Archives of Physical Medicine and Rehabilitation

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.

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

Recovery of hand and arm function is critical for improving quality of life in individuals with tetraplegia due to spinal cord injury (SCI). Nerve transfer procedures can restore meaningful hand and arm function in chronic SCI, yet postoperative outcomes vary widely. We conducted a prospective, single-arm, open-label trial to assess the impact of intensive, robot-assisted rehabilitation training on functional recovery and cortical reorganization following nerve transfer. The primary endpoint was assessment of hand and arm function measured by the Box and Blocks Test. We report the results from three participants, AIS A at enrollment, who completed six weeks of intensive robotic training at least 1 year after nerve transfer surgery (NCT04041063). All participants demonstrated minimally important difference improvements in at least one secondary clinical outcome. These improvements were accompanied by cortical reorganization measured by transcranial magnetic stimulation motor mapping, indicating integration of the newly established peripheral motor pathways. No serious adverse events related to surgery or rehabilitation occurred. Although recruitment was limited by the COVID-19 pandemic and precludes definitive conclusions regarding efficacy, these findings suggest that standardized, intensive robotic rehabilitation may enhance functional outcomes after nerve transfer surgery for chronic tetraplegia.

BACKGROUNDFreezing of gait (FOG) is a disabling feature of Parkinsons disease (PD). Although physical practice (PP) improves gait, maintaining gains remains challenging. Mental practice (MP), including Dynamic Neuro-Cognitive Imagery (DNI), may enhance gait control, but evidence on remote combined interventions is limited. PURPOSETo investigate whether adding MP grounded in DNI principles to remote physical practice supports greater and more sustained improvements than remote physical practice alone in people with PD and FOG. METHODSA prospective, single-blind, parallel-group randomized controlled trial was conducted. Forty-three participants with idiopathic PD and FOG were randomized to an experimental group (EG, n = 20) or control group (CG, n = 23), stratified by cognitive performance. Both groups received 10 remote sessions over 6 weeks. All performed structured physical practice targeting gait components; the EG additionally performed MP based on DNI, while the CG performed time-matched seated stretching. Assessments were conducted at baseline (BI), post-intervention (AI), and 30-day follow-up (FU). The primary outcome was Rapid Turns Test performance; secondary outcomes included FOG severity, motor aspects of daily living, mobility-related quality of life, and global cognition. RESULTSAll randomized participants were included in intention-to-treat analyses; 38 completed all assessments. Significant group x time interactions were found for Rapid Turns Test duration (p = 0.0019) and FOG time (p = 0.0108). Both groups improved short-term, but only the EG maintained gains at follow-up. Additional interactions favored the EG for mobility-related quality of life (p = 0.001) and global cognition (p = 0.0018). Self-reported FOG improved over time in both groups (p < 0.001) without between-group differences, while motor aspects of daily living showed a time effect only (p = 0.001). CONCLUSIONMP based on DNI principles may enhance retention of gains when combined with remote physical practice, supporting its use as an adjunct in FOG rehabilitation. Trial registrationThis trial is registered at ClinicalTrials.gov with trial registration number NCT06957405 (registered on April 25, 2025). Protocol and statistical analysis planThe full trial protocol and statistical analysis plan are available upon request from the corresponding author. Data sharingThe datasets generated, used and analyzed during the trial are or will be available from the corresponding author upon reasonable request. Funding and conflicts of interestThis article was produced as part of the activities of FAPESP Research, Innovation and Dissemination Center for Neuromathematics (grant #2013/07699-0, Sao Paulo Research Foundation). Co-author PRS received individual support from FAPESP (grant number 2025/14403-7). The authors declare no conflict of interest.

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 [&ge;]18 years of age, [&ge;]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 [&ge;]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.

