From Dyad to Triad: Eliciting XAI Requirements in Stroke Rehabilitation

Tailoring stroke rehabilitation requires assessing how movements are organized, not merely if they succeed. Currently, this assessment is a rate-limiting bottleneck. Instruments like the Action Research Arm Test (ARAT) compress rich behavioral observations into single ordinal endpoints, discarding the movement-quality details that distinguish recovery from compensation. Automated alternatives typically chase accuracy on noisy, single-observer labels to output opaque scores - a technology-centric approach that rarely reaches clinical practice. To address this, we present xAARA: an engine designed to augment rather than replace clinical judgment. From multi-view video, xAARA returns ARAT assessments with calibrated uncertainty and explanations across task, movement-phase, and movement-quality levels. Treating clinical scoring as an ill-posed inference problem, xAARA composes 692 calibrated multimodal models via a Dynamic Bayesian Network with entropy-based gating. It qualifies results against clinical validity rules and defers low-confidence cases. In 105 stroke survivors (788 exercises), xAARA achieved 94.2% task accuracy (Cohen's kappa=0.934) and 81.3% movement-phase accuracy (kappa=0.727), reducing predictive uncertainty by 96.1% compared to single-clinician scoring. For subjective cases, it matched at least one rater 100% of the time and never returned out-of-range scores. Four independent clinicians validated the assessments and indicated willingness to adopt the system. We argue that principled uncertainty quantification and clinician-aligned explainability are the critical bridges moving automated assessment from technical demonstration to a deployable clinical tool.

Feature-attribution methods such as SHAP provide useful evidence about individual model predictions, but their numerical outputs are rarely sufficient for audiences with different expertise, goals, and risks of misinterpretation. In medical AI, the same local explanation must reach patients, clinicians, and data scientists through markedly different forms of communication, and naive verbalization through large language models (LLMs) is prone to weak grounding, conflation of attribution with causal language, and outputs that are persuasive without being faithful to the underlying model evidence. We introduce XstrAI, an audience-aware multi-agent framework that treats local explanations as fixed evidence and structures how it is communicated to each target reader. Each prediction case is encoded as an immutable structured representation, shared identically across audiences so the underlying evidence remains fixed. Generation is factored into three specialized LLM agents responsible for audience-aware planning, linguistic realization, and validation for grounding, attribution consistency, communicative risk, and audience appropriateness, with a bounded revision loop triggered on detected inconsistencies. We evaluate XstrAI on diabetes and stroke risk prediction against 11 baselines, ranging from direct verbalization to a re-implementation of a state-of-the-art narrator. The evaluation combines an intra-narrative regime measuring fidelity to SHAP evidence with an extra-narrative regime assessing audience appropriateness through reference corpora, multi-family LLM judges, and a survey with target readers. In both evaluations, XstrAI's narratives are consistently assigned to their intended audience by independent judges, and preferred over all baselines on Clinician and Patient audiences, with competitive performance on Data Scientist, where audience-conditioned single-prompt baselines lead.

The evaluation of explainable AI (XAI) approaches often relies on three families of methods: subjective measures (e.g., questionnaires on trust or satisfaction), objective measures (e.g., task performance metrics), and mathematical metrics (e.g., for faithfulness). Yet, it remains unclear how these families align or diverge in practice. In a{preregistered} between-subjects study (N=166), we use three established saliency map techniques (LIME, Grad-CAM, Guided Backpropagation) as a testbed to examine this issue. We find that each family of methods leads to different conclusions: participants reported no differences in trust or satisfaction, Grad-CAM improved user performance, while mathematical metrics favored Guided Backpropagation. At the same time, mathematical metrics were only partially related to user performance, and these relationships were sometimes counterintuitive. Our findings highlight the methodological importance of comparing subjective, objective, and mathematical approaches when evaluating XAI, illustrating both tensions and aspects that are aligned. We discuss implications for XAI evaluation frameworks.