more comprehensive assessment of upper-limb motor performance than those from wrist-worn accelerometers, supporting their use for real-world monitoring in stroke survivors. Furthermore, the improvements in clinimetric properties of wearable-based motor performance measures with longer monitoring durations highlight the importance of multi-day monitoring to mitigate day-to-day variability and ensure robust assessment.

Background and purpose: Patellofemoral pain syndrome (PFPS) is a multifaceted condition where proximal, local, and distal factors may contribute to symptoms and limitations. How these factors collectively contribute to PFPS remains poorly understood. Therefore, this study compared proximal, local, and distal mechanical characteristics between individuals with and without PFPS and investigated their association with pain intensity and functional disability. Methods: Eighty participants were included: 40 individuals with unilateral or bilateral PFPS, 40 healthy controls. Isometric muscle strength of hip, trunk, and ankle was assessed using a handheld dynamometer. Joint alignment (Q-angle, rearfoot angle, pelvic tilt) and muscle flexibility (iliotibial band, hamstrings, quadriceps, gastrocnemius, and soleus) were measured using standard clinical techniques. Pain severity was assessed using a visual analog scale (VAS), and functional disability was evaluated using the Kujala score. Results: Individuals with PFPS showed reduced iliotibial band flexibility, decreased hamstring and soleus length, lower hip abductor strength, and greater anterior and lateral pelvic tilt (all p < 0.02). Multivariate analysis identified reduced iliotibial band flexibility (OR = 7.48) and greater anterior pelvic tilt (OR = 11.75) as independent associates of PFPS. Anterior pelvic tilt predicted pain severity, while anterior trunk muscle strength and Q-angle predicted disability. Discussion: Reduced iliotibial band flexibility and increased anterior pelvic tilt were independently associated with PFPS, while anterior pelvic tilt predicted pain severity and anterior trunk muscle strength and Q-angle predicted functional disability. Clinical assessment and rehabilitation of PFPS should therefore extend beyond the knee to include iliotibial band flexibility, pelvic alignment, and trunk muscle strength.

Age-related decline in postural control is an important factor that increases the fall risk of older adults. Fingertip vibrotactile stimulation has been developed to provide light touch-like somatosensory input. However, evidence regarding differences among older age groups is limited. This study examined the effects of fingertip vibrotactile stimulation on postural control in 348 community-dwelling older adults classified as young-old (age 65-74 years), old-old (age 75-84 years), and oldest-old (age 85 years or older). Participants stood with eyes closed and feet together under stimulation and no stimulation conditions. The center of pressure (COP) velocity and COP area were measured using a force plate. The natural log-transformed COP area was used for the analysis. Linear mixed models were used to examine the effects of age group, stimulation conditions, and measurement segments. The COP velocity under the stimulation condition was significantly lower than that under the no stimulation condition; however, the COP area did not change significantly. Significant main effects of age group were observed for both COP indices, but no interaction between age group and stimulation condition was observed. Fingertip vibrotactile stimulation may reduce the COP velocity across older age groups, thus reflecting the effects on postural adjustment frequency.

Purpose: Lower-limb prosthesis use involves interacting physical, psychosocial, and device-related outcomes that may not be fully captured by conventional clinical assessment. This study aimed to develop and evaluate a stakeholder-informed framework of outcome domains relevant to meaningful everyday prosthesis use. Materials and Methods: A mixed-methods participatory design comprised a structured synthesis of selected clinically relevant content from five established patient-reported outcome measures; semi-structured interviews and importance and actionability ratings with 18 contributors (12 prosthesis users, four clinicians, and two industrial partners); and integration of the synthesis, qualitative, and rating findings. Interview records were analysed using reflexive thematic analysis, and ratings were analysed descriptively. Results: The resulting framework comprised four interrelated domains: Mobility, Physical Function, Psychosocial Wellbeing, and Prosthesis Experience. Mobility showed the clearest convergence across stakeholder perspectives. Prosthesis users showed the largest importance actionability gap for Prosthesis Experience (4.5 vs 3.0), whereas clinicians showed the largest gap for Psychosocial Wellbeing (5.0 vs 3.0). Interviews highlighted day-to-day variability in prosthesis use and the influence of confidence, fatigue, comfort, environmental conditions, social context, and device usability. Conclusions: Meaningful outcome assessment in prosthetic rehabilitation should extend beyond mobility alone to consider physical function, psychosocial wellbeing, and prosthesis experience within everyday contexts. The proposed framework provides a stakeholder-informed foundation for multidimensional outcome assessment in prosthetic rehabilitation.

