Lancet Commission on Global Surgery have highlighted the need for increased investment to enhance surgical capacity in low- and middle-income countries. A neglected issue, however, is surgery-related rehabilitation, which is known to optimize functional outcomes after surgery. Increased investment to enhance surgical capacity therefore needs to be complemented by promotion of rehabilitation interventions. We make the case for strengthening surgery-related rehabilitation in lower-resource countries, outlining the challenges but also potential solutions and policy directions. Proposed solutions include greater leadership and awareness, augmented by recent global efforts around the World Health Organization’s Rehabilitation 2030 initiative, and professionalization of the rehabilitation workforce. More research on rehabilitation is needed in low- and middle-income countries, along with support for system approaches, notably on strengthening and integrating rehabilitation within the health systems. Finally, we outline a set of policy implications and recommendations, aligned to the components of the national surgical plan proposed by the Lancet Commission: infrastructure, workforce, service delivery, financing, and information management. Collaboration and sustained efforts to embed rehabilitation within national surgical plans is key to optimize health outcomes for patients with surgical conditions and ensure progress towards sustainable development goal 3: health and well-being for all.Global surgery initiatives such as the  Lancet Commission on Global Surgery 2030 highlights the shortage of essential, safe and affordable surgical procedures to more than half of the world’s population and the negative impact this shortage has on mortality, morbidity and functioning.The report of the Rehabilitation has been defined as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.”,–,–It is well-established that rehabilitation prevents complications and improves postoperative and long-term pain and functional outcomes across several health conditions.,Without adequate rehabilitation, the outcome of many surgical procedures will be suboptimal. However, little attention is currently given to the importance of pre- and postoperative rehabilitation in low- and middle-income countries.,Strengthening surgery-related rehabilitation services in low- and middle-income countries is challenging.,Most research on rehabilitation has been conducted in high-income countries, where many factors – including patients’ health conditions and the types of surgery as well as the health system infrastructure and human resources – are not comparable to low- and middle-income countries. These differences are especially evident in conflict and emergency settings, where trauma surgery predominates.The first step is to establish a general understanding of the processes and benefits of rehabilitation.,We approach the issue as physiotherapists and surgeons with long-term experience in lower-resource countries and humanitarian settings. Our own experiences confirm that surgery-related rehabilitation is rarely considered an essential part of the continuum of care.,The awareness of surgeons and other hospital staff in low- and middle-income countries is often limited to wound care after surgical intervention. To free up beds for new patients, the condition for discharge is commonly wound closure, after which advanced rehabilitation towards functional independence should start. A lack of rehabilitation facilities and follow-up in the form of accessible outpatient structures or community-based services often leads to this key stage of the rehabilitation process being left out.,Several recent global initiatives such as the World Health Organization’s (WHO) Emergency Medical Teams and Rehabilitation 2030 initiative are welcome efforts to raise awareness among policy decision-makers about developing rehabilitation capacity.We believe that multisectoral and multilevel leadership will yield several benefits: a unified voice and greater collaboration among the global rehabilitation community; improved awareness and advocacy of the importance of rehabilitation; a strategy for expanding the rehabilitation workforce; and the momentum to drive research that will inform policy. Together, these benefits will ultimately improve access to quality rehabilitation to meet population needs.,,,Strengthening the rehabilitation health workforce in contexts where existing staffing levels are low and where demand is greatest is a challenge.Early rehabilitation in conflicts and disasters is a handbook for rehabilitation professionals working in conflict and disaster response and is the result of a joint project of humanitarian, professional and disease-specific organizations and individual experts from high- and lower-income countries.Multisectoral collaboration is a key driver of knowledge translation from research into practice and strengthening of the rehabilitation workforce. Where universities and nongovernmental organizations collaborate, practical experience in local settings and knowledge of training priorities can be combined with experience in curriculum development and education delivery. Establishing competency-based education programmes will allow population health needs to be matched to rehabilitation worker skill sets. These programmes can be informed by WHO’s Rehabilitation Competency Framework, a detailed framework that captures the key activities and competencies required to provide quality rehabilitation service delivery.Professionalization of the discipline is needed to enhance the professional qualities of the rehabilitation sector. This process requires increasing the number of people training and enhancing the quality of training programmes for rehabilitation professionals. Career pathways progressing from basic to advanced practice competencies are required. It may help to develop