Disability and Rehabilitation

Background: Task challenge is recognized as a core principle of neurorehabilitation and is frequently mentioned within stroke rehabilitation guidelines. However, guidance for operationalizing challenge in clinical practice remains limited. Examining how therapists and people with stroke currently use challenge in practice may help address this gap. Objective: To examine how challenge is operationalized in routine stroke rehabilitation practice. Methods: This study used focused video analysis to examine eight video-recorded stroke rehabilitation sessions across physiotherapy, occupational therapy, and speech-language therapy contexts. Video data were supplemented by observational memos. Analysis was conducted iteratively through four stages: immersion, detailed transcription, in-depth episode analysis, and comparative analysis. These stages enabled examination of material, embodied, social, and contextual aspects of challenge-related interactions as they unfolded during rehabilitation. Results: Twenty individuals, comprising four patient-therapist dyads and four triads participated. Challenge was operationalized through three intersecting practices: (i) Structuring challenge-related work through temporal phases determined when challenge was introduced, experienced, and consolidated across the session and within tasks; (ii) Establishing the macro-architecture of challenge guided what and how it was operationalized by constructing a challenge plan, shaping an optimal bandwidth by tailoring challenge to the persons abilities and/or experiences, and facilitating its transfer beyond the session; (iii) Modulating challenge through micro-calibrations involved moment-to-moment adjustments (e.g., adapting physical assistance, communication style, environmental setup) to modulate active practice, navigate differing perspectives, and cultivate an atmosphere conducive to engaging with challenge. These overarching practices were dynamically enacted through a range of explicit and implicit practices. Conclusion: Challenge in stroke rehabilitation is not merely a task parameter; it is operationalized through an interplay of explicit and implicit practices that structure and enable its responsive implementation. Considering challenge through these practices may help therapists and people with stroke co-construct meaningful experiences of challenge, both within and beyond formal stroke rehabilitation sessions.

Background: Long COVID can result in persistent functional limitations, pain, and fatigue after acute COVID-19. Evidence describing these outcomes among survivors in Bangladesh remains limited. This study assessed functional impairment, pain, and fatigue and explored factors associated with these outcomes among long COVID survivors in Bangladesh. Methods: This multisite cross-sectional study included 240 adults with a history of COVID-19. Functional status was assessed using the Post-COVID-19 Functional Status Scale. Pain and fatigue were assessed using the Brief Pain Inventory and Brief Fatigue Inventory, respectively. Descriptive statistics, Spearman correlation, and regression analyses were used to examine functional impairment and factors associated with pain and fatigue outcomes. Results: Functional limitations were common, with moderate limitation particularly frequent in basic activities of daily living, while slight limitation predominated across several other domains. Pain and fatigue measures showed significant correlations. Older age was associated with greater impairment in basic activities of daily living. Booster vaccination was associated with lower pain and fatigue scores, although the booster subgroup was small (n = 17). Tobacco non-use was also associated with lower scores across several pain and fatigue domains. Physiotherapy-related variables showed associations with some functional and symptom outcomes; however, these findings may reflect confounding by indication because participants with greater impairment or more complex symptoms may have been more likely to receive rehabilitation. Conclusions: Long COVID survivors in Bangladesh experience substantial and multidimensional functional, pain, and fatigue burdens. The findings support a comprehensive assessment that considers functional status, pain, fatigue, and participation together. Longitudinal studies with larger samples and standardized rehabilitation protocols are needed to clarify symptom trajectories, identify potentially modifiable factors, and evaluate the effectiveness of individualized rehabilitation interventions.