Conventional transfemoral amputation disrupts native neuromuscular pathways, limiting prosthetic joint control, sensory feedback, and the perception of the prosthesis as part of the body. To ameliorate these pathologies, we restored the agonist-antagonist relationship of residual muscles in two individuals with above-knee amputation through an interventional surgical revision. Participants trained with a bionic knee prosthesis before and after the surgical revision while generating neuromuscular, cortical, functional, and affective data. Both individuals demonstrated improvements after the revision that could not readily be attributed to training effects, including: 1) increased proprioceptive afferents and stronger activation in cortical regions associated with sensorimotor integration of their missing joints, 2) improved control of the bionic knee during functional tasks including sit-to-stand and stair ascent, and 3) generally greater prosthesis embodiment, proprioception, and phantom limb definition as assessed through questionnaires and interviews. In contrast, training outcomes were more participant-specific and more variably correlated with amount of exposure, especially before the revision. These pilot findings suggest that revisional augmentation of residual neuromuscular tissues to restore agonist-antagonist dynamics may promote sensorimotor coherence and enhance both functional and perceptual integration with a bionic prosthesis, and remaining participant-specific heterogeneities may be attributable to inter-individual difference in residual limbs neuromuscular system, amputation history, and personal beliefs about prosthesis usage.

Background: Prolonged mechanical ventilation is associated with inspiratory muscle weakness and difficulty weaning from respiratory support. While decades of research have demonstrated that inspiratory strength training (IST) is beneficial in adult critical care populations, the literature on its use in pediatric cardiac critical care remains limited. We sought to evaluate the feasibility, safety, and physiologic response to IST in children in the pediatric cardiac intensive care unit (PCICU). Methods and Results: We performed a single-center retrospective cohort study of children with congenital heart disease referred for IST between January 2015 and August 2021. Feasibility was defined as completion of [&ge;]1 IST session following referral. Safety outcomes included physiologic events documented during IST sessions. Changes in maximal inspiratory pressure (MIP) were assessed in patients who completed [&ge;]2 IST sessions. Of 105 eligible patients, 93 (89%) successfully completed at least 1 IST session. Monitoring events were reviewed across 389 IST sessions and included pre-oxygenation (62%), desaturations (13%), bradycardia (7%), and hypertension (2%). All events were transient and did not require escalation of care. 84% of patients were successfully liberated from mechanical ventilation and required a median of 2 (IQR 1-4) sessions of IST. Among patients completing [&ge;]2 IST sessions, MIP improved signicantly over time (p>0.0001). Improvements were observed in both patients who did and did not wean from mechanical ventilation. Patients who failed to wean from mechanical ventilation had longer ventilator exposure prior to IST initiation and were more sedated at the outset of IST. Conclusions: IST was feasible and well tolerated in this medically complex PCICU cohort. High completion rates and improvements in MIP support the use of IST as a clinically deliverable intervention that can produce measurable improvements in inspiratory muscle strength during critical illness.

