BMC Neurology

IntroductionVentriculoperitoneal (VP) and Lumboperitoneal (LP) shunts are the most common treatments for Idiopathic Normal Pressure Hydrocephalus (iNPH). Shunt procedure choice is generally based on surgeon on preference rather than evidence. We performed a systematic review and meta-analysis to address this gap for evidence-based shunt selection in iNPH treatment. MethodsPublications on post-operative outcomes for LP and VP shunts in iNPH were identified in MEDLINE and EMBASE. Papers were selected based on pre-specified inclusion and exclusion criteria and meta-analysis was conducted for outcome measures after shunt procedure. Results17 papers were included. LP Shunt patients showed greater cognitive improvement with an average increase of 2.00 points (95% CI: 1.08; 2.93, p < 0.0001) on their MMSE score post-operatively compared to VP shunt patients who improved on average by 1.30 points (95% CI: 0.81; 1.79, p < 0.0001). The LP group had considerable heterogeneity (I2 = 66.42%, p = 0.0003) whereas the VP shunt group had minimal heterogeneity (I2 = 0.00%, p = 0.8447) reflecting more uniformity across its included studies. For overall symptomatic improvement measured by the iNPHGS, VP shunts patients demonstrated a larger reduction in overall symptom scores with an average decrease of 2.91 points (95% CI: -3.78; -2.05, p < 0.0001) but with a high heterogeneity (I2 = 79.12%, p = 0.0012) compared to LP shunt patients with an average reduction of 1.91 points (95% CI: -2.31; -1.51, p < 0.0001) with no detected heterogeneity (I2 = 0.00%, p = 0.8454). ConclusionsOur findings demonstrate that LP and VP shunts show differing patterns of improvement across the cognitive domain and the broader iNPH triad, with LP shunting showing greater cognitive improvement and VP shunting showing greater overall symptomatic improvement. These differences represent a signal warranting further investigation, specifically whether symptom profiles should inform shunt selection.

ObjectiveTo identify patient characteristics and medication factors associated with perceived comfort with migraine treatments and control of migraine symptoms. BackgroundPatient perceptions of migraine treatment influence adherence and outcomes, yet little is known about their underlying drivers. Our study objective was to identify clinical features of migraine associated with comfort and perceived control of symptoms, and medication classes associated with higher patient comfort and efficacy. MethodsParticipants in the Headache Assessment via Digital Platform in United States (HeAD-US) study completed a cross-sectional survey on demographics, migraine burden, mood, disability, and medication use. Comfort and control were defined using corresponding items from the Migraine Treatment Optimization Questionnaire (mTOQ-6) and categorized as "high" or "low". We compared patient characteristics, clinical features, and medication classes by reported comfort and control. ResultsAmong 5717 participants (mean age 41.5 {+/-} 13.1 years, 91.2% female), 58.5% reported high comfort with migraine treatments, while only 27.5% reported high control of migraine symptoms. High comfort was associated with fewer monthly headache days (mean 9.9 vs. 14.2, p<0.001), lower migraine symptom severity (median MSSS 18 vs. 19, p<0.001), and lower disability (MIDAS severe: 72.7% vs 91.2%, p<0.001) and mood symptom scores (PHQ-4 severe: 9.5% vs. 21.0%, p<0.001). High perceived control showed similar associations with employment (OR=1.25, CI 1.15-1.48, p = 0.013), monthly headache days (mean 9.0 vs 12.7,p<0.001), migraine severity (median MSSS 18 vs 19, p<0.0001), disability (severe: 66.0 vs 85.8, p<0.001), and mood symptoms (severe: 7.6 vs 16.9, p<0.001) but was not associated with income or education. Among those on monotherapy, gepants and triptans were associated with higher comfort and efficacy than OTC medications or opioids/barbiturates. For preventive therapy, beta blockers and botulinum toxin were associated with the lowest perceived comfort and efficacy. ConclusionPerceived comfort and control were linked to headache frequency, severity and disability and mood symptoms. Medication class use influenced perceptions, with gepants and triptans rated most favorably. These findings underscore the importance of incorporating patient perspectives into treatment planning, with particular attention to mood, disability, and choice of medication.