Background: As musculoskeletal physiotherapy evolves toward advanced practice and direct access, evaluating high levels of clinical competence has become pressing. Quality indicators underpin large-scale audit systems, but indicators discriminating advanced competence remain insufficiently defined. Objective: To identify and characterize indicators capable of discriminating high levels of clinical competence in musculoskeletal physiotherapy. Methods: A modified Delphi comprised an exploratory pre-round and two consensus rounds. Experienced French-speaking musculoskeletal physiotherapists were recruited using an expertise scoring grid. Candidate indicators, generated from open-ended responses and existing quality indicators, were rated on 6-point Likert scales for relevance, formulation, and tool adequacy. Consensus was predefined as [≥]75% of ratings [≥]5. Results: Thirty-two experts completed the pre-round, 29 the first round, and 27 the second (84% retention), generating 49 candidate indicators. Thirteen reached consensus for relevance, and 10 also for formulation. Retained indicators primarily reflected advanced clinical reasoning: real-time adaptation, hypothesis prioritization, decision-making under uncertainty, and error management. Only one outcome indicator reached consensus: clinical performance weighted by case complexity. Conclusion: High levels of clinical competence in musculoskeletal physiotherapy appear characterized less by standardized outcome attainment than by managing complexity, uncertainty, and error through advanced clinical reasoning. These findings may inform competence-oriented audit and feedback systems. Trials registration: Not applicable.

Aims: Our primary aim was to determine the immediate effects of using a supported stepping device on the real-time locomotor behavior of pre-walking infants with Down syndrome (DS). Our secondary aim was to characterize the role of the caregiver in facilitating infant locomotor behavior by quantifying infant-initiated and caregiver-initiated walker movement, and to test whether walker movement encourages stepping behavior. Methods: Pre-walking infants with DS played with their caregiver in two conditions--with and without assistance from a wheeled suspension walker. To examine changes across development, we recorded infants across one to four sessions from 10 to 19 months of age. Results: Across developmental stages, we found that suspension walkers robustly increased infants' locomotor behavior: The walker increased upright time, percent time stepping, stepping rate, upright bout rate, percent time locomoting, and total bout rate. Most walker movement was initiated by caregivers, and infants stepped more while the walker was moving compared to stationary. Conclusions: Even without practice, pre-walking infants with DS were able to take advantage of the suspension walker to increase their locomotor behavior. Caregivers facilitated infants' activity by moving the walker. Future work will examine the potential of overground suspension walkers for home-based intervention.

Aim. To evaluate the accuracy, run-to-run consistency, and agreement of large language models on the Ukrainian Integrated Licensing Examination Krok 2 for the Specialty of Physical Therapy. Materials and Methods. Five cloud-based LLMs (ChatGPT-5.5, Claude 5 Sonnet, Gemini 3.5 Flash, Grok 4, DeepSeek-V3) were evaluated using 150 Ukrainian-language multiple-choice questions from the official Krok 2 database. Each model completed two independent runs with identical inputs. Accuracy (with 95% confidence intervals, Wilson method), run-to-run consistency, and agreement were assessed. Statistical analysis included Cohen's {kappa}, Cochran's Q and pairwise McNemar tests with Holm-Bonferroni correction. Results. All models achieved >80% accuracy in both runs, exceeding the passing threshold of [≥]64%. In the first run, accuracy ranged from 80.00% (DeepSeek-V3) to 93.33% (Gemini 3.5 Flash); in the second run, from 82.67% (Claude 5 Sonnet) to 88.67% (Gemini 3.5 Flash). In the first run significant differences were observed between Gemini 3.5 Flash and Grok 4 (93.33% vs 84.00%; p=0.0022) and DeepSeek-V3 (93.33% vs 80.00%; p=0.0001). There were no statistically significant differences between models in the second run. R2R consistency exceeded 90% for all models with the highest in ChatGPT-5.5 (98.67%) and lowest in DeepSeek-V3 (90.00%). Cohen's {kappa} ranged from 0.64 to 0.94, indicating substantial to almost perfect agreement. The stability of LLMs' response correctness across two runs ranged from 77.33% (DeepSeek-V3) to 88.00% (Gemini 3.5 Flash). Conclusions. All LLMs demonstrated high performance on Ukrainian-language Krok 2 examination tasks. Gemini 3.5 Flash showed the highest accuracy in both runs and response correctness stability while ChatGPT-5.5 exhibited the greatest response consistency and agreement. Although the accuracy and stability of LLM responses may be interrelated, they represent distinct aspects of model performance. This highlights the need for a comprehensive approach to evaluating LLMs. The findings indicate the potential of LLMs as an auxiliary tool in the professional practice of physical therapy specialists.