Breast cancer survivors frequently experience upper-limb impairments, making continuous monitoring essential for effective rehabilitation. We propose REINA (Recognize-Then-Infer Wearable-to-App AI Framework), a two-stage deep-learning approach for remote monitoring of motor function during breast cancer rehabilitation using wearable-device data. Inertial measurement unit (IMU) signals from wearable devices are first used to recognize physical activities via supervised learning, followed by an activity-specific recurrent neural network (RNN) to infer corresponding electromyography (EMG) signals. REINA establishes reliable inference of neuromuscular activity from wearable IMU data, enabling real-time, cost-effective assessment of motor function recovery in real-world settings.

Impaired motor control post-stroke results in reduced walking speeds and increased gait variability. This variability reduces reliability and makes identifying longitudinal changes via gait analysis difficult since changes may occur within the margin of measurement error. We quantified intra-class correlation coefficients (ICC) and minimal detectable change (MDC) in post-stroke individuals and neurotypical individuals walking at matched speeds, to isolate the impact of gait speed and post-stroke impairments on gait-analysis reliability. We collected gait data over two days from N=15 post-stroke individuals walking on a treadmill at their self-selected speed, and from N=13 age- and sex-matched neurotypical controls walking at both their self-selected speed and a speed matched to a post-stroke participant. We calculated ICC and MDC values for spatiotemporal variables, bilateral joint ranges of motion (ROM), and bilateral peak propulsive and peak vertical ground reaction forces (GRF). Spatiotemporal ICCs showed excellent reliability across groups (range [0.813-0.988]), yet MDC values were greater post-stroke than in speed-matched controls. ICCs for joint ROM ranged from poor to excellent reliability across groups ([0.362-0.960]). Post-stroke joint ROM MDCs were 27%-53% of the gait ROM compared to 11%-42% in neurotypical controls. ROM MDCs were greater in the non-paretic compared to the paretic extremity. ICC for peak GRFs showed good to excellent reliability across groups (range [0.778-0.980]), with post-stroke peak GRF MDCs greater than in speed-matched controls. Our results suggest that stroke related neuromotor impairments influence reliability beyond the effects of walking speed alone, and we provide quantitative MDC benchmarks for interpreting gait changes post stroke following clinical interventions.

Importance: There are very few interventions designed for individuals with the most severe mobility impairments. Robotic walking may be an effective way to facilitate exercise in this population. Objective: To examine how robot-assisted walkers physical parameters and user characteristics moderate the exercise intensity achieved by individuals with neuromotor disorders causing mobility impairments. Design: A prospective study. Intervention: A single-session intervention involving an overground robot-assisted walker that can be used in an endurance mode requiring no voluntary movement or a strength mode during which voluntary movement could impact the gait pattern. Participants: Individuals with pediatric-onset mobility impairments Main Outcome Measures: Participants were characterized based on their age, sex, diagnosis, and Gilette Functional Assessment Questionnaire (FAQ) levels. Heart rate during the final minute of four 5-minute walking conditions: strength mode at fast speed, strength mode at slow speed, endurance mode at fast speed and endurance mode at slow speed was expressed as a percentage of each participant heart rate reserve (%HRR). Linear mixed-effects models were used to evaluate the impact of speed, device mode and user characteristics on the level of exercise achieved. Results: 29 individuals (aged 2-26 years) with mobility impairments (FAQ levels 1-6) completed this study. Fast speeds were associated with a higher %HRR (beta= 2.11, SE = 1.03, p = 0.044). Participants in FAQ class 1 exhibited significantly higher %HRR compared with those in FAQ classes 2 and 3 (beta=18.6, SE=7.31, p=0.017; beta= 16.9, SE = 8.13, p = 0.047, respectively). No other device or participant characteristics were associated with exercise intensity. Conclusions: To facilitate higher exercise levels, users of robot-assisted walkers can increase their speed. Individuals who cannot take steps due to their neuromotor impairments experience the highest levels of exercise. Relevance: The findings in this study highlight the promise of robot-assisted walkers to improve health, particularly in those who often face the greatest barriers to exercise.