BackgroundPsychedelics exert widespread effects on brain activity, but their impact on motor function is unclear. This is clinically relevant given the emerging interest in psychedelic-assisted physical therapy for disorders of motor function. This studys primary objectives examined the feasibility and safety of administering movement tasks following low-to-moderate doses of psilocybin in healthy volunteers. MethodsHealthy participants were randomly assigned three psilocybin doses consisting of either (1) 5mg, 10mg, and 15mg, or (2) 10mg, 15mg, and 20mg, with at least one week between doses. Movement tasks were administered during the acute drug effects. Participants, physiotherapists, and statisticians were blinded to the dosing order. Feasibility was assessed by evaluating completion of the de Morton Mobility Index and Functional Movement Exploration (measures of gross motor function). Safety outcomes included vital signs and adverse events. Additional exploratory motor outcomes included the Action Research Arm Test (assessing dexterity), Box and Block Test (Original and Modified versions) (combining dexterity with motor speed), Digit Symbol Substitution Test (combining motor speed with intellectual functions), and Reaction Time Ruler Drop Test (assessing reaction time). The 5-Dimensional Altered States of Consciousness and Ego-Dissolution Inventory assessed changes in states of consciousness. Blinding efficacy was assessed by asking participants and physiotherapists to guess the doses administered. ResultsThirteen participants were randomised: seven to 5mg, 10mg, and 15mg; six to 10mg, 15mg, and 20mg. One participant was unable to complete several movement tasks at 20mg. Nausea (n=8, 62%) and headache (n=7, 54%) were the most common adverse events. No serious adverse events or adverse events related to movement task administration occurred. Median values [interquartile ranges] remained near-perfect across doses for the de Morton Mobility Index (92.5-100.0 [85.0-100.0]), Functional Movement Exploration (100.0 [96.0-100.0]), and Action Research Arm Test (56.0-57.0 [52.0-57.0]). Baseline Box and Block Test (Original) median scores (65.0 [60.0-67.0]) improved to 79.0 [70.0-83.0] at 5mg and 4.5 hours post-dose (5mg-4.5H), and worsened to 57.5 [51.0-64.0] at 20mg-1.5H. Baseline Box and Block Test (Modified) median scores (48.0 [47.0-53.0]) worsened to 43.0 [35.0-45.0] at 20mg-1.5H. Baseline Digit Symbol Substitution Test median scores (73.0 [66.0-77.0]) improved to 87.0 [81.0-90.0] at 10mg-4.5H, and worsened to 62.0 [54.0-86.0] at 20mg-1.5H. Reaction Time Ruler Drop Test scores lacked consistent dose-related changes across participants. Changes in states of consciousness were greatest at 20mg. Participants and physiotherapists correctly guessed the administered dose 53% and 50% of the time, respectively. ConclusionsMovement tasks were feasible during psilocybin dosing up to 15mg. Impairments emerged at 20mg in tasks that combined motor and additional cognitive functions. These findings support the feasibility of performing complex movement tasks during psilocybin dosing and will inform the conduct of trials utilising psilocybin-assisted physical rehabilitation in neuropsychiatric disorders. Trial RegistrationAustralian New Zealand Clinical Trials Registry: ACTRN12621000560897 Date registered: 12 May 2021 URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381526&isReview=true Key FindingsO_LIThere is growing interest for psychedelic-assisted physical therapy in neuropsychiatric disorders of motor dysfunction, however, the impact of psychedelics on motor function remains unclear. C_LIO_LIThis study investigated the feasibility, safety, and impact on motor function of administering movement tasks following low-to-moderate doses of psilocybin in healthy volunteers. C_LIO_LIThese findings support the feasibility of performing complex movement tasks during psilocybin dosing up to 15mg and will inform the conduct of trials utilising psilocybin-assisted physical therapy in neuropsychiatric disorders. C_LI

BackgroundMiddle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative strategy for the management of chronic subdural hematoma (cSDH). Although accumulating studies suggest potential benefit, uncertainty remains regarding its safety profile, recurrence-prevention effect, and the reliability of adverse event reporting. This systematic review and meta-analysis re-evaluate contemporary evidence, incorporating new randomized trials and large observational cohorts. MethodsThis systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO. PubMed, Scopus, Web of Science Core Collection, Embase, and CENTRAL were searched from inception to 12 September 2025 without language restrictions. Randomized controlled trials, prospective or retrospective cohort studies, and non-randomized clinical studies evaluating middle meningeal artery embolization (MMAE) for chronic subdural hematoma were eligible. Data extraction and risk-of-bias assessment were performed independently using Joanna Briggs Institute appraisal tools. Where outcomes were sufficiently comparable, quantitative synthesis was undertaken using random-effects single-arm proportion meta-analysis with logit transformation. Recurrence after MMAE was pooled across observational studies and MMAE arms of randomized trials with available event-level data, with prespecified subgroup analyses by study design. Mortality was synthesized from randomized trials reporting event-level data within a [&le;]90-day follow-up window. Complication rates and technical success were analyzed descriptively due to heterogeneity in definitions and follow-up durations. ResultsNineteen studies met eligibility criteria, including seven randomized controlled trials, sixteen retrospective cohorts, and one prospective cohort, comprising an elderly and medically complex population (mean ages 61-89 years). Common comorbidities included hypertension, diabetes, cardiovascular and cerebrovascular disease, renal dysfunction, and antithrombotic use. Technical success of middle meningeal artery embolization (MMAE) was consistently high, with a pooled success rate of 100% (95% CI 0.99-1.00; I2 = 0%). Recurrence after MMAE was consistently low across randomized and observational studies, including high-risk populations, and was uniformly lower than in comparator groups. Radiographic outcomes showed substantial hematoma volume reduction and high rates of complete or near-complete resolution, with favorable functional recovery. Complications were uncommon but heterogeneous; the pooled overall complication rate was 14% (95% CI 0.08-0.21). Pooled 90-day all-cause mortality from randomized trials was 8% (95% CI 0.07-0.10; I2 = 0%). ConclusionMMAE is a safe and effective adjunctive or alternative treatment for chronic subdural hematoma, demonstrating a reproducible and clinically meaningful reduction in recurrence across randomized and observational datasets with homogeneous outcome definitions. However, variability in adverse event reporting, insufficient documentation of rare complications, and inconsistent definitions of radiographic versus clinical recurrence highlight the need for standardized outcome frameworks and harmonized follow-up protocols. Future well-designed trials with robust adverse event adjudication are essential to define the long-term safety profile of MMAE and to guide its optimal integration into cSDH management pathways.

