Neurorehabilitation and Neural Repair

BackgroundMild traumatic brain injury (mTBI) affects millions worldwide, with cognitive impairment substantially impacting daily functioning. Despite this burden, evidence-based non-pharmaceutical interventions remain lacking in clinical practice. Emerging evidence suggests aerobic exercise may improve post-mTBI cognition; however, the methodological limitations, particularly inadequate control groups, prevent definitive conclusions. ObjectiveThis pilot randomized controlled trial examined the feasibility and preliminary efficacy of a 12-week virtual exercise intervention for community-dwelling adults aged 18-55 years with mTBI within one year of injury. MethodsThirty-seven participants were randomized to either symptom-guided aerobic exercise or active balance control; both delivered virtually three times weekly for 30 minutes over 12 weeks. Primary outcomes assessed feasibility metrics; secondary outcomes examined cognitive function. ResultsOf enrolled participants, 75% completed the intervention with 94.2% session adherence and zero adverse events, demonstrating excellent feasibility and safety. The aerobic group demonstrated greater improvements in executive function compared to balance controls, with large effect sizes for TMT B-A difference scores in both post-intervention comparisons (Hedges g = 1.20, 95% CI [0.00, 2.41]) and Group x Time interactions (Hedges g = 1.38, 95% CI [0.27, 2.49]). Additionally, the aerobic group reported fewer sleep disturbances post intervention (g = 1.65, 95% CI [0.22, 3.09]). ConclusionThese findings establish that virtual, supervised, symptom-guided exercise interventions are feasible and safe for mTBI populations, with preliminary evidence suggesting aerobic exercise specifically benefits cognitive flexibility and sleep quality following mTBI. A fully powered randomized controlled trial is warranted to confirm these effects

This systematic review and meta-analysis primarily aimed to investigate the differential effectiveness of motor dual-task training (MDT) and cognitive dual-task training (CDT) on gait performance, balance control, and motor function in stroke survivors, and explored other important moderating factors such as stroke chronicity and individual functional profiles to inform a precision-based, personalized approach. Twenty-one RCTs involving 786 stroke survivors were included. Dual-task training demonstrated a medium overall beneficial effect on both temporal and spatial gait performance (SMD=0.50, p=0.03; SMD=0.5, p=0.04) and balance control (SMD=0.71, p=0.02), whereas no statistically significant improvement was observed in lower-extremity motor function. Subgroup analysis revealed that dual-task training modality was a critical determinant of treatment response. MDT was significantly superior for gait performance on both gait speed and stride length (SMD=1.15, p=0.01; SMD=0.89, p<0.01), while CDT demonstrated a significant benefit for balance control (SMD=0.59, p<0.01). Those modality-specific effects were further supported by meta-regression analysis. Stroke survivors at high risk of falls showed greater balance improvements following dual-task training. Furthermore, improvements in balance control and motor function were observed in non-chronic stroke survivors ([&le;]6 months post-stroke) but not in chronic stroke survivors. These results offer crucial prescriptive insights, guiding clinicians to match the dual-task modality and timing of intervention to the individual patients functional profile. However, the high heterogeneity among studies and the lack of direct comparative trials between CDT and MDT limit the conclusive strength of these recommendations.

AIMExecutive functions (EF) are advanced cognitive processes that play an essential role in daily functioning and may be of increased importance in cerebral palsy (CP), given the complexity of primary and associated impairments. This study aims to synthesize existing evidence on the relation between EF and domains of the International Classification of Functioning, Disability and Health (ICF) in individuals with CP, and to quantify the magnitude of these associations through meta-analysis. METHODA systematic literature search was conducted in eight electronic databases up to 14 July 2025, examining associations between EF and ICF domains in CP. EF outcomes were classified into inhibitory control, working memory, cognitive flexibility, higher-order EF, and EF composite scores. Outcome measures were mapped onto ICF domains: Body Functions and Structures, Activity, Participation, and Contextual factors, using the CP Core Sets. Correlation coefficients were transformed to Fishers z and entered into three-level meta-analyses to estimate pooled effect sizes. Single moderator analyses examined CP subtype, EF domain, EF assessment type, and mean age. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTSFrom 4637 identified records, 38 studies were included, comprising a total sample of 1633 participants with CP. There was substantial heterogeneity in CP subtype, participant age, and EF conceptualization, while the ICF Contextual factors domain was underrepresented. A medium-to-large association was found between EF and functioning across all ICF domains combined (r=0.26, p<0.001). Domain-specific analyses showed a medium association of EF with Body Functions and Structures (r=0.21, p<0.01), a medium-to-large association with Activity (r=0.38, p<0.001) and Participation (r=0.26, p<0.01). CP subtype and mean age significantly moderated the overall EF-functioning association, with mixed CP and younger age associated with stronger effects. INTERPRETATIONEF are meaningfully associated with multiple domains of functioning in individuals with CP. These findings support the relevance of routine EF assessment and suggest that EF are an important cognitive correlate to consider when addressing broader aspects of daily functioning. WHAT THIS PAPER ADDSO_LIExecutive functions (EF) showed medium-to-large associations with all ICF domains in people with cerebral palsy (CP) C_LIO_LIThe strongest and most consistent associations were found between EF and ICF Activity C_LIO_LIOverall associations highlight the relevance of EF as a meaningful intervention target in CP C_LI