Prosthesis non-use and abandonment remain common among people with lower-limb amputation, yet current outcome measures capture only limited aspects of how prostheses are used in everyday life. Clinical assessments are typically conducted in controlled settings and rely on self-report or aggregate activity counts, which do not adequately represent functional performance, physiological effort, or lived experience during real-world prosthesis use. Wearable and ambient sensing offer a means of addressing this gap, but existing approaches tend to measure single dimensions in isolation and are rarely validated against laboratory reference standards before free-living deployment. This protocol describes an integrated multimodal framework for assessing real-world lower-limb prosthesis use across three complementary domains: classification of activities of daily living, estimation of energy expenditure, and assessment of emotional state. Approximately 40 adults with unilateral transfemoral or transtibial amputation complete a two-phase protocol. In the laboratory phase, wearable inertial, physiological, and ambient sensing are validated against established reference standards, including video annotation and indirect calorimetry. In the free-living phase, validated models are applied during a single seven-day home monitoring period, unifying all three domains within one deployment. A defined data harmonisation and quality-control procedure aligns heterogeneous sensor streams and preserves traceability between laboratory calibration and free-living measurement, enabling reproducible interpretation of functional behaviour, metabolic cost, and momentary emotional experience in relation to established clinical outcome domains. By integrating multimodal sensing at the level of study design rather than post-hoc analysis, the framework provides a validated, reproducible methodology for characterising prosthesis use beyond the capacity of conventional instruments, offering a transferable approach for real-world monitoring in rehabilitation research

Background: Prolonging ambulation is an important treatment goal in children with Duchenne muscular dystrophy (DMD). Clinical management targets 'actionable' (i.e., modifiable) impairments, such as progressive muscle weakness and contractures, that underlie gait pathology. Gait classification may improve clinical decision-making, but the utility of gait classification in clinical practice depends on understanding how underlying, actionable impairments contribute to distinct gait patterns, which remains insufficiently understood. The research questions were: (1) Can DMD gait patterns be accurately classified from actionable impairments? and (2) Can the model's predictions be explained, and do these explanations provide clinical utility and increase trust in the model? Methods: A retrospective dataset of 274 lower-limb observations from 137 assessments in 30 boys with DMD was analyzed, including 3D gait analysis, instrumented strength assessment, and clinical examination (manual muscle testing, goniometry and clinical stiffness scale). Observations were classified into the mildly affected, tiptoeing, or flexion gait pattern. Ten predictors representing actionable impairments were included: nine predictors related to muscle weakness and contractures, and body mass index (BMI). A balanced random forest classifier was evaluated with leave-one-group-out cross-validation. Model interpretability was explored using SHapley Additive exPlanations to generate global and local explanations. An interview with a clinical expert assessed the utility of the explanations as the primary outcome, with trust in and expectations of both the model and the explanations as secondary outcomes. Results: The model achieved an accuracy of 74.5%. Global explanations identified hip and knee weakness, gastrocnemius-soleus contractures, and BMI as the most important predictors across gait patterns. Local explanations illustrated how patient-specific impairments informed individual predictions. The user study demonstrated the clinical utility of the explanations, as they were perceived as interpretable, provided useful insights, and these insights were actionable. The explanations largely aligned with the expectations and increased self-reported trust in the model. Conclusions: Gait patterns in DMD can be predicted from clinically actionable impairments, and explainable artificial intelligence can translate model outputs into meaningful clinical insights. This approach is promising for supporting both general and personalized rehabilitation and orthopedic strategies aimed at prolonging ambulation in DMD. Further validation in larger, multi-center cohorts is needed.