Structured AbstractO_ST_ABSObjectiveC_ST_ABSGeneral cognitive ability (g), a latent variable derived from cognitive data, can predict life outcomes (e.g., educational attainment and occupational success) among neurologically healthy individuals. The value of g for predicting post-stroke functional outcomes is unknown. We addressed this gap here. MethodWe derived g using exploratory structural equation modeling of 15 neuropsychological tests administered to 112 patients with stroke, 69 of whom also had functional outcome data (42 men; mean age = 53.23 years (SD = 10.54)). We used logistic regressions to compare g and individual tests in terms of their ability to predict the Functional Assessment Measure (FAM) and the Functional Independence Measure (FIM; motor and cognitive subscales) at 12 months post-stroke. Resultsg was a statistically significant predictor of FAM (X2 = 6.86, p = 0.013) and the cognitive (X2 = 11.48, p = 0.002) but not motor FIM subscale (X2 = 0.93, p = 0.154). Individual tests varied widely in terms of predictive utility (X2 range: 0.07-21.03), with the most robust predictors being measures of visuospatial functions. ConclusionsAcute measures of cognition, including g, can predict functional independence 12 months after stroke. g and visuospatial ability measures were the most robust predictors. Statement of Research SignificanceO_ST_ABSResearch QuestionC_ST_ABSGeneral cognitive ability (or, g) is composite score based on scores on performance-based tests of cognition. In neurologically healthy people, g can predict long-term life outcomes. The value of g measured acutely after stroke for predicting functional outcomes one year later is unknown. We evaluated the utility of g for predicting post-stroke functional outcomes. Main FindingsA g factor based on neuropsychological test data collected from acute stroke patients was a statistically significant predictor of cognitive and psychosocial functional outcomes one year later. Lower g after stroke was linked to higher chance of needing functional assistance. Study ContributionsWhen neuropsychological test data are collected in the acute post-stroke period, it may be possible to derive a g factor score based on those data. Our findings suggest that this g factor score could help clinicians tailor treatment strategies to a patients expected long-term functional outcomes.

BackgroundNeurointerventional therapy is a cornerstone in managing head and neck vascular disorders, with cerebral angiography serving as its fundamental diagnostic and therapeutic backbone. However, manual cerebral angiography is associated with several inherent limitations. While existing robotic-assisted systems have shown promise in mitigating some of these issues, they face challenges such as limited compatibility, lengthy setup times, and a lack of high-quality real-world evidence. MethodsThe ERASE trial is a multicenter, prospective, randomized controlled trial (RCT). A total of 450 eligible patients will be enrolled from six comprehensive stroke centers in China and randomized 1:1 to either the robotic-assisted group or the control group. Both groups use the Seldinger technique for femoral/radial artery access. Operators undergo standardized training on the robotic system, and all patients are followed up at baseline, end of surgery, 24 hours postoperatively, and 7 days post-discharge. ResultsThe primary efficacy outcome is the clinical success rate. The primary safety outcome is the incidence of perioperative/postoperative complications (e.g., vascular perforation, dissection, pseudoaneurysm), serious adverse events, and device malfunctions. Secondary outcomes include technical failure rate, overall procedural time, pre-puncture setup time, target vessel super-selective catheterization time, digital subtraction angiography fluoroscopy time, participant radiation doses and contrast agent volume. A key safety endpoint is the rate of new asymptomatic cerebral infarctions detected via postoperative brain MRI-diffusion-weighted imaging. ConclusionsAs the RCT focusing on the YDHB-NS01 Ver 2.0 system, the ERASE trial addresses critical unmet needs in neurointerventional practice and will generate high-quality evidence for robotic-assisted cerebral angiography. Trial registration number: ClinicalTrials.gov NCT07182188. Clinical Perspective1) What Is New? This multicenter RCT evaluates the YDHB-NS01 Ver 2.0 robotic-assisted system and provides rigorous evidence on its safety and efficacy compared with manual cerebral angiography, while validating targeted design enhancements addressing prior systems shortcomings 2) What Are the Clinical Implications? The study s findings could standardize the clinical application of robotic-assisted cerebral angiography and inspire further research on refining robotic interventional workflows to improve patient outcomes and provider safety.