BackgroundFunctional recovery after chronic stroke remains limited, requiring intensive and engaging rehabilitation approaches. Non-immersive virtual reality (NIVR) provides task-oriented, feedback-driven training that may enhance motor recovery in this population. ObjectiveTo evaluate the clinical effectiveness of a NIVR-based intervention (MindMotion GO) on upper limb motor function in patients with chronic left middle cerebral artery ischaemic stroke (LMCA stroke). MethodsA single-blind randomized controlled trial was conducted in 26 patients with chronic middle cerebral artery stroke. Five participants were lost to follow-up, resulting in a final sample of 21 patients allocated to the non-immersive virtual reality group (NIVR, n = 9) and conventional occupational therapy group (n = 12). Both groups completed an 8-week intervention consisting of two 30-40-minute sessions per week. The primary outcome was upper limb motor function assessed using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Secondary outcomes included health-related quality of life (SF-12v2), emotional status (Hospital Anxiety and Depression Scale), and caregiver burden (Zarit Burden Interview). Statistical analyses were performed using the intention-to-treat principle with non-parametric tests. ResultsThe NIVR group showed a clinically meaningful improvement in FMA-UE (median {Delta}21), exceeding the minimal clinically important difference (MCID = 7.35), whereas the control group showed smaller gains ({Delta}2.50) that did not reach clinical relevance. Both groups improved significantly over time; however, between-group differences were not statistically significant (P > 0.05). No significant changes were observed in quality of life, mood, or caregiver burden. ConclusionsNIVR using MindMotion GO is a safe and feasible intervention that can induce clinically meaningful improvements in upper limb motor function in chronic stroke patients. These findings support the incorporation of accessible, task-oriented virtual rehabilitation strategies in long-term stroke care.

Background: Freezing of gait (FOG) in Parkinson's disease (PD) is provoked by turning, doorways and dual-task walking. We evaluated WALK, a cadence-linked vibration neuromodulation combined with motor-learning training. Methods: Single-centre, sham-controlled pilot randomised trial. Adults with PD (Hoehn and Yahr 2 to 4) and neurologist-verified FOG were randomised 1:1 to intervention (WALK; vibration enabled) or sham (WALK; vibration disabled), alongside identical supervised home-based training for 6 weeks (3 sessions per week). OFF-medication assessments were performed at S0, S8 and S16. At S8 and S16, assessments were completed without a device and then with a device (fixed order). The primary endpoint was the mZ-FOG total (0 to 36). Results: Forty participants completed follow-up assessments (intervention n=24; sham n=16) with 100% session adherence and no serious device-related adverse events. In the intervention group, mZ-FOG total improved when assessed with the device at S8 ({Delta}=8.08) and S16 ({Delta}=9.21) relative to S0, with partial retention when assessed without the device at S16 ({Delta}=5.54). Conclusions: Cadence-linked, localised vibration neuromodulation plus motor-learning training was feasible and was associated with clinically meaningful within-intervention-group reductions in FOG. Taken together, the effect sizes and task-specific pattern support progression to a multicentre, assessor-blinded trial with an active sham, powered for between-group comparisons and durability and/or adherence endpoints.

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: Spinal pain, including neck pain and low back pain (LBP), is a common musculoskeletal condition and major contributor to disability worldwide. Evidence comparing disability, fatigue and mental health across acute and chronic stages remains limited, particularly in conflict-affected and low-resource settings. This study assessed these outcomes among patients with acute and chronic neck pain and LBP in the Gaza Strip. Methods: A comparative cross-sectional study was conducted among 410 adults attending outpatient physical therapy at Nasser Medical Complex, Khan Younis, Gaza Strip. Participants included 204 with neck pain and 206 with LBP, classified as acute neck pain (n=101), chronic neck pain (n=103), acute LBP (n=102) and chronic LBP (n=104). Disability, fatigue, psychological distress and sleep disturbance were assessed using the Neck Disability Index (NDI)/Oswestry Disability Index (ODI), Fatigue Severity Scale (FSS), Patient Health Questionnaire-4 (PHQ-4) and PROMIS Sleep Disturbance Short Form 8a. Independent t-tests, adjusted linear regression, correlation analyses, clinical-threshold analyses and binary logistic regression were performed. Results: Chronic neck pain and chronic LBP were associated with significantly higher disability, fatigue and psychological distress than acute pain. Chronic neck pain patients had higher NDI, FSS and PHQ-4 scores than acute neck pain patients; chronic LBP patients had higher ODI, FSS and PHQ-4 scores than acute LBP patients (all p<0.001). Sleep disturbance did not differ significantly between groups. Female participants reported higher psychological distress in both pain groups, with higher fatigue in neck pain and higher disability in LBP. Adjusted analyses confirmed that chronic pain status remained associated with higher disability, fatigue and psychological distress. Fatigue was the most consistent factor independently associated with chronic pain status. Conclusions: Chronic spinal pain was associated with greater disability, fatigue and psychological distress than acute spinal pain, while sleep disturbance was common across groups. These findings support early multidimensional assessment, including screening for fatigue and psychological distress. Longitudinal studies are needed to clarify whether these factors contribute to transition from acute to chronic spinal pain.