Background: School-based implementation of robot-assisted walking may support increased physical and social participation for children with physical disabilities, but evidence from an adequately powered trial is needed. This pilot study evaluated implementation strategies and study procedures to inform a future definitive trial. Methods: Participants were randomized to 12-weeks of robot-assisted walking or control, with subsequent crossover to the other condition. In the intervention arm, targeted dose was 75 minutes of robot-assisted walking, spread across three days/week. Implementation strategies for the child's classroom team included educational materials, centralized technical assistance, school champions, and on-going training. Implementation strategy evaluation focused on intervention protocol feasibility (i.e., weekly device use, troubleshooting) and fidelity (documentation of implementation strategy modifications). Preliminary estimates participation goal changes were obtained using the Canadian Occupational Performance Measure (COPM) 'Performance' scale (/10). Results: Eight children with neurodevelopmental physical disabilities participated (mean age 3.5, SD 0.5 years). Device use varied from 2.1 to 4.3 days/week (median 3.3) with a range of 48 to 96 minutes/week (median 80). Target use of >= 3 days/week was achieved for 66% of weeks and met the >=75-minute target for 33% of weeks. Troubleshooting occurred in 18.5% of sessions. Two implementation strategies were modified to improve feasibility. COPM mean change was 3.56 (SD 1.07) for robot-assisted walking and 2.11 (SD 2.41) for control (dz=0.74). Conclusions: This pilot study provided preliminary evidence regarding both the feasibility of robot-assisted walking implementation in schools and its potential effectiveness for children with physical disabilities. Findings support progression to a definitive trial.

Background: Safely walking through complex environments requires the use of visual information to plan and regulate steps, while managing competing cognitive demands. Age-related changes in visual control of gait and executive function may contribute to unsafe stepping behaviour, particularly under cognitive load. Route previewing may support visual motor planning, but its effects under dual task conditions in older adults are not well understood. Research Question: Does cognitive dual tasking influence gait and gaze behaviour during adaptive walking in older adults, and does previewing the walking route before gait initiation mitigate these effects? Methods: Thirty nine community dwelling older adults (Mage=73.4 years, SD=8.1; 14 male) completed four adaptive walking conditions, combining single and dual-task walking with and without previewing. Per condition, participants completed six trials across different 8-m long coloured walking routes. Gait characteristics were assessed using an instrumented walkway and video-analysis, while gaze behaviour was recorded using mobile eye tracking. Cognitive load was manipulated using a serial subtraction task. Gait and gaze outcomes were evaluated using linear mixed effects models. Results: Dual task performance significantly increased stepping errors, cross-steps, and double limb support, while reducing stride length (p < .001). It also significantly increased the number and duration of task irrelevant fixations (p < .001). After previewing, participants exhibited more efficient gaze behaviour, as evidenced by looking further ahead (larger forward gaze transitions) and fewer irrelevant gaze fixations (p < .002). Significant Task-by-Preview interactions revealed that previewing mitigated the negative effects of dual-tasking on stepping errors and cross steps (p < .001). Significance: Route previewing prior to gait initiation attenuates negative effects of cognitive load on adaptive gait in older adults, likely by supporting visual motor planning. These findings highlight the potential value of simple visual planning interventions for improving adaptive gait in older adults.

Frailty assessment is important while awaiting lung transplantation (LTx), as frailty is associated with disability and death before and after LTx. We assessed known risk factors and/or frailty indicators in frail, pre-frail, and non-frail patients according to the Short Physical Performance Battery (SPPB) and the Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI), and evaluated the value of SHARE-FI as a proxy to detect frail patients. Frailty was assessed using SPPB and SHARE-FI in 82 patients on a waiting list for LTx. Demographic, anthropomorphic, and clinical variables were collected, and patients underwent respiratory/cardiorespiratory, biochemical, and quadriceps muscle performance assessments. The mean age was 57.3 {+/-} 9.4 years. Chronic obstructive pulmonary disease (COPD) (41.5%) and interstitial lung disease (ILD) (30.6%) were the most common indications for LTx. Four (4.9%), 13 (15.9%), and 65 (79.3%) patients were classified as frail, pre-frail, and non-frail by SPPB, respectively. These figures were 26 (31.7%), 41 (50%), and 15 (18.3%) with SHARE-FI. SPPB found differences between frail/pre-frail and non-frail patients in physical performance (6-minute walking distance) and muscular assessment, while SHARE-FI found differences in age, 6-minute walking distance, and oxygen saturation, and a trend in muscular strength. For COPD and ILD, frailty discrimination was better with SPPB. Concordance between the two measurements was weak, although all SPPB-frail ILD patients were detected by SHARE-FI. In patients awaiting LTx, SPPB showed better discrimination than SHARE-FI for COPD and ILD. SHARE-FI seems appropriate as a preliminary screening instrument for patients with ILD.