BackgroundPersistent Spinal Pain Syndrome (PSPS) type II represents a challenging clinical entity with limited therapeutic options. Various spinal cord stimulation (SCS) modalities have emerged as potential treatments, but their comparative effectiveness remains unclear. ObjectiveOur goal in this paper is to systematically evaluate and compare the efficacy of different SCS modalities in patients with PSPS type II through meta-analysis of available randomized controlled trials. Evidence ReviewWe conducted a systematic review following PRISMA guidelines, searching major databases for randomized controlled trials evaluating SCS modalities in PSPS type II patients until the end of May 2025(search updated on October 3rd). Primary outcomes included pain intensity (VAS) and functional disability (ODI) at 6 and 12 months. Subgroup analyses compared tonic versus burst stimulation and high-frequency versus low-frequency SCS. FindingsNine randomized controlled trials were included, encompassing 565 patients across different SCS modalities. For the primary outcome of clinically meaningful pain relief ([&ge;]50% reduction), pooled analysis demonstrated that 45% (95% CI: 18-75%, I{superscript 2} = 92.2%) of patients achieved this threshold for back pain and 55% (95% CI: 45-65%, I{superscript 2} = 0%) for leg pain. Subgroup analysis revealed significant differences in back pain responder rates by stimulation modality: High-frequency SCS demonstrated responder rates of 92% (95% CI: 79-98%) versus 28% (95% CI: 13-49%) for conventional frequencies (p < 0.001). For leg pain, no significant difference was observed between tonic (51%, 95% CI: 37-65%) and burst stimulation (60%, 95% CI: 45-74%, p = 0.36) and mean VAS scores demonstrated significantly lower pain with high-frequency SCS (13.30, 95% CI: 8.82-17.78) compared to conventional frequency (28.42, 95% CI: 24.02-32.88, p<0.0001). For back pain, mean VAS scores decreased from a baseline of 73.03 to 41.67 (95% CI: 36.12-47.22, I{superscript 2}=22.8%) at 6 months and remained stable at 35.66 (95% CI: 25.39-45.93, I{superscript 2}=75.0%) at 12 months. Leg pain showed more pronounced improvement, with VAS scores declining from a baseline of 61.81 to 23.75 (95% CI: 17.69-29.81, I{superscript 2}=78.8%) at 6 months and 29.16 (95% CI: 24.81-33.52, I{superscript 2}=0%) at 12 months). Meta-regression identified longer pain duration and older age as positive predictors of response, while higher baseline leg pain predicted lower responder rates. Serious adverse events occurred in 10%, with a 16% revision surgery rate. Only two studies demonstrated a low risk of bias across all domains. ConclusionsCurrent evidence demonstrates that various SCS modalities provide clinically meaningful pain relief in PSPS type II patients, with approximately half achieving [&ge;]50% pain reduction. High-frequency SCS shows significantly superior responder rates for back pain compared to conventional tonic stimulation, while burst stimulation yields significantly superior reductions in continuous pain intensity metrics. However, the limited number of studies, substantial heterogeneity, and lack of head-to-head comparisons prevent definitive recommendations regarding optimal stimulation parameters. Future large-scale randomized trials with standardized protocols and responder-based outcomes are needed to establish evidence-based treatment algorithms for PSPS type II patients.

IntroductionPatients undergoing anterior cruciate ligament (ACL) reconstruction experience substantial postoperative pain, which delays recovery and leads to both immediate and long-term opioid use. In other knee procedures, infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) has demonstrated analgesic and opioid reducing effects. However, the effect in patients undergoing ACL reconstruction has not been investigated. We aimed to investigate the real-world effect of IPACK in patients undergoing ACL reconstruction on immediate postoperative opioid consumption. ParticipantsIn this single-centre difference-in-differences cohort study, all patients who underwent ACL reconstruction surgery at Bispebjerg Hospital, Denmark, from 1 February 2024 to 30 June 2025 are included. The study further includes a similar reference cohort, comprising all patients who underwent trochleaplasty, Elmslie-Trillat, or medial patellofemoral ligament reconstruction during the same period, and at the same hospital. InterventionThe primary exposure is the implementation of IPACK as part of perioperative management for ACL reconstruction on 1 January 2025. The IPACK was performed under ultrasound guidance, immediately before surgery, administering 20 mL of ropivacaine 0.5% between the popliteal artery and the posterior knee capsule. OutcomesThe primary outcome is the cumulative opioid consumption from surgical incision to 2 hours postoperatively. Secondary outcomes include the cumulative opioid consumption from incision to 24 hours postoperatively, the worst reported pain score at 0-24h postoperatively, occurrence of postoperative nausea or vomiting (PONV) 0-24h postoperatively, length of PACU stay, length of hospital stay, and nerve injuries. As an exploratory outcome, carbon dioxide emissions will be investigated. Statistical analysisThe main analysis will be a standard two-way fixed effects DiD regression assessing the changes occurring at the time of implementation of IPACK in the ACL cohort, with adjustment for the underlying time trend. Continuous outcomes are reported as mean difference (95% confidence interval [CI]), and binary outcomes as absolute and relative risks (95% CI).