BACKGROUNDThe recovery from sport-related concussion (SRC) is highly heterogenous, with many individuals experiencing symptoms that persist beyond typical recovery timeframes. The early identification of individuals at risk of prolonged symptoms is therefore critical to inform timely interventions and set realistic recovery expectations. Although acute symptom burden is one predictor of future symptom burden, reliance on self-reported measures may limit objectivity and reduce clinical utility in settings where symptom evaluation may be unreliable. In this prospective cohort study, we evaluated the discriminatory accuracy of the CogState Brief Battery, alone and in combination with the Sport Concussion Assessment Tool (SCAT), to classify Australian football players with SRC from Australian footballers without SRC at 24-hours post-injury/match. Furthermore, we examined whether CogState performance and symptom severity at 24 hours were associated with symptom outcomes at one-week post-injury. Adult amateur Australian football players (n=181) were recruited following SRC (n=109 SRC, 86% male) or after a non-injured match (n=72, 90% male). Participants completed the CogState Brief Battery, SCAT and Rivermead Post Concussion Questionnaire (RPQ) at 24-hours and one-week post-injury or match. Area under the receiver operating characteristic (AUC) analyses quantified the ability of 24-hour CogState task performance and SCAT symptom severity to distinguish SRC from controls. Linear regression models examined associations between CogState performance and symptom severity (SCAT and RPQ), within and across the 24-hour and one-week time points. Additional models evaluated whether combining 24-hour symptom severity assessments with CogState performance improved prediction of one-week symptom burden and symptomatic status. SCAT symptom severity demonstrated excellent discriminatory classification accuracy for SRC versus controls at 24-hours post-injury (AUC [95% CI]: 0.949 [0.916 - 0.981]). CogState task performance showed lower discriminatory accuracy but demonstrated fair classification and prognostic utility (e.g., Identification task AUC [95% CI]: 0.666 [0.582 - 0.750]). CogState performance at 24-hours was significantly associated with overall symptom severity at both 24-hours and one-week, as well as with symptom severity across individual symptom domains. In combined models, 24-hour symptom severity and CogState performance independently contributed to the prediction of symptomatic from asymptomatic individuals at one-week post-SRC (e.g., Identification task AUC [95% CI]: 0.721 [0.606 - 0.835] for classification based on <4 versus [&ge;]4 symptoms). These findings indicate that CogState performance at 24-hours post-SRC may serve as an objective adjunct to subjective symptom-based reporting, supporting both diagnosis and early prognostication in the clinical evaluation of SRC.

Background/ObjectivesWorking memory (WM) is a core component of cognition, supporting learning, reasoning, and daily functioning. In severe dyskinetic cerebral palsy (CP), profound motor impairments and involuntary movements make reliable cognitive assessment and access to cognitive interventions difficult. Eye-tracking technology offers an optimal computer interface for administering computerized cognitive assessments and training programs. This study explored the feasibility and efficacy of an adaptive, eye-tracking WM training in young people with severe dyskinetic CP. MethodsFour individuals with severe dyskinetic CP (age range 10-20 years old, 4 female) completed a 5-week intensive Cogmed WM training (five 30-45-minute sessions per week). Primary outcome was the Cogmed Improvement Index, reflecting near-transfer on trained WM tasks. Secondary outcomes included tests from the Wechsler Intelligence Scale for Children-Fifth Edition (WISC-V) to assess near-transfer on untrained WM tasks (Picture Span) and far-transfer to fluid reasoning (Matrix Reasoning, Figure Weights) and visual-spatial reasoning and planning (Visual Puzzles). Language comprehension was evaluated using the Computer-Based instrument for Low motor Language Testing (C-BiLLT), and executive functions behaviour using the Behavior Rating Inventory of Executive Function-2 (BRIEF-2). Descriptive statistics were used. ResultsParticipants completed 23-25 sessions (100% adherence). Cogmed Improvement Index increased by +10.5 to +27, and Picture Span by +12 to +21 post-intervention, mostly retained at 3-month follow-up. Far-transfer effects were variable, except language comprehension which improved consistently and remained stable. ConclusionsThese preliminary findings suggest the feasibility and potential cognitive benefits of adaptive eye-tracking WM training in severe dyskinetic CP. Randomized controlled trials are needed to confirm efficacy and generalisation effects.