Abstract Background Community-based exercise may support physical and cognitive recovery after stroke, but the preferences of stakeholders involved in receiving, supporting and delivering these programmes are poorly understood. This study piloted a discrete choice experiment (DCE) that aimed to evaluate stroke survivors, carers, clinicians, and fitness instructors preferences for community-based exercise programmes for stroke survivors. The pilot aimed to assess the feasibility of conducting and analysing data for a larger-scale study and inform the sample size for a definitive DCE. Methods A DCE design was developed using literature reviews, stakeholder consultations, and evaluations of current services. Six attributes were included in the design: location, price, session frequency, individualisation, carer involvement, and recovery. Sixteen Bayesian D-optimal choice sets were developed, then blocked into two sets of eight to reduce cognitive burden. Main-effects were analysed using a mixed logit model, and stakeholder differences were explored using a conditional logit interaction model. Willingness to pay was also calculated. Results Overall, 161 respondents started the survey and 106 (66%) fully completed it. Stakeholders significantly preferred programmes that were delivered at a leisure centre, lower priced, individualised, had carer-specific sessions and offered greater chances of recovery. The largest willingness-to-pay estimates were {pound}49.41/ month for 80% chance of meaningful recovery vs 20%, and {pound}18.61/ month for leisure centre delivery vs online. Significant preference heterogeneity was identified in the main-effects model. Exploratory stakeholder interactions suggested clinicians were more price sensitive and placed greater importance on recovery and carer-specific sessions than stroke survivors, while fitness instructors placed greater importance on programme location and recovery. Carer interaction estimates were unstable due to the small subgroup sample. Conclusions The pilot supported the feasibility of the DCE design and analytical approach but identified limitations in the recruitment methods and survey completion. Addition of face-to-face recruitment methods are recommended for a larger-scale study. A larger sample size is required to investigate differences in preferences between stakeholder groups.

BackgroundTrunk flexor and extensor measurement tools are useful for measuring progress throughout the identification, treatment and management of spinal pathologies. Handheld dynamometry is popular amongst clinicians due to its convenience. However, poor standardisation of the testing position can lead to suboptimal intra-rater reliability, which consequently reduces the validity of the results. The VALD ForceFrame Strength Testing System is a portable and standardized hybrid strength-assessment system that quantifies strength and power outputs. ObjectiveThis study aims to assess the test-retest reliability of isometric trunk flexion and extension strength using the ForceFrame testing technology. MethodsA total of 29 healthy participants undertook two testing sessions, each requiring them to perform maximal isometric trunk flexion and extension using the ForceFrame. Test re-test reliability was assessed using the Intraclass Correlation Coefficient (ICC), and the standard error of measure (SEM) was used to calculate the minimum detectable change. ResultsExcellent reliability was observed for both trunk flexion (ICC 0.92; 95% CI 0.83-0.96) and extension (ICC 0.93; 95% CI 0.86-0.97) tests, and the minimum detectable changes observed were 71.35N and 101.20N, respectively. ConclusionsThe results from this study suggest that the VALD force frame offers clinicians a reliable method of assessing change in trunk flexor and extensor strength.