BackgroundPatients understanding of pain and its biopsychosocial nature is thought to be important in order to optimize treatment decisions and treatment outcomes. A validated Spanish questionnaire for patients based on a biopsychosocial model assessing knowledge and attitudes of pain was unavailable. The aim of this study is to validate the Spanish version of the PACKA, to have a Spanish questionnaire to be used among pain patients in both clinical and research settings. MethodsPhase 1: forward and backward translation, and expert committee; Phase 2: a cross-sectional and longitudinal study among Fibromyalgia patients. In the cross-sectional study (n =330), internal consistency, structural validity and hypothesis testing were examined. ResultsThe 26-item PACKA was translated and validated in 4 stages. Acceptable internal consistency and test-retest reliability was demonstrated. Internal consistency: Cronbachs =0.776. Hypotheses testing: associations with the Neurophysiology of Pain Questionnaire r =0.31. ConclusionThis Spanish version of PACKA has shown acceptable validity and reliability in patients with Fibromyalgia. Further use and reanalysis of the questionnaire might improve this preliminary validation.

AbstractsO_ST_ABSBackgroundC_ST_ABSSelf-management is essential for stroke survivors to maintain a healthy lifestyle and reduce recurrence risk. Although theory-based self-management interventions are widely recommended, the theoretical frameworks underpinning them and their comparative effectiveness remain unclear. AimsTo systematically identify the theories, models, and frameworks (TMFs) used in self-management interventions for stroke survivors, to explore how they guide interventions, and evaluate their effectiveness on self-management behaviors and self-efficacy. MethodsPubMed, Embase, Web of Science, ProQuest Health & Medical Collection and the Cochrane Library were searched from inception to July 15, 2025. Randomized controlled trials or quasi-experimental studies evaluating theory-based self-management interventions for stroke survivors were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias (Cochrane RoB 2.0). Meta-analyses were performed using random-effects models. ResultsFrom 11,495 records, 32 studies with 3,212 participants were included. Sixteen distinct TMFs were identified; self-efficacy theory was most frequent (13/32), followed by social cognitive theory (6/32). All TMFs were middle-range theories. Meta-analysis showed TMFs-based interventions significantly improved self-management behaviors (SMD = 4.26, 95%CI: 0.20-8.31, I{superscript 2} = 98.2%) and self-efficacy (SMD = 0.60, 95%CI: 0.32-0.88, I{superscript 2} = 72.8%). However, the effect for behaviors is likely inflated due to extreme heterogeneity and theoretical diversity. Theory-specific analysis of self-efficacy theory (k = 8) confirmed significant effects on self-efficacy (SMD = 0.64, 95%CI: 0.21-1.08). ConclusionsThis review identified 16 distinct theoretical models; self-efficacy theory was most frequently applied, followed by social cognitive theory. Theory-based interventions significantly improved self-management behaviours and self-efficacy.

BackgroundOxycodone is widely prescribed for managing acute pain in emergency departments (ED), but the appropriateness of this prescription is not fully established. Although concerns about opioid misuse and dependence drive efforts to reduce inappropriate prescribing, there is increasing recognition of the importance of adequate pain management. Therefore, it is essential to develop appropriate prescribing criteria that balance the risks and benefits of opioids, ensuring their benefits are maximised while minimising potential harm. ObjectiveFollowing the recommended format for a research protocol paper, this protocol describes the process and methods used to develop evidence-based criteria for oxycodone prescribing in the ED, informed by scientific evidence and expert clinical judgment, using the RAND/UCLA Appropriateness Method. MethodThe process will be carried out in sequential stages. First, scope and key terms will be defined, and then a targeted literature review will be conducted to synthesise available evidence. Subsequently, based on this synthesis and the investigator teams clinical insights, clinical scenarios will be developed in collaboration with field experts. A multidisciplinary panel comprising specialists in emergency medicine, emergency nurses, and pharmacists will evaluate these scenarios in two rounds. Each scenario will be rated on a 1-9 scale, where 1 indicates that harm outweighs benefit and 9 indicates that benefit outweighs harm. The median rating score will fall between 1 and 9, where 1-3 without disagreement is inappropriate, 4-6 without disagreement is uncertain, and 7-9 without disagreement is appropriate. Disagreement is defined as at least three experts scoring in both extremes. Final scenario ratings will be presented according to their assessed appropriateness and used to inform appropriateness criteria for prescribing oxycodone in the adult ED. ConclussionThe RAND/UCLA Appropriateness Method offers a systematic and evidence-informed framework for developing prescribing criteria to support the appropriate use of oxycodone in adult ED.