BackgroundVirtual reality (VR) is increasingly used to enhance upper limb rehabilitation after stroke, yet its effectiveness during the acute and subacute phases--critical windows for neuroplasticity--remains unclear. This systematic review and meta-analysis evaluated the effects of VR-based interventions on upper limb outcomes in individuals within six months post-stroke and examined potential moderators of treatment response. MethodsFive databases and grey literature were searched to June 2024. Randomised controlled trials including adults [&le;]6 months post-stroke and comparing VR-based rehabilitation with non-technological interventions were eligible. Random-effects models were used to pool mean differences (MDs). Subgroup analyses, random-effects meta-regressions, and sensitivity analyses were performed when data allowed. Risk of bias (RoB2) and certainty of evidence (GRADE) were assessed. The review was registered in PROSPERO (CRD420251104058). ResultsTwenty-eight trials (1,310 participants) were included. VR significantly improved motor impairment (FM-UE: MD = 3.82, 95% CI 2.16 5.48; I{superscript 2} = 83.8%) and movement speed (WMFT-time: MD = -0.52, 95% CI -0.87 to -0.18; I{superscript 2} = 0%). No significant effects were found for ARAT, BBT, or handgrip strength. Heterogeneity was substantial across most outcomes. Moderator analyses identified an age-related reduction in VR effects on handgrip strength and a time-dose interaction for BBT. Sensitivity analyses confirmed the stability of pooled estimates. ConclusionsVR-based rehabilitation may enhance motor impairment and execution speed in the subacute phase after stroke, but evidence for functional improvements is limited. High heterogeneity, low methodological quality of included trials, and very low GRADE certainty for most outcomes warrant cautious interpretation. High-quality, standardised, and adequately powered trials are needed.

BackgroundConventional evaluations of digital health interventions typically assess mean treatment effects, potentially masking heterogeneous impacts across the functional recovery distribution. Patients at the lower and upper tails of recovery trajectories may respond differently to AI-enhanced telerehabilitation, yet standard regression approaches cannot capture these distributional nuances. ObjectiveThis study applied Recentered Influence Function (RIF) quantile regression with Oaxaca-Blinder decomposition to examine how AI-enhanced telerehabilitation differentially affects functional recovery outcomes across the entire distribution, and to decompose observed disparities into explained (composition) and unexplained (structure) components. MethodsWe analyzed data from 486 post-stroke patients across three rehabilitation centres in Singapore (January 2023-December 2025). Patients received either AI-enhanced telerehabilitation (n=241) incorporating natural language processing-based progress monitoring and adaptive exercise prescription, or standard care (n=245). RIF-quantile regressions were estimated at the 10th, 25th, 50th, 75th, and 90th quantiles of the Functional Independence Measure (FIM) score distribution. Oaxaca-Blinder decomposition at each quantile partitioned group differences into composition effects (attributable to differences in observable characteristics) and structure effects (attributable to differential returns to those characteristics). ResultsThe AI-enhanced telerehabilitation group demonstrated significantly greater FIM improvements across all quantiles, with the largest effects at the 10th quantile ({beta} = 12.74, 95% CI: 8.92-16.56, p < 0.001) and 25th quantile ({beta} = 9.83, 95% CI: 6.71-12.95, p < 0.001), diminishing at the 90th quantile ({beta} = 3.21, 95% CI: 0.88-5.54, p = 0.007). RIF decomposition revealed that at the 10th quantile, 68.3% of the treatment-control gap was attributable to structure effects, indicating that AI-enhanced telerehabilitation fundamentally altered recovery mechanisms for lower-performing patients rather than merely leveraging differences in patient characteristics. ConclusionsAI-enhanced telerehabilitation produces its most pronounced benefits among patients at the lower end of the functional recovery distribution, suggesting a potential mechanism for reducing outcome inequality in stroke rehabilitation. RIF-quantile regression decomposition offers a methodologically rigorous framework for understanding distributional treatment effects that are invisible to conventional mean-focused analyses.