Background: Sacroiliac joint (SIJ) pain is a common musculoskeletal condition among postpartum women due to hormonal, biomechanical, and physiological changes during pregnancy and childbirth. Increased ligament laxity, altered posture, weight gain, and pelvic instability may contribute to sacroiliac joint dysfunction. This condition often leads to pelvic girdle pain, low back pain, and functional limitations that affect daily activities such as walking, sitting, standing, and childcare. Objective: To determine the prevalence of sacroiliac joint pain and assess the level of disability among postpartum females in Sialkot. Materials and Methods: A descriptive cross-sectional study was conducted among 300 postpartum women aged 20-40 years from public and private hospitals in Sialkot. Non-probability convenience sampling approach was employed. Sacroiliac joint pain was assessed using clinical provocation tests including FABER, compression, and distraction tests. Pain intensity was measured using the Numerical Pain Rating Scale (NPRS), and functional disability was evaluated using the Oswestry Disability Index (ODI). Data were analyzed using SPSS version 25. Results: Clinical provocation testing demonstrated positive SIJ pain provocation in 84.0% (n=252) of acute postpartum participants, with severe functional disability observed in 46.0% (n=138). Most women reported moderate pain (74.7%), while 20.7% experienced severe pain. According to the ODI, 46% of participants had severe disability, 37.7% moderate disability, 10.7% minimal disability, and 5.7% were classified as crippled. Conclusion: Sacroiliac joint pain is highly prevalent among postpartum females and is associated with considerable functional disability. Early screening and physiotherapy-based rehabilitation may help reduce pain and improve functional outcomes. Keywords: Sacroiliac joint pain, Postpartum women, Pelvic girdle pain, Functional disability, Oswestry Disability Index.

Abstract Introduction Selecting an appropriate sham control is a key challenge in trials of mirror therapy, specifically paradigms using mirror visual feedback (MVF), because visually similar control conditions may still elicit mirror-related cortical responses. This protocol describes an acute mechanistic, within-participant fNIRS screening study designed to identify the sham mirror-therapy material condition with the most "neutral" neural signature relative to true MVF during a single exposure. Methods and analysis This is a single-centre, within-participant, randomised crossover study conducted at Wuhan Wuchang Hospital (Wuhan, China). Healthy adults aged 18-35 years will complete four conditions in one visit: C1 true MVF and three prespecified sham-material conditions (C2-C4), with condition order counterbalanced using a Latin-square schedule. fNIRS will be acquired during a standardised grasping task. Online acquisition-time quality control (SCI and CV thresholds) will be applied with prespecified re-acquisition rules. The primary outcome is ROI-level task-evoked change in oxygenated haemoglobin (Delta HbO) within prespecified ROIs (PMC and SM1/M1), estimated primarily using GLM-derived beta estimates. Condition effects will be analysed using linear mixed-effects models with prespecified contrasts and Holm multiplicity adjustment to rank sham conditions by a prespecified neutrality decision rule. Ethics and dissemination Ethics approval was obtained from the Ethics Committee of Wuchang Hospital Affiliated to Wuhan University of Science and Technology (Approval No.: 2025-112-01). Findings will be disseminated through publication of this protocol manuscript and a subsequent results manuscript, with key supplementary materials provided as online appendices/supplements as required by the target journal. Trial registration number Chinese Clinical Trial Registry: ChiCTR2600116634. Strengths and limitations of this study - Within-participant randomised crossover design reduces between-participant variability and is well suited for acute mechanistic screening of sham conditions. - Prespecified sham conditions and neutral-ranking decision rule, including prespecified ROIs, contrasts, and Holm multiplicity control, help limit analytic flexibility and support transparent interpretation. - Operational reproducibility safeguards are specified, including standardised task timing/instructions, acquisition-time QC thresholds with re-acquisition rules, and frozen channel-to-ROI mapping and material-definition records in the Supplementary materials. - Single-centre, healthy-participant, single-session paradigm may limit generalisability to clinical stroke populations and to longer-term therapeutic effects. - Blinding may be imperfect because perceptual differences between materials can affect expectancy and attention; blinding assessment is included but residual bias is possible. - fNIRS is susceptible to motion, scalp-coupling variability and physiological noise; despite prespecified QC and preprocessing, residual artefacts may remain and can reduce sensitivity.