Introduction Low back pain (LBP) is a common leading cause of functional disability in adults worldwide, presenting with Modic changes that are visible within the endplates of the vertebral body under magnetic resonance imaging (MRI). Modic changes (MC) are not just a coincidental imaging finding; they reflect underlying pathology that needs treatment focus. This study aimed to ascertain the prevalence and patterns of Modic changes in the lumbar spine among adult patients with a history of low back pain attending the Kilimanjaro Christian Medical Centre (KCMC) Orthopedic clinic. Methods A descriptive cross-sectional study was conducted at the KCMC orthopedic clinic from 2nd October 2024 to 30th May 2025. Data from adult patients with a history of low back pain who had undergone lumbar spine MRI were collected, cleaned, and analyzed in SPSS (version 25). Categorical variables were summarized by frequency and proportion, while continuous variables were summarized using the mean and standard deviation. Frequency tables, histograms, and pie charts were used for results presentation. Results Of the 283 patients enrolled in the study, the mean age was (57.2 {+/-}15.7) years, with the majority (145; 51.2%) being aged > 59 years. Most patients, 203 (71.7%), were females, while 176 (62.2%) were married, and 142 (50.2%) were overweight. The prevalence of MC on the lumbar spine among patients with a history of low back pain was 66.4% (n=188). Among patients with lumbar spine MC, the majority, 112 (59.6%), were aged over 59 years, and 125 (66.5%) had lumbar spine MC type II, which was the most predominant compared to other types of MC. Conclusion Modic changes on the lumbar spine are prevalent in adult patients with low back pain, particularly those over 59 years, with type II being the most common. Healthcare professionals and policymakers should recognize Modic changes as clinically relevant findings that require consideration in the management of patients with a history of low back pain rather than dismissing them as mere incidental or coincidental observations.

Background: Excessive inflammation in early phases post-ischemic stroke is associated with poor long-term outcome and increased stroke recurrence. Interventions capable of downregulating persistent states of inflammation could improve recovery and prevent secondary stroke. Cardiovascular exercise (CE) has well-established anti-inflammatory effects but its capacity to attenuate the exaggerated inflammatory response triggered by ischemic stroke is unclear. Methods: We investigated the impact of eight weeks of CE on the serum concentration of inflammatory mediators in the early subacute phase post-stroke. Seventy-one patients with firstever ischemic stroke were randomly assigned to moderate-to-vigorous CE (n=45) or standard care (SC) (n=26). Concentrations of CRP, IL-6, IL-8, IL-10, TNF- and IL-1{beta} were measured at baseline and after the interventions. Differences between groups were analyzed with linear mixed models adjusted for age and sex. Results: Compared with the CE group, the SC group showed significant increases in IL-6 ({beta}=0.585, 95% CI=0.164-1.006, p=0.0073), IL-8 ({beta}=0.160, 95% CI=0.004-0.317, p=0.0447), and TNF- ({beta}=0.0845, 95% CI=0.0137-0.1553, p=0.0206). The SC group also showed greater increases in CRP ({beta}=0.250, 95% CI=-0.407, 0.906, p=0.4499) and IL-10 ({beta}=0.251, 95% CI=-0.024, 0.527, p=0.0729) but group differences were not significant. IL-1{beta} levels remained stable and differences between groups were not significant ({beta}=-0.008, 95% CI=-0.058, 0.042, p=0.7618). Conclusions: When introduced in the early subacute phase of stroke recovery, moderate-tovigorous CE mitigates increases in inflammation, but the effect differs across mediators. To what extent reducing the inflammatory response in the early stages post-stroke with CE can impact longterm recovery and stroke recurrence needs to be determined.