PurposeFalls are common in adults with cerebral palsy (CP) and remain a significant concern. The study examined whether fall risk, fall incidence, and fall-related injuries differ by GMFCS level, CP type, age, and gender in adults with CP. Materials and MethodsA cross-sectional, retrospective chart review was conducted for adults 18 years or older with CP who received outpatient specialty care between December 2022 to May 2023. CP diagnosis and type were determined using ICD-10 codes; GMFCS level was extracted from electronic medical record notes. Fall risk was determined using the Morse Fall Scale (MFS), with scores [&ge;]45 indicating high fall risk. ResultsAmong 647 adults with CP, ambulatory individuals (GMFCS II-III) had significantly higher MFS scores and fall incidence than non-ambulatory individuals (p < 0.001). CP type and gender showed significant group differences, whereas age did not. Individuals with spastic diplegia and unspecified CP showed higher fall risk. Females were twice as likely as males to report a recent fall, although MFS scores did not differ by gender. Five injuries were reported among ambulatory individuals in the past three months. ConclusionsFindings highlight the importance of refining fall-risk assessment and prevention strategies for higher-risk groups.

PurposeEvidence suggests the contralesional cortico-reticulospinal tract (cCRST) upregulates after stroke, and that this upregulation correlates with worse motor function, suggesting it may be harmful for walking recovery. However, this relationship may be confounded by the extent of ipsilesional corticospinal tract (CST) and CRST damage, which could cause both greater cCRST upregulation and worse walking function. No previous studies have tested whether this confounding relationship exists, nor whether the amount of damage to the ipsilesional motor tracts is related to the amount of cCRST upregulation. We hypothesized that lower ipsilesional motor tract strength would: (1) be associated with greater cCRST compensation; and (2) explain the negative association between cCRST compensation and worse walking function. MethodsTen individuals with chronic stroke and ten age- and sex-matched controls completed diffusion MRI, from which quantitative anisotropy was derived to evaluate the strength of the ipsilesional and contralesional CRST and CST. Walking capacity was assessed using 6-minute walk distance (6MWD). Linear regressions were applied to examine relationships among ipsilesional corticomotor tract strength (iCRST and iCST combined), cCRST strength, and 6MWD. ResultsCompared with controls, participants with stroke had lower ipsilesional and higher contralesional strength for both motor tracts. Lower ipsilesional tract strength was associated with greater cCRST strength z-score (-0.12 SDs [-0.23, -0.02]). The unadjusted association between greater cCRST strength z-score and lower walking capacity (-72 meters [-136, -9]) was no longer present after adjusting for ipsilesional tract strength (-3 meters [-28, 23]). ConclusionsGreater damage to ipsilesional motor tracts (lower strength) was associated with increased cCRST strength. The extent of ipsilesional tract injury fully explained the negative association between cCRST strength and worse walking capacity. These findings suggest that cCRST upregulation is an adaptive compensation mediated by the extent of ipsilesional tract damage, and unlikely to impede walking recovery.

BackgroundSedentary behavior is highly prevalent following traumatic brain injury (TBI) and compounds existing risks for cardiovascular, neurodegenerative, and affective disorders. The cognitive and behavioral sequelae of TBI, including impaired decision-making, blunted reward processing, and cognitive fatigue, create particular barriers to adopting and maintaining an active lifestyle. Despite this, effective behavior change interventions targeting physical activity in community-dwelling TBI survivors remain scarce. Here, we evaluated the feasibility, compliance, and preliminary efficacy of a 12-week remotely delivered walking intervention combining planning, behavioral reminders, and monetary micro-incentives. MethodsFifty-six adults aged 40-80 years with a mild-to-moderate TBI diagnosed between 3 months and 15 years prior were randomized to either a planning, reminders, and micro-incentives intervention (n=23) or a health advice control condition (n=25). Participants wore a Fitbit Inspire 3 continuously throughout the study. Intervention participants completed weekly phone calls to plan five 30-minute walks for the following week, received daily text message or email reminders on planned walk days, and earned small monetary incentives upon walk completion. Control participants received weekly health education calls. Feasibility was assessed through recruitment, retention, and adverse event rates. Compliance was assessed via phone call completion rates and Fitbit wear time. Efficacy outcomes included weekly walk counts, walking duration, and step counts, modeled using Poisson generalized linear mixed models and linear mixed-effects models over 12 weeks. ResultsForty-eight participants completed the study (retention rate: 84.2%), with high phone call compliance in both groups (intervention: 98.4%; control: 98.1%). Intervention participants completed significantly more walks than controls from week 1 onward (aIRR = 5.33, 95% CI: 2.27-12.5, p < 0.001), with the group difference growing over time (interaction aIRR = 1.09 per week, 95% CI: 1.01-1.17, p = 0.029). Estimated marginal means indicated that intervention participants completed 5.5 times more walks than controls at week 1, increasing to 15.5 times more by week 12. The intervention group also walked significantly longer at week 1 (b = 62.14 min, 95% CI: 1.05-123.23, p = .046), with the advantage growing over time; by week 12, intervention participants walked 5.3 times longer than controls. Similarly, the intervention group accumulated significantly more steps during walks at week 1 (b = 4,779 steps, 95% CI: 45.50-9,513.00, p = .048), accumulating 3.1 times more steps than controls by week 12. ConclusionsA remotely delivered, multicomponent walking intervention targeting planning, behavioral reminders, and micro-incentives was feasible, well-tolerated, and produced meaningful increases in walking activity in community-dwelling adults with TBI. With high retention and compliance, and consistent effects on walk counts, duration, and steps across the intervention period, these findings provide compelling support for a larger, fully powered trial.