PurposeMyasthenia gravis (MG) is a rare neuromuscular disease. In-person appointments in specialized centers are not readily available, especially on short notice. The purpose of this study was to analyze patient-specialist communication through a telemedical platform. MethodsIn a randomized controlled study 45 MG patients were observed over three months. The intervention group (N=30) was monitored via a mobile application ( app) that enabled chat function and assessed MG-specific outcome measures and data from external devices. We quantitatively evaluated communication patterns for patients and specialists from the chat. Controls (N=15) received standard of care. Perceived MG specialist accessibility and contact with physicians outside the study team regarding MG-related issues was assessed in both groups. FindingsIn total, MG specialists were contacted a median of six times per patient via the chat concerning medical (54.5%), technical (25.3%), organizational (19.1%), and other (1.1%) topics. Specialists initiated contact a median of eight times per patient, most frequently addressing medical concerns (49.4%), 38.4% of which were recommendations for medication changes. Specialists also addressed technical (40.0%), organizational (9.4%) and other (1.3%) issues. Contacts with physicians outside the study team did not differ significantly between groups. Perceived specialist accessibility was rated significantly higher with telemedical support by the intervention group. ConclusionsMG patients have a significant demand for timely advice especially concerning treatment recommendations. Future studies should evaluate the potential of telemedical solutions to prevent worsening of symptoms. Trial registrationThe study was registered under DRKS00029907 on August 19, 2022.

BackgroundStroke is the leading cause of adult-onset disability, with impairments across motor, language, cognitive, swallowing, mood, and gait domains. Non-invasive brain stimulation techniques like repetitive transcranial magnetic stimulation (rTMS) have emerged as promising tools to augment rehabilitation therapies to improve post-stroke impairments. This systematic review and meta-analysis will evaluate the efficacy of rTMS for post-stroke recovery across multiple functional domains and identify moderators of treatment response. MethodsWe systematically searched five databases for randomized controlled trials (RCTs) published from February 16, 2004 to July 1, 2024. Eligible studies compared active rTMS with sham rTMS in stroke survivors and reported validated outcomes. Risk of bias was assessed using the Cochrane Collaboration tool. Random-effects meta-analyses were conducted for each outcome domain. Subgroup analyses examined timing of intervention (acute/subacute, early chronic, late chronic). Meta-regression evaluated continuous moderators, including stimulation intensity (% resting motor threshold), number of sessions, age, and sex. ResultsFifty-two studies met inclusion criteria (2,472 participants, mean age 59.8 years; 35.1% female). rTMS was associated with significant improvements in motor function (UE-FMA, MD = 4.68, 95% CI [2.18, 6.54]), language (CCAT, MD = 0.62, 95% CI [0.22, 1.01]), cognition (MMSE, MD = 2.12, 95% CI [1.34, 2.92]), dysphagia (PAS, MD = -1.50, 95% CI [-2.40, -0.57]), and mood (HAMD-17, MD = -2.34, 95% CI [-4.38, -0.30]), but not gait. Subgroup analyses showed significantly larger treatment effects when rTMS was delivered within 3 months post-stroke, particularly for motor outcomes. Meta-regression indicated that stimulation intensity, number of sessions, and participant demographic distribution were not significant moderators. ConclusionsrTMS improves post-stroke outcomes across multiple functional domains, with the strongest evidence for motor recovery in the acute/subacute phase. Standardization of protocols and larger trials in understudied domains are needed to maximize therapeutic outcomes.

BackgroundTraumatic spinal cord injury (SCI) is a major cause of long-term neurological disability, with limited pharmacological therapies targeting secondary inflammatory and neurodegenerative injury mechanisms. Minocycline, a tetracycline derivative with anti-inflammatory and neuroprotective properties, has been investigated in both experimental and clinical settings; however, its therapeutic efficacy in acute traumatic SCI remains uncertain. MethodsA systematic review was conducted in accordance with PRISMA 2020 guidelines. Major electronic databases were comprehensively searched to identify preclinical animal studies and human clinical studies evaluating minocycline, alone or in combination therapies, for acute traumatic SCI. Risk of bias was assessed using Joanna Briggs Institute (JBI) critical appraisal tools tailored to study design. Qualitative synthesis included all eligible studies, while quantitative synthesis was restricted to clinical studies reporting extractable effect estimates for neurological improvement. ResultsA total of 11 studies met inclusion criteria for qualitative synthesis, including experimental animal studies and human clinical investigations. Preclinical studies demonstrated consistent biological effects of minocycline on inflammatory markers, oxidative stress, and histopathological outcomes, particularly in combination therapies, although functional recovery with minocycline monotherapy was inconsistent. Clinical studies indicated that minocycline was generally well tolerated; however, most trials did not demonstrate statistically significant improvements in neurological or functional outcomes. Only two clinical studies provided suitable data for meta-analysis, yielding a pooled odds ratio of 1.70 (95% CI 0.95-3.06) for neurological improvement, which did not reach statistical significance. ConclusionCurrent evidence suggests that while minocycline exhibits promising biological activity and an acceptable safety profile in acute traumatic SCI, robust clinical efficacy has not been conclusively demonstrated. Well-designed, adequately powered randomized controlled trials with standardized outcome reporting are required to determine whether these biological effects translate into meaningful functional recovery.