modular course structures beginning with training for mid-level rehabilitation workers and advancing to professional degrees in rehabilitation. Courses need to span rehabilitation practice for community- and primary care-based workers, up to specialized rehabilitation experts.,Online learning and educational technology can be harnessed to support these programmes and offer continuous professional development opportunities.,Research to inform best practice is essential for strengthening rehabilitation within health systems. Close collaboration between universities in high-income and low- and middle-income countries and with humanitarian and international cooperation agencies is necessary to merge research expertise with field experience, harness research funding opportunities and demonstrate impact.Lancet Commission on Global Surgery report. Future research directions must also include the impact of rehabilitation on surgical outcomes.Another research gap is quality evidence on the outcomes and impact of injury- and surgery-related rehabilitation in low- and middle-income settings.Strengthening of rehabilitation should not be limited to health systems. Health ministries, higher education, social affairs and labour should join forces to allow professional regulation, education and training, decent working conditions, better infrastructure, adequate pay and retention of staff.Rehabilitation is often associated with disability in low- and middle-income countries. The strength of the sector is thus its position at the intersection of the health and social care professions, with the potential to advocate with both sectors. Rehabilitation as a health service leads to better functioning for patients; as a social service it prepares people with disabilities for enhanced social and economic participation within their communities. Rehabilitation must be seen as essential throughout the continuum of care, from health promotion and prevention, pre- and post-surgical rehabilitation, through non-surgical related interventions, up to the social inclusion of people with disabilities. Collaborations on a systemic level with the health, education and labour sectors are crucial to allow working towards a common vision: the optimal functioning of individuals with health conditions and thus of communities and society.Lancet Commission strongly advocates for the development of national surgical plans to ensure “proper planning of surgical care delivery, education and research.” Yet rehabilitation, which is a key part of the continuum of care following some types of surgery, was not included.Achieving universal health coverage (UHC) – so that all people and communities receive the health services that they need without suffering financial hardship – is a key policy goal of the sustainable development goal agenda.To make progress in the development of surgery-related rehabilitation in low- and middle-income countries, there is a need for greater collaboration between surgery and rehabilitation professionals, and across the health, education and labour sectors. Rehabilitation needs to be integrated into national surgery policies. Below we outline some strategies to achieve this, using the national surgical plan framework: infrastructure, workforce, service delivery, financing and information management.Surgical facilities must be equipped to enable delivery of basic post-surgical rehabilitation interventions: for example, space to facilitate early mobilization and ambulation, chairs for upright sitting or assistive devices such as mobility aids. The continuum of care after surgery should include, where appropriate, referral systems to step-down facilities offering rehabilitation or to outpatient services to ensure that patients have access to essential rehabilitation services such as fitting of prosthetics.Education and training strategies within national surgical plans must include training of rehabilitation staff based on the population and needs of the country. Inclusion of rehabilitation within surgical training programmes is needed. WHO’s Rehabilitation Competency FrameworkEvidence-based surgical rehabilitation protocols need to be developed and adapted at the local level for the health conditions that would benefit most from rehabilitation. WHO is currently developing a package of interventions for rehabilitation which will serve as a platform to enable service providers to plan and implement specific rehabilitation interventions.Funding plans for basic surgical care pathways must include funding for the provision of rehabilitation interventions, including the necessary workforce, facilities and assistive devices. Of course, there are financial implications to providing surgery-related rehabilitation to those who need it. However, neglecting rehabilitation increases the chances of lengthy or permanent disability that has implications on individuals and households, such as the impact on return to work or schooling. In lower-resource settings, rehabilitation is considered a luxury and often available to patients based on ability to pay rather than need.Surgical information systems need to include short- and longer-term patient outcomes relating to function (such as mobility and activities of daily living) and participation . These processes also need to be monitored to enhance quality improvement processes. Capacity-building for rehabilitation research must be championed and supported. Research priorities relating to rehabilitation that are locally relevant should be identified and funded.Surgery has the potential to save hundreds of thousands of lives, whether in peacetime or in conflicts. But mere survival is not good enough. We call on our colleagues in surgery and on managers and policy-makers in low- and middle-income countries to give surgery-related rehabilitation a greater role in their work towards achieving the targets of their national surgical plans.