BackgroundThe ability to elicit a rapid, reactive step to recover balance after a postural destabilization is paramount to fall prevention. In response to a given balance perturbation magnitude, people after stroke display impaired spatiotemporal stepping kinematics. Yet, spatiotemporal stepping kinematics at individualized perturbation magnitudes after stroke and the underlying neural correlates remain unknown. Here, we tested whether stepping kinematics differ in people after stroke at individualized balance perturbation magnitudes and further examined neuromechanical mechanisms underlying impaired stepping kinematics after stroke. Methods16 participants with chronic (>6mo.) stroke and 16 age-matched controls underwent standing balance perturbations at individualized step threshold, the perturbation magnitude that elicited unintentional steps in approximately 50% of trials. We quantified the spatiotemporal kinematics of the first reactive step and weight-bearing asymmetry immediately prior to the perturbation onset. Cortical N1s, perturbation-evoked brain responses reflecting cortical processing for balance control, were extracted from Cz signals and identified as the most negative local minimum (100-300ms). ResultsWhile there were no group-level differences in step duration, step velocity, and step trajectory, people with stroke showed delayed step initiation (Cohens d= 0.89, p=0.02) and termination latencies (Cohens d= 0.81, p=0.03). Delayed step initiation latencies after stroke correlated with lower clinical balance function (e.g., miniBEST score; r= -0.67, p=0.004) and delayed cortical responses (r=0.58, p=0.02) but not weight-bearing asymmetry (p>0.86). ConclusionsThe relationships between delayed step initiation, lower clinical balance function, and slower cortical responses suggests cortical processing speed may be a limiting factor for post-stroke balance function and identifies neuromechanical targets for fall prevention.

Stroke can affect sensorimotor control, impairing balance and locomotion. These impairments increase the risk of falls, limit patient independence, and reduce their quality of life. In this study, we investigated how stroke affects the bilateral coordination of soleus motor units during standing, in individuals undergoing subacute rehabilitation. Fourteen participants (n=7 females; time since stroke=19{+/-}8 days; age=60.2{+/-}15.9 years) were recruited after admission for inpatient rehabilitation together with sixteen age- and sex-matched controls (n=8 females; age=61.2{+/-}14.7 years). Both groups attended the laboratory for two sessions separated by one week, during which high-density EMG signals were recorded from soleus muscles during quiet standing on force plates. Patients also performed the Berg Balance Scale in their clinical rehabilitation. To investigate the neural control of soleus muscles during quiet standing, the EMG signals were decomposed into motor unit spike trains, from which peristimulus time histograms and EMG waveform averages were computed in relation to peaks in the center of pressure (COP). The amplitude of motor unit and EMG activity around COP peaks, their directional tuning, and bilateral synchronization were estimated. Individuals post-stroke demonstrated improved scores on the Berg Balance Scale between visits, but the amplitudes of their COP displacement and speed were still greater than controls. In controls, the activity of soleus from both limbs exhibited an anteriorly-oriented tuning. In individuals post-stroke, while the activity of the soleus from the unaffected limb exhibited the same anteriorly-oriented directional tuning, the activity of the soleus from the affected limb was tuned laterally. Synchronization of soleus activities, quantified by computing the amplitude of motor unit and EMG activation in one soleus time-locked to prominent peaks in activity in the contralateral muscle, were also reduced in the affected limb compared to controls. Furthermore, cross correlation demonstrated a greater lag in motor unit and EMG activation between limbs in individuals post-stroke compared to controls. The absolute lag between limbs, measured through peristimulus time histograms, decreased between visits in individuals post-stroke (p=0.008), and this metric was the sole predictor of Berg Balance Scale with forward regression (R2=0.582, P<0.001). These results highlight the importance of bilateral motor unit coordination in balance, which is disrupted in both spatial and temporal domains following stroke.