INTRODUCTIONCore cognitive deficits in iNPH include slowed information processing, psychomotor slowing and executive dysfunction. However, the cognitive benefits of iNPH treatment with shunt surgery are not well understood. This review synthesised evidence on cognitive assessment methods and outcomes following shunt surgery in iNPH. METHODSPubMed, Scopus, PsycINFO and Web of Science were searched for peer-reviewed studies including adults with iNPH who underwent shunt surgery and had within-subject cognitive evaluations pre- and post-operatively. Key data were extracted and study quality was assessed. Random-effects meta-analyses were performed on pooled baseline and post-shunt difference scores for frequently reported cognitive tests with comparable data. RESULTSOf 1,876 records, 195 met the inclusion criteria, comprising 11,445 patients. Cognitive evaluation methods ranged from subjective reports and NPH grading scales to brief screening tools and comprehensive test batteries. Over 193 distinct tests were reported and 54.4% of studies did not formally assess any core iNPH cognitive deficits. Post-shunt improvement rates, follow-up times and criteria for defining improvement varied widely. Eighty-five studies contributed data to meta-analyses of ten outcomes. Pooled estimates indicated post-shunt cognitive improvement, with Trail Making Test-A, Grooved Pegboard-Dominant and Trail Making Test-B showing changes exceeding thresholds for clinically significant improvement. CONCLUSIONSCognitive assessment in iNPH is highly heterogeneous and frequently omits core domains, limiting detection of treatment effects. When domain-relevant cognitive measures are used, shunt surgery is associated with statistically and clinically significant cognitive improvement. These findings highlight the need for standardised iNPH-specific cognitive evaluation tools with validated criteria for detecting clinically meaningful change and have direct implications for clinical assessment, interpretation of shunt response and the selection of cognitive endpoints in future interventional studies. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSCognitive outcomes after shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) have been inconsistently reported, with cognitive improvement reported less reliably than gait outcomes, in the context of highly variable assessment practices across centres. What this study addsThis systematic review of 195 studies (11,445 patients) shows substantial heterogeneity in iNPH cognitive assessment and demonstrates that when tests sensitive to frontal-subcortical dysfunction are used, shunt surgery is associated with statistically and clinically meaningful cognitive improvement. Widely used dementia screening tools, including the MMSE and MoCA, show changes largely within expected practice-effect ranges and do not adequately capture core iNPH cognitive deficits. How this study might affect research, practice or policyThese findings demonstrate the need to standardise cognitive assessment in iNPH using appropriate iNPH-specific tools with validated metrics for determining clinically meaningful improvement. This will enable robust trial endpoints and accurate evaluation of cognitive benefits of shunting in routine clinical practice.

BackgroundChronic pain affects 28 million UK adults. While physiotherapy and social prescribing are recognised as effective, evidence on integrating them remains limited. Digital biomarkers could objectively assess movement quality and pain physiology to support clinical decision-making. ObjectivesTo explore whether simple kinematic and electroencephalography (EEG) biomarkers can discriminate between correct versus incorrect exercise performance and high versus low pain states, and to consider how such tools might streamline social prescribing pathways for chronic pain. MethodsSecondary analyses of two open datasets: (1) KERAAL kinematic dataset: 900 recordings of trunk rotation exercises (21 participants) labelled "correct" or "incorrect" by physiotherapists; (2) EEG dataset: 145 resting-state recordings (100 individuals with chronic pain) categorised as high or low pain. Classification models (logistic regression, support vector machines, gradient boosting) were trained on extracted kinematic features (range of motion, smoothness, symmetry, jerk, coordination) and EEG features (frontal alpha asymmetry, connectivity, sample entropy, aperiodic exponents). Performance was assessed using accuracy, F1 score, AUC and calibration curves. ResultsKinematic classification achieved near-perfect performance: 100% accuracy and AUC = 1.00. Key features were shoulder abduction peak angle, symmetry index and jerk. EEG classification was strong: 93% accuracy, 0.97 AUC. Global theta and alpha connectivity, frontal alpha asymmetry and sample entropy were most informative. ConclusionAutomated kinematic and EEG markers can reliably differentiate correct exercise performance and current pain state. These digital biomarkers could inform physiotherapists and link workers when triaging patients into social prescribing programmes. Integrating digital assessment into social prescribing may reduce unnecessary appointments, enhance self-management and align care with the biopsychosocial model. Further studies should validate the approach in broader populations and examine implementation in real-world social prescribing services.