Objective: To examine changes in function and pain interference among patients utilizing a digital exercise therapy application (DETA) for knee and shoulder pain. Methods: We conducted a retrospective analysis of data from patients utilizing a DETA for non-operative knee and shoulder pain. Primary outcomes for the study were 8-week changes in physical function, measured using the PROMIS-Physical Function (knee pain) and PROMIS-Upper Extremity Function (shoulder pain); and pain interference, measured using the PROMIS-Pain Interference. Data on patient characteristics was used to examine outcomes among specific patient subgroups. Results: We observed a 3.5 point (SD: 7.8) increase in function and a 3.9 point (SD: 7.5) decrease in pain interference overall (p<0.001), with changes in function and pain interference surpassing the minimal clinically important difference for patients with knee and shoulder pain. Patients with knee pain experienced greater improvements in function than those with shoulder pain (p=0.02), as did patients who report moderate-high levels of exertion during exercise compared to those reporting low levels of exertion (p=0.05). We saw greater reductions in pain interference among those with higher education (p=0.03), those with more acute symptoms (p=0.01) and those reporting moderate-high levels of exercise exertion (p=0.02). Conclusion: We observed a clinically meaningful improvement in pain interference and function among patients utilizing a DETA for knee and shoulder pain. Patients with knee pain, higher levels of education, more acute symptoms, and those who reported higher levels of exertion with exercise experienced the greatest changes in function and pain. Impact Statement: This study indicates that self-guided interventions, such as those delivered through a DETA, may be beneficial for patients with knee and shoulder pain. These results may also inform the development of patient profiles that can be used to identify patients most appropriate to receive care through a mobile application.

Background: Post-stroke spasticity is commonly assessed using the Modified Ashworth Scale (MAS), despite its limited objectivity and variable reliability. This study introduces ScoreE, a novel isokinetic dynamometry-derived metric designed to quantify elbow and wrist flexor hyper-resistance by comparing patients torque-angle profiles with a healthy reference corridor. Methods: Thirty-five post-stroke patients and twenty-one healthy controls were included. Elbow and wrist hyper-resistance was assessed using the MAS and an isokinetic dynamometer in two testing conditions: seated on the dynamometer chair (ergo chair) and seated in the patient wheelchair. Two dynamometer-derived metrics were analyzed: ScoreE and peak torque (PeakT). Feasibility, inter-rater and test-retest reliability, and associations with MAS grades were assessed. Exploratory PRE-POST changes following a 10-min local vibration session were also described. Results: ScoreE showed good to excellent inter-rater and test-retest reliability across joints and testing conditions. Inter-rater ICCs ranged from 0.81 to 0.89, and test-retest ICCs from 0.76 to 0.93. PeakT showed moderate to good reliability. In contrast, MAS agreement was lower and more variable. ScoreE showed moderate associations with MAS grades, particularly at the elbow, with weaker and less consistent associations at the wrist. MAS assessment was faster, but all assessments were well tolerated, with median pain ratings of 0/10 in all testing conditions. PRE-POST vibration changes were small and heterogeneous, preventing formal assessment of responsiveness. Conclusion: ScoreE provides a reliable, objective, and visually interpretable quantification of post-stroke elbow and wrist flexor hyper-resistance. By comparing the full torque-angle profile with normative data, this approach preserves information on both the magnitude and angular span of abnormal resistance, supporting its potential for targeted longitudinal monitoring.

Background: Gait propulsion (anterior ground reaction force) is commonly impaired after stroke. Force plates and wearable sensors can quantify propulsion but are not routinely available in clinical settings. Walking speed alone does not adequately capture the heterogeneity of propulsion deficits. Objective: To determine whether standardized clinical measures can estimate post-stroke propulsion metrics and classify propulsion impairment. Methods: Forty individuals post-stroke participated: 33 for model development and cross-validation (11 with repeated observations for longitudinal validation) and 7 for independent-cohort validation. Clinical measures included the 6-Minute Walk Test (6MWT), comfortable walking speed (CWS), Functional Gait Assessment (FGA), Fugl-Meyer Assessment of the Lower Extremity (FMA-LE), Short Physical Performance Battery (SPPB), Timed Up and Go test (TUG), and stroke chronicity. Regression models were developed to estimate three propulsion metrics: paretic propulsion peak and impulse, and interlimb propulsion symmetry. Model performance was evaluated using R2 and RMSE. Propulsion impairment was classified from symmetry estimates using a prespecified cutoff of 31.5%, with classification accuracy reported. Results: Models using the 6MWT, SPPB, TUG, and chronicity estimated paretic propulsion peak (R2 = 0.77, RMSE = 3.00 %body weight) and impulse (R2 = 0.81, RMSE = 0.65 %body weight {middle dot} %stance phase). FMA-LE, SPPB, TUG, and chronicity estimated propulsion symmetry (R2 = 0.75, RMSE = 8.56%) and classified propulsion impairment with 84.8% accuracy. Classification accuracy was 91.7% in longitudinal validation and 85.7% in independent-cohort validation. Conclusions: A multidomain clinical assessment framework may support practical and accurate estimation and classification of post-stroke propulsion impairment in clinical settings where specialized instrumentation is unavailable.