Brain imaging studies have demonstrated that adults with spinal cord injury (SCI) exhibit deficits in body and interoceptive awareness. However, there is limited research on the degree and impact of these deficits. Few clinical trials have examined interventions to improve body and interoceptive awareness in this population. We compared scores on the Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2) and the Revised Body Awareness Rating Questionnaire (BARQ-R) between adults with SCI and uninjured adults. We also assessed changes in body and interoceptive awareness in adults with SCI following one of two body awareness interventions, i.e., Qigong and Cognitive Multisensory Rehabilitation (CMR). Adults with SCI reported worse interoceptive awareness than uninjured adults on the MAIA-2 dimensions "Not-distracting" [Median(IQR), SCI vs healthy=1.33 (1.17) vs 2.30 (1.5); p<.0001] and "Trust" [3.50 (1) vs 3.70 (1.3); p=.02]. Conversely, they scored better on "Noticing" [3.50 (1.38) vs 3.00 (1.50); p=.035], "Attention Regulation" [3.50 (1) vs 2.70 (1.3); p<.0001], "Self-regulation" (3.75 (1) vs 3.00 (1.5); p<.0001], and "Body Listening" [3.75 (1) vs 2.30 (1.70); p<.0001]. Adults with SCI displayed worse body awareness, indicated by higher BARQ-R scores [18 (6.50) vs 15 (7); p<.0001]. Post-intervention results revealed improvements on the MAIA-2 dimension "Not-Worrying" [pre: 3.00 (0.80) vs post: 3.40 (1.40); p=.03] and the BARQ-R [pre: 18 (7) vs post: 16 (7); p=0.0004]. Given the demonstrated deficit in body and interoceptive awareness and the potential for improvement with interventions, our results encourage further exploration on how improving body and interoceptive awareness can impact quality of daily life.

Executive dysfunction affects nearly 50% of individuals with traumatic brain injuries (TBI), yet interventions targeting the underlying neural mechanisms remain limited. This study examined whether aerobic exercise modulates functional connectivity to improve executive function in individuals with mild TBI and identified the neural pathways mediating these improvements. In this secondary analysis of a 12-week pilot randomized controlled trial, participants with mild TBI (n=24) were randomized to aerobic exercise (n=12) or active balance control (n=12). Resting-state fMRI with multivariate pattern analysis revealed that aerobic exercise selectively altered functional connectivity patterns of the anterior cingulate cortex (ACC) compared to balance control. Post-hoc seed-to-voxel analyses identified widespread ACC connectivity differences between groups post-intervention while controlling for baseline, across 19 cortical regions spanning default mode, frontoparietal control, and salience networks. Critically, greater anticorrelation between the ACC and insula following aerobic exercise was associated with improved Trail Making Test B-A performance in the aerobic group ({beta}=46.92, p=0.04) but not the balance group, indicating that participants who developed stronger ACC-insula functional segregation showed greater reductions in executive function completion times. These findings establish the ACC-insula circuit as a critical neural substrate mediating exercise-induced executive function recovery after TBI and identify this pathway as a promising therapeutic target for exercise-based rehabilitation interventions.

BackgroundPost-stroke disability contributes substantially to long-term functional limitation, yet access to rehabilitation remains inequitable in low and middle-income countries (LMICs), where workforce and service delivery constraints are pronounced. Global priorities, including WHOs Rehabilitation 2030 agenda, emphasize integrating scalable rehabilitation into health systems and decentralizing services beyond tertiary-centers. Evidence supports home and community-oriented approaches, including caregiver-mediated exercise, that can achieve gains comparable to centre-based therapy when dose is matched. The Karnataka Brain Health Initiative (KaBHI) is a public-sector model strengthening neurological care pathways through district Brain Health Clinics (BHCs). ObjectiveTo evaluate short-term changes in balance, mobility, and global disability among community-dwelling stroke survivors completing the KaBHI physiotherapy programme. MethodsThis prospective, single-group pre-post evaluation included adults aged 18-90 years enrolled at KaBHI BHCs (April-December 2024). Participants received a structured six-week balance and mobility programme prescribed by physiotherapists and implemented with caregiver support and follow-up within routine-care. Outcomes assessed at baseline (day 0) and post-intervention (day 45) were the Berg Balance Scale (BBS), Timed Up and Go (TUG), and Modified Rankin Scale (mRS). ResultsAmong 199 participants (mean age 54.9 {+/-} 14.5 years; 71% male), BBS improved from 28.9 to 37.2 (p < 0.001), TUG improved from 22.7 s to 19.8 s (p < 0.001), and mRS decreased from 3.30 to 2.45 (p < 0.001). Clinically meaningful improvement was common: 51% achieved [&ge;]7-point gains on BBS, and 70% improved by [&ge;]1 mRS grade. No programme-related serious adverse events were reported. ConclusionsIn a real-world public health setting, a physiotherapist-led, caregiver-supported KaBHI rehabilitation model delivered through district BHCs demonstrated significant short-term improvements in balance, mobility, and disability. These findings align with evidence supporting decentralized, home-/community-oriented, caregiver-mediated rehabilitation and support KaBHI as a potentially scalable strategy to strengthen stroke rehabilitation capacity in resource-constrained settings; controlled and longer-term evaluations are warranted.