BackgroundHealth literacy (HL) influences communication quality, treatment adherence, and equity in care. However, how general practitioners (GPs) recognize and respond to patients HL in everyday clinical reasoning remains insufficiently understood. ObjectiveTo investigate how Danish GPs incorporate patients health literacy into decisions about prescribing pain medication for chronic musculoskeletal pain, using insights from surveys, interviews, and a literature review. MethodsA mixed-methods design combined survey data from 39 Danish GPs, seven qualitative interviews, and a synthesis of 14 studies on HL in general practice. The literature was used to contextualize and contrast the empirical findings. Quantitative data were analyzed descriptively, while qualitative data underwent thematic analysis. All three datasets were integrated through mixed-methods comparison to assess convergence, divergence, and complementarity. ResultsAcross the integrated survey, interview, and literature findings, HL emerged as a largely implicit but consistent element of GP decision-making. In the Danish survey and interview data, some GPs explicitly reported considering HL in prescribing decisions, yet interviews showed that HL more often influenced clinical reasoning indirectly through intuition and conversation. GPs adapted communication, explanations, and treatment planning to their perceptions of patient understanding, but these adjustments were rarely guided by structured tools or frameworks. Conversation appeared as the main approach for assessing comprehension, echoing patterns observed in the literature. Many Danish GPs perceived most patients as competent and self-managing, a perception the literature cautions may mask hidden comprehension challenges. Finally, both local interviews and existing studies highlighted digital HL as an emerging theme, with GPs commonly managing patients online health information through conversational reframing rather than formal strategies. ConclusionsHL is tacitly integrated into GP reasoning but remains under-recognized as a professional skill. Making HL an explicit component of communication training, reflective practice, and prescribing guidelines could improve patient understanding, shared decision-making, and treatment equity.

BackgroundChronic autoimmune diseases such as Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), Multifocal Motor Neuropathy (MMN), and Thyroid Eye Disease (TED) impose a considerable burden on affected individuals. Patient-reported outcome measures (PROMs)--both disease-specific and generic--are widely used to assess functioning, quality of life, and treatment effects in these populations. However, most PROMs currently lack reference values derived from the general population, limiting the interpretability of patient scores. ObjectiveThe GENESIS (GENEral population normS--An International Survey) study aims to establish general population norms for a range of PROMs used in CIDP, MMN, and TED across six countries: Germany, Italy, Japan, Spain, the United Kingdom, and the United States. These norms will improve patient score interpretation and help quantify unmet needs in patients with these rare autoimmune diseases. MethodsGENESIS is an observational, cross-sectional, online survey of the adult general population (N=21,000). Participants will be recruited to be representative by age, gender, region, and education. The survey includes validated instruments such as the EQ-5D-5L, I-RODS, MMN-RODS, CAP-PRI, GO-QoL, BPI-SF, RT-FSS, FACIT-Fatigue, HADS, and WPAI, along with items on demographics, caregiver need, and healthcare utilization. To reduce respondent burden, participants will be randomized into two groups, each completing a subset of the full questionnaire. A subset of respondents (n=2,333) will be re-surveyed after two months to support psychometric validation. Data will be analyzed descriptively to generate normative values for each PROM by country and in aggregate. Results and DisseminationData collection is scheduled to begin in August 2025, with results expected by Q4 2025. Findings will be disseminated via peer-reviewed publications and conference presentations. ConclusionGENESIS will provide foundational normative data across six countries for PROMs commonly used in rare autoimmune diseases. These data will support more meaningful interpretation of PROM scores in both clinical practice and research settings.

ObjectiveA comparative analysis was conducted on the rehabilitation effects of limb functions in patients with post-stroke yawning-induced parakinesia brachialis oscitansysis (PBO), patients without PBO, and patients whose PBO naturally disappeared after the onset of the disease. MethodsThe study included ischemic stroke patients diagnosed and treated in our hospital from March 2024 to June 2024. Patients were divided into two groups: the PBO group and the non-PBO group, based on whether PBO was administered. Propensity score matching was employed to account for all covariates and perform a 1:2 matching to balance the baseline characteristics of the two groups. The matched data were used for subsequent analysis to observe the Lovett scores and FMA scores of the two groups 3 months after the onset. For 33 patients with PBO, they were divided into two groups: the persistent group and the disappearing group, based on whether the PBO lasted for more than 1 month. The Lovett scores and FMA scores of the two groups were observed 3 months after the onset. ResultsAfter propensity score matching, there were 26 patients in the PBO group and 52 patients in the non-PBO group. The baseline characteristics of the two groups were basically balanced, and the difference was not statistically significant (P>0.05). Compared with the non-PBO group, the Lovett scores and FMA scores of the PBO group 3 months after the onset were higher, and the difference was statistically significant (P < 0.05). Compared with the PBO persistent group, the FMA score of the PBO disappearing group 3 months after the onset was higher than that of the persistent group, and the difference was statistically significant (P < 0.05). There was no statistically significant difference in Lovett muscle strength between the two groups (P > 0.05). ConclusionThe functional recovery of patients with PBO was better than that of patients without PBO manifestation 3 months after the initial diagnosis. Moreover, patients whose PBO appeared first and then disappeared had better functional recovery than those whose PBO persisted.

We describe the design of the first non-pharmacological prevention trials of Parkinsons Disease worldwide: the randomised controlled Slow-SPEED trials. The three trials examine the feasibility and preliminary efficacy of a gamified, remotely administered exercise intervention vs. active control program over 18-36 months in the Netherlands (n=110), United Kingdom (n=110) and United States (n=600). Each trial focuses on a complementary prodromal subgroup: isolated/idiopathic REM sleep behavioural disorder, hyposmia, or LRRK2/GBA1 mutation carriers. These trials will provide unique insights for large-scale Parkinsons Disease prevention studies.