ImportanceChildren with Down syndrome (DS), a genetic condition associated with neuromotor impairments, walk [~]1 year later than typically developing peers. Treadmill training is the most successful known intervention for accelerating walking onset in DS. Overground stepping with mobility devices better mimics critical properties of real-world walking, but it is unknown how overground stepping develops in pre-walking infants with DS. ObjectiveWe aimed to characterize the developmental trajectory of stepping quantity and quality in supported overground stepping compared to supported treadmill stepping. We also measured infants ability to self-propel in the walker. Finally, we assessed caregivers perspectives on both devices. DesignWe tested infants at 10, 13, 16, and/or 19 months of age. SettingThis study occurred in a university laboratory in the United States. ParticipantsWe tested 31 pre-walking infants with Down syndrome across 69 sessions. ExposureAt each session, infants completed four trials per task (treadmill and walker) and a test of self-propulsion in the walker. Main Outcomes and MeasuresWe measured step quantity (overall step rate and alternating step rate), step quality (percentage of steps that were alternating, forward, and flat-landing), the ability to self-propel the walker, and caregiver perspectives on both devices. ResultsStep quantity increased with age and varied by task--infants took more steps per minute in the walker compared to the treadmill. Moreover, steps were of equal or higher quality in the walker. By 16 months, about half of infants could self-propel. Caregivers viewed both devices favorably, though the majority preferred the walker for home and/or community use. ConclusionsOverground walkers promote more stepping than a treadmill in pre-walking infants with DS, with stepping of similar or higher quality. Caregivers feel positively about overground walkers. RelevanceOverground stepping using a suspension walker shows promise as an intervention for pre-walking infants with Down syndrome.

Introduction: High-intensity locomotor training (HIT) is recommended for improving walking capacity, but treatment responses are variable. Understanding the brain changes underlying responsiveness to training could provide insight into this variability. Emerging evidence suggests upregulation of the contralesional cortico-reticulospinal tract (CRST) may contribute to walking function after stroke. However, it is unclear whether CRST upregulation is supportive or maladaptive, and no studies have examined CRST changes after HIT. This study investigated how CRST and corticospinal tract (CST) strength and laterality reorganize, and their relationship with walking capacity after locomotor HIT. Methods: Ten participants with chronic stroke completed a 4-week no-intervention control phase then 4-weeks of HIT. Diffusion MRI and 6-minute walk distance were obtained at weeks 0, 4, and 8. Analysis tested changes in ipsilesional and contralesional CRST and CST strength and laterality. Associations between changes in tract laterality and walking capacity were examined. Results: During the treatment phase (vs. the control phase), there were significantly greater increases in contralesional CRST strength (1.02 SD [95% CI: 0.25, 1.79]), contralesional CRST laterality (4.44 [2.15, 6.72]), and 6-minute walk distance (33 meters [17, 50]). Walking capacity improvements were associated with changes in CRST laterality (r = 0.77, p = 0.01), but not CST laterality (r = -0.01, p = 0.98). Discussion: Following HIT, increases in contralesional CRST strength and laterality were observed. CRST laterality changes were strongly associated with walking improvements, suggesting a possible supportive role of contralesional CRST in mediating training-related improvements in walking function after stroke.

BackgroundStroke leads to both motor and cognitive impairments that can substantially limit daily activities and independence. Although these impairments are often treated separately in rehabilitation, growing evidence suggests they are interconnected. Understanding how cognitive and motor impairments relate to one another is essential for developing more effective, integrated rehabilitation strategies. ObjectiveThis longitudinal study addressed three key questions: (1) Do motor and cognitive impairments co-occur after stroke? (2) Does cognitive ability influence motor recovery? (3) Are cognitive and motor recovery trajectories associated? MethodsWe followed 148 individuals in the subacute phase of stroke, assessing them at 1 and 3 months post-stroke. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) and the clock drawing test. Motor impairment was assessed using the Fugl-Meyer Assessment (FMA) and grip strength. Activity was evaluated using the Action Research Arm Test (ARAT), 10-Meter Walk Test (10MW), and Timed Up and Go (TUG). ResultsAt one month post-stroke, cognitive and motor impairment and activity levels were not correlated, although strong within-domain correlations were observed. Baseline cognitive ability did not predict motor impairment recovery. However, improvements in cognitive ability from 1 to 3 months were moderately correlated with gains in motor activity measures (r = 0.22-0.29, p < 0.05). ConclusionsAlthough cognitive and motor impairments may arise independently after stroke, their recovery processes appear partially linked. These findings underscore the importance of addressing both domains in rehabilitation and advancing understanding of shared mechanisms that support recovery across functional systems.

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.