Conventional therapy after stroke focuses on reducing physical impairments. However, the decisions that guide peoples movements may have far-reaching consequences towards recovery. We lack the tools to characterize these decisions. Recently, researchers have created a quantitative behavioral assessment of effort-based decision-making and applied it to some clinical populations. The purpose of this paper is to examine the feasibility of evaluating effort-based decision-making during walking after stroke. We recruited five neurotypical participants in an initial study. We conducted a subjective effort valuation on the neurotypical individuals with and without a knee immobilizer to simulate the biomechanics of reduced knee flexion during post-stroke gait. Participants cleared obstacles of varying heights during overground walking, followed by rating their perceived effort and then completing an effort choice paradigm to calculate subjective effort value. In a second experiment, we recruited five individuals with stroke to perform a similar protocol without an immobilizer during harnessed treadmill walking. We found that rated perceived effort increased monotonically with obstacle height across groups, that individuals could recall obstacle heights without cues, and that subjective effort value increased with knee immobilization in the control group as expected. We conclude that adapting an effort-based decision-making assessment to a walking context in people with stroke is feasible.

BackgroundAdapted dance is a promising rehabilitation intervention for physical and psychosocial impairments in people with chronic stroke. However, in-person attendance is hindered by limited community ambulation, transportation, and schedule conflicts. At-home participation with a live-streamed dance program could address these issues, but psychosocial benefits may be diminished because of reduced social interactions. The primary objective of this study was to assess the feasibility and safety of a live-streamed dance program for chronic stroke. Secondary objectives were to characterize participants who choose live-stream vs in-person options and quantify pre-post changes in balance, gait and social connection. MethodPeople with chronic stroke were given the choice of attending a live-streamed adapted dance program either in-person or at home twice a week for 4 weeks. A priori feasibility criteria were tracked, and participants were characterized with self-report (Center for Epidemiologic Studies Depression Scale; CES-D) and performance-based measures (e.g., Montreal Cognitive Assessment, Chedoke McMaster Assessment) at baseline. Pre-post measures of secondary outcomes included gait speed, Mini Balance Evaluation Systems Test (Mini-BESTest), Activities of Balance Confidence Scale (ABC), and Inclusion of Community in Self scale (ICS). Unpaired median/mean differences in baseline clinical presentation were used to compare in-person and live-stream participants. Paired median/mean differences were used to examine change in secondary outcomes with dance. ResultsInterest and enrollment rates for both groups combined were 87% and 38% respectively. Of the 13 people who enrolled, 8 chose in-person and 5 chose live-stream. In-person and live-stream attendance rates were 83% and 89% respectively, and retention rates were 80% and 75% respectively. At baseline, the in-person group had greater depressive symptoms (CES-D score, median [IQR] difference: 11.5 [-21.5, -5]), and faster mean gait speed (-25.8cm/s [-50.98, 0.006]) than the live-stream group. There were no pre-post changes in secondary outcome measures. ConclusionsA live-streamed dance intervention featuring in-class and at-home participation is safe and feasible for people with chronic stroke. These results will inform a future randomized controlled trial to investigate the effects of a live-stream dance program with a longer duration while considering how factors such as gait function and mood may relate to the choice between in-person and at-home attendance.