Background Owing to a growing body of evidence, clinical guidelines now recommend exercise for stroke survivors. However, many stroke survivors are physically inactive and may need more support to engage with exercise in the community. There are between 600-800 exercise referral schemes in the United Kingdom, but engagement from stroke survivors is very low. This study aimed to evaluate the accessibility of exercise referral schemes in England to stroke survivors. Methods A cross-sectional, online survey was conducted throughout England. All 317 local authorities in England were invited to participate. Geospatial mapping was used to visualise the accessibility of exercise referral schemes across England. Data on scheme design and delivery parameters were analysed descriptively. Results Data were collected from 147 local authorities. Exercise referral schemes were offered in 134 local authorities, of which, stroke survivors were able to access 128. However, stroke-specific schemes were available in only 17 local authorities. Significant variations in exercise referral scheme design and delivery were identified across the country. Only two consistencies were found between schemes: the involvement of fitness instructors, and the lack of transport provision. The capacity of exercise referral schemes did not correlate with the general population, stroke population, or stroke prevalence within a local authority. Conclusions Exercise referral schemes are widely available across England, and the majority are open to stroke survivors. However, stroke-specific services are very limited and there is substantial variation in scheme eligibility, capacity, costs, and referral pathways. These inconsistencies, paired with the lack of transport provision, may explain the low uptake of exercise referral schemes within the stroke population.

Background: System One Model is designed for structured decision-making and can provide probabilistic outputs, but their performance in domain-specific physical therapy tasks has not been established. Objective: To evaluate the performance and potential utility of Jev, a System One Model, for professional knowledge-based selection tasks in physical therapy by comparing it with GPT-4o. Methods: A total of 380 multiple-choice questions from the 2024 and 2025 Korean Physical Therapist Licensing Examinations were independently submitted to Jev and GPT-4o. The outcomes included answer accuracy, subgroup performance, output validity, API response latency, token usage, estimated API cost, and Jev's prediction uncertainty. A retrospective probability-based model-cascading simulation was also performed. Results: Jev correctly answered 282 questions (74.2%), whereas GPT-4o answered 326 (85.8%), a difference of -11.6 percentage points. Jev produced valid structured responses for all questions, whereas GPT-4o produced three invalid responses. Jev's selected-answer probabilities discriminated correct from incorrect answers (AUROC = 0.866), and accuracy reached 99.3% when probabilities were greater than or equal to 0.90. The median API response latency was 0.94 s for Jev and 1.06 s for GPT-4o, with estimated costs of US$0.008 and US$0.161, respectively. At a retrospective cascading threshold of 0.70, accuracy was 86.6% with 175 simulated GPT-4o calls. Conclusion: Jev showed lower overall accuracy than GPT-4o but provided reliable structured outputs, informative prediction probabilities, lower latency, and lower estimated cost. Its probabilistic outputs warrant further prospective evaluation for selective model escalation and decision-support workflows in physical therapy.

Background: Temporomandibular disorders (TMDs) are common conditions in the general population. Several therapeutic approaches are available, but there is no consensus on the most effective, particularly in physiotherapy. Objectives: To assess the efficacy of manual therapy (MT) and therapeutic exercise (TE) in reducing pain in patients with TMDs. Methods: Four databases (MEDLINE, PEDro, EMBASE, CINAHL) were searched up to March 2025. We included randomized controlled trials (RCTs) evaluating the effects of MT and/or TE in individuals with TMDs, compared to any other rehabilitation treatment, with pain intensity as the primary outcome. The methodological quality was assessed using the PEDro scale. A network meta-analysis was performed to compare the effectiveness of different rehabilitative approaches. Results: 25 RCTs for a total of 1,540 people were included. The main comparisons were: MT and/or TE vs no treatment or placebo, occlusal splint, and instrumental physiotherapy. In most studies, MT and TE were more effective than controls in reducing pain. However, the network meta-analysis indicated that multimodal treatments were the most effective. The methodological quality of the included studies ranged from 3 to 9 points. Conclusion: MT and TE are effective strategies for reducing pain in subjects with TMDs and should be used as first-line interventions before more invasive treatments; the combination of dry needling and manual therapy appears to be the most effective approach. Nonetheless, the variability in study quality suggests that further high-quality research is needed to confirm these findings.