Allergic rhinitis is prone to recurrence, and clinical treatments focus on control symptoms; however there is no radical cure. Our aim was to use network pharmacology and molecular docking to reveal the hub genes, biological functions, and signaling pathways of Tongqiao Huoxue decoction against allergic rhinitis. First, the chemical components and target genes of Tongqiao Huoxue decoction were obtained from the Traditional Chinese Medicine Systems Pharmacology database. Similarly, allergic rhinitis targets were screened using online Mendelian Inheritance In Man and GeneCards database. Then, all potential targets of Tongqiao Huoxue decoction in the treatment of allergic rhinitis were identified, the Venn diagram was portrayed using R software, and protein-protein interaction network was built using String. The hub genes were analyzed using enrichment analyses. Finally, molecular docking was used to verify the reliability of the key gene prediction. The core targets for Tongqiao Huoxue decoction to improve allergic rhinitis were AKT1, TP53, IL6, and so on. The enrichment analysis results showed that Tongqiao Huoxue decoction treatment in allergic rhinitis might be involved in the AGE-RAGE signaling pathway and fluid shear stress and atherosclerosis pathway. The molecular docking verification indicated that its ingredients bound well to the core targets of allergic rhinitis, and stigmasterol’s docking ability with TNF  is particularly prominent. Based on these findings, it may be deduced that stigmasterol treated allergic rhinitis by acting on TNF targets. But, this conclusion needs to be confirmed by further in vitro and in vivo trials. The incidence of AR is 19% among adults and 22% among children in China, and boys showing a higher prevalence than girls.,3 The global prevalence of AR is between 10% and 40%. AR as a chronic disease what does not cause death, but it imposes a heavy socioeconomic burden on patients and seriously impairs their quality of life.,6 Although the etiology of AR is still unclear, it is environmental, genetic, and epigenetic that strongly associated with onset of AR according to some current reports. AR can be triggered while exposed to allergens including pollen, mold, dust, egg, seafood, and soybean, et al. Health education for patients, irritant and allergen avoidance measures, pharmacotherapy, allergen immunotherapy, biologics, nasal irrigation, acupuncture and surgery are present common therapeutic measures for patients of AR. But there are no radical cure for AR, and clinical treatments are mainly used to control symptoms of AR. Moreover, the efficacious of traditional Chinese medicine (TCM) against AR have been proven and TCM treatment without obvious adverse effects. Tongqiao Huoxue decoction (THD), originated from “Corrections on the errors of medical works” written by the Qing Dynasty physician Wang Qingren is a traditional Chinese prescription, and it’s ingredients include 6 grams of red red peony, 6 grams of Chuanxiong, 6 grams of safflower, 9 grams of peach kernels, 9 grams of ginger 0.15 grams of musk, and 7 red dates. The main therapeutic effect of THD is to improve local blood circulation by dispersing blood stasis and dredging collateral. TCM theory believes that nose is connected to the brain, and the level of interleukin-6 in the blood serum closely relating with the increased occurrence of AR can significantly be reduced by THD. Therefore, THD can be used to treat nasal diseases and the addition and subtraction of Chinese medicine drugs was carried out on the basis of THD in this study. Through the summary of clinical treatment experience, it is found that some Chinese medicines such as comfrey, madder and lnk lotus have excellent efficacy in the treatment of AR. Based on this discovery, we added and subtracted the composition of THD to formulate a new THD, which includes astragalus, codonopsis ginseng, poria, Baizhu, Chuanxiong, red peony, madder, comfrey, lnk lotus, licorice, and the effective of ingredients modified THD has been clinically proven. However the drug active mechanisms of ingredients modified THD in the treatment of AR are still unclear and need to be further explored.Allergic rhinitis (AR) is a nasal mucosa atopic disorder mediated by immunoglobulin E (IgE) and is characterized by nasal pruritus, clear rhinorrhea, sneezing, nasal congestion, post-nasal drip, and pale discoloration of the nasal mucosa.In this research, network pharmacology was firstly applied to identified the active ingredients and targets of THD in the treatment of AR. Next, the protein-protein interaction (PPI) network analysis and enrichment analysis were used to predict the critical molecules of THD for AR treatment. Lastly, molecular docking was performed to reveal molecular regulatory mechanisms in a high-throughput manner.http://tcsmpw.com/tcsmp.php) Database. Oral bioavailability (OB) ≥ 30% and drug-likeness (DL) ≥ 0.18 were set as the thresholds for screening the active components in AR. Then, the targets of these active ingredients were obtained from this website. The aggregated targets were input into Uniprot (http://www.uniprot.org/) to obtain gene symbols and gene IDs.The active ingredients of THD were collected through the Traditional Chinese Medicine Systems Pharmacology , and GeneCards database (relevance score ≥ 2) (http://www.genecards.org/). The AR-related targets from different databases were merged and dereplicated. Finally, these targets were unified as gene names on UniProt.