AimTo determine the mechanistic relationship between segmental trunk control in the neutral vertical posture (NVP), assessed using the Segmental Assessment of Trunk Control (SATCo), and the Gross Motor Function Classification System (GMFCS); and hence to identify the means to enhance function in children with cerebral palsy (CP). MethodThis cross-sectional study included 101 children with CP (34 female, 10y(3y8m), 1.32(0.27)m, 33.4(18.4)kg) classified across GMFCS Levels I-V and tested with SATCo. Association and variation between GMFCS Levels and SATCo results were examined. ResultsSATCo results differed significantly (p<.05) between GMFCS Levels in static, active and reactive tests of trunk control. As neuro-ability increases through GMFCS Levels V-I, ability to control the head and trunk in NVP increases ({rho}(99)=-0.61 to -1,p<.0001) and variation in head and trunk control increases ({rho}(3)=-0.9 to -1,p<.05). InterpretationSATCo provides mechanistic insights supporting its use following GMFCS. In severe CP, NVP control is minimal across all children. In mild CP, large variation in results shows that SATCo discriminates between the use of full trunk control from compensatory strategies to achieve function. For each GMFCS Level, SATCo identifies the training required to improve trunk control in NVP, thus improving functional performance and reducing long-term risk of deformity. What this paper addsO_LISATCo results are related to GMFCS Levels, and complements GMFCS C_LIO_LISATCo provides the mechanistic explanation for what is observed in GMFCS C_LIO_LISATCo-GMFCS reveals if function is attained with trunk control or compensatory strategies C_LIO_LICompensatory strategies often used in mild CP are not captured by GMFCS C_LIO_LISATCo identifies the training required to improve function and reduce deformity risk C_LI Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=115 SRC="FIGDIR/small/26344472v2_ufig1.gif" ALT="Figure 1"> View larger version (19K): org.highwire.dtl.DTLVardef@3e97cdorg.highwire.dtl.DTLVardef@1603bdcorg.highwire.dtl.DTLVardef@fa21a4org.highwire.dtl.DTLVardef@1b6a1c4_HPS_FORMAT_FIGEXP M_FIG C_FIG O_LIExample above: GMFCS Level I child leaning backwards when tested for lower thoracic NVP trunk control. Same child showing compensatory lordotic lumbar posture while standing. C_LIO_LISATCo can be used in combination with GMFCS to identify specific training targets to improve postural control, enhance function, and reduce deformity risk. C_LI

Three-dimensional gait analysis is widely used to support clinical decision-making in neuromuscular disorders, with the Conventional Gait Model (CGM) being the most commonly applied biomechanical model in clinical practice. Recent developments of the CGM, grouped under the open-source CGM2 framework, introduced methodological updates intended to improve robustness while preserving backward compatibility. However, the reliability of these successive CGM2 iterations has not been comprehensively evaluated, particularly in pathological gait populations. This study investigated within- and between-assessor reliability of lower-limb kinematics across three CGM2 versions (2.1, 2.2, and 2.3) in asymptomatic participants and individuals with cerebral palsy. Reliability was quantified using standard error of measurement and minimal detectable change across the gait cycle. Overall measurement error remained low and consistent across models and participant groups, with standard errors close to 2{degrees} and minimal detectable changes around 6{degrees}. Introducing kinematic fitting had minimal influence on reliability, while adding tracking markers on the thigh and shank produced a modest reduction in hip transverse rotation error. These findings indicate that methodological refinements implemented in CGM2 preserve the reliability of the original CGM while providing incremental improvements for clinically relevant parameters, supporting its use in both asymptomatic and pathological gait analysis and longitudinal clinical assessments

BackgroundChildren with unilateral spastic cerebral palsy (USCP) often rely on trunk compensation due to impaired upper limb control, but current clinical tools do not directly capture trunk involvement. Marker-based systems are challenging to use with children, while computer vision methods like OpenPose offer a promising, scalable alternative for kinematic analysis but need to be validated. PurposeWe validated OpenPose for quantifying trunk recruitment during bimanual play in children with USCP and examined how the interventions Constraint-Induced Movement Therapy (CIMT) and Hand-Arm Bimanual Intensive Therapy (HABIT) influence trunk use. MethodsWe analyzed videos of children with USCP who underwent CIMT or HABIT. OpenPose was used to extract trunk displacement angle (TDA) and trunk rotation angle (TRA), which were compared to hand function scores. OpenPose was validated against a 3D motion analysis system in typically developing adults. Reach-phase kinematic variables were also assessed. ResultsOpenPose showed high validity for TDA and lower validity for multi-planar TRA. TDA and TRA did not correlate with baseline hand function. HABIT reduced TDA, while CIMT slightly increased it. No significant changes were found in velocity, movement time, or variability. ConclusionsOpenPose is a viable tool for capturing gross trunk motion. Trunk recruitment patterns differed by intervention, supporting the need for personalized approaches.