Background: Knee osteoarthritis (OA) is characterized by progressive joint degradation and altered gait biomechanics. Inter-limb load asymmetry during daily living tasks may accelerate joint deterioration, particularly when combined with physical fatigue. This study investigates the relationship between daily physical fatigue and inter-limb load asymmetry patterns during functional activities in individuals with unilateral knee OA. Objective: To evaluate the impact of fatigue on inter-limb load asymmetry and joint loading rates during daily living tasks in patients with unilateral knee osteoarthritis, and to identify biomechanical and clinical factors associated with load distribution patterns. Methods: One hundred eighteen participants with unilateral knee OA (mean age 62.6 (SD 7.4) years, BMI 29.9 (SD 4.2) kg/m2) completed biomechanical assessments during non-fatigued and fatigued conditions. Ground reaction force measurements were obtained during functional tasks including stair climbing, sit-to-stand transitions, and level walking. Load asymmetry was quantified as the inter-limb difference in peak vertical ground reaction forces. Statistical analysis was conducted using Python (v3.9), including paired t-tests, analysis of variance, and linear regression modeling. Results: Participants demonstrated significantly increased load asymmetry under fatigue conditions (mean difference 8.7% (SD 12.3) %, p < 0.001). Fatigue-induced asymmetry was task-dependent, with stair negotiation showing the greatest increase (11.2% (SD 14.1) %). Peak loading rates on the affected knee were inversely correlated with time-to-peak load during fatigued conditions (r = -0.68, p < 0.001). Disease severity (WOMAC score) and age significantly predicted asymmetry changes (R2 = 0.52, p < 0.001). Conclusions: Physical fatigue exacerbates inter-limb load asymmetry in unilateral knee OA, potentially accelerating joint degeneration. Task-specific interventions targeting fatigue management and load redistribution may improve long-term outcomes. Future longitudinal studies should examine the temporal relationship between acute biomechanical changes and progressive structural joint damage. Keywords: Knee osteoarthritis, load asymmetry, fatigue, biomechanics, ground reaction forces, functional tasks.

Current evidence supports resistance training for stroke recovery but autonomic dysregulation following stroke can lead to exaggerated fluctuations in blood pressure (BP) in response to exercise, thus challenging perceptions about safety and feasibility of resistance exercise. This study compared the post-exercise BP response following a single bout of leg-press exercise between people with and without stroke. Data from 11 individuals with chronic stroke (age 39-76 years, 5 female, 1-9 years post-stroke) and 19 recreationally active controls (age 18-33 years, 11 female) were included. Brachial artery BP was measured before exercise and immediately following a single set of leg-press (8 repetitions, target rating of perceived exertion 5-7/10). The difference between pre- and post-exercise BP was calculated and compared between groups using an independent t-test of equal variance. Additionally, a two-way analysis of covariance was used to examine potential cofounding effects of activity level and baseline BP on between group differences in BP response. No group differences were observed in post-exercise change in systolic (mean difference=3.61 mmHg, 95%CI:-8.36, 15.57, p=0.54); and diastolic (mean difference=5.38 mmHg, 95%CI:-6.11, 16.86, p=0.35) BP. Results were unchanged after controlling for baseline BP, and activity levels. Our work suggests that individuals with and without chronic stroke experience similar acute BP responses immediately following resistance exercise; however, work with more appropriately matched controls and greater sample sizes is needed to support these findings. Future studies may elucidate mechanisms related to the acute cardiovascular response to resistance exercise in individuals with stroke.