“Allergic Rhinitis” was used as the keyword to search all the possible targets against AR in the online Mendelian Inheritance in Man database (http://bioinfogp.cnb.csic.es/tools/venny/). The coincident target genes were displayed in the overlapping domain after amalgamation and striking out the duplicates.The intersection target genes between both AR and THD were obtained through Venn 2.1 (http://string-db.org/). According to the corresponding calculation method the species was set as “Homo sapiens” and the threshold was set as 0.9 to show the PPI network. PPI network was visualized in Cytoscape 3.9.1 software and algorithms of cytoHubba plug-in: the Degree Value were used to sift the top 10 hub targets form the network.PPI network of AR and THD reclosing target genes was depicted using the STRING database  and Kyoto encyclopedia of genes and genomes (KEGG) pathway enrichment analyses were performed using Bioconductor package and clusterProfiler package in R 4.2.1 software under the condition of http://www.rcsb.org/) in Protein Data Bank format. The active component structure as ligands was downloaded from the PubChem compound database (http://pubchem.ncbi.nlm.nih.gov/). After removing the water molecules and organic compounds from ligands and proteins and adding non-polar hydrogen bridge to them by PyMol 2.6.0 software, the format of the molecular ligands and proteins was transformed into pdbqt format. Subsequently, the docking of ligands and proteins was performed by AutoDockTools 1.5.7 software. Each group of molecular docking was run 50 times, and the ionization energy was calculated. The minimum energy value was selected as the docking affinity. Finally, the docking results were visualized using PyMol software.To explore the relationship and action mechanisms between candidate proteins and active ingredients, molecular docking simulations were conducted to evaluate the strength and mode of interactions between components and hub targets. Crystal structures of critical targets protein receptors were acquired from the Protein Data Bank database , and leukotriene, resulting in further aggravation of AR. The THD mentioned in this study has been shown to be effective in controlling the symptoms of AR and reducing the number of AR attacks in patients. The theoretical concepts of network pharmacology are coincide with the multi-components and multi-targets of TCM, it can serve as a significant method to analyze drugs, components, and diseases targets.AR is a very common disorder that occurs especially in adolescents. Although AR is not a serious illness, it is clinically relevant because it underlies many complications, is a major risk factor for poor asthma control, and not only is detrimental to health but also has societal costs without effective treatment. In addition to exerting anticoagulant effects by increasing the content of cAMP and cGMP in platelets and relieving platelet aggregation, perlolyrine could also combat the vasoconstriction effect of posterior pituitary hormones. Spinasterol possessed several important pharmacological properties for example anti-inflammation, antiulcer, neuroprotection and anti-pain. And its ant-inflammatory mechanisms included inhibition of cyclooxygenases, antagonism of TRPV1 receptor and attenuation of proinflammatory cytokines and mediators. There is research found that stigmasterol reduced the release of inflammatory factors and the level of oxidative stress induced by interleukin-1β through sterol regulatory element binding transcription factor 2, which indicated the protective effect of stigmasterol on cells. Ethyl oleate could enhance drug OB by both elevating drug solubility and promoting lymphatic transport.In this study, a total 232 compounds of THD were found in the TCSMP platform, ethyl oleate (NF), mandenol, perlolyrine, spinasterol, and stigmasterol were identified as core active compounds. Mandenol (ethyl linoleate) by down-regulating inducible nitric oxide syntheses and cyclocxygenase-2 expression and thereby reducing nitric oxide, TNF-α, interleukin-1β, interleukin-6, and prostaglandin E2 production induced by macrophages, inhibited inflammatory activity. The study of Xiaohan et al confirmed that AKT1 was closely related to cell proliferation and AR could be alleviated by activating AKT1. MYC as a cancer-causing gene expresses three proteins: MYC-1, MYC-2, and MYC-3. The MYC proteins were involved in the regulation of a variety of cellular processes including cell growth, cell cycle, differentiation, apoptosis, angiogenesis, and metabolism et al. In the Bioinformatics analysis of nasal epithelial cell gene expression in seasonal and perennial allergic rhinitis founds that AR patients allergic to house dust mite had significant down-regulation of MYC. The variation of TP53 in amino acid at codon 72 promotes mucous cell hyperplasia by reducing Bcl-2 mRNA half-life and stability. TNF was an important cytokine in the pathology of AR that TNF-α disrupted tight junctions of human airway epithelium and promotes inflammatory cytokines release and TNF-α triggers airway constriction, hyperresponsiveness, and sputum neutrophilia. ESR contains ERα, ERβ, and G protein-coupled estrogen receptor (GPER), of which GPER was significant in immune regulation. It has been demonstrated that GPER-specific receptor agonist G-1 could attenuated the symptoms of AR mice and inhabited the TH2 cell associated inflammatory response by decreasing the level of IL-4, IL-5, and IL-13, and elevating Treg cells proportion and the specific cytokines IL-10 and Foxp3 transcription factor. MAPK3 was one of the MAPK family effectors could regulate the expression of related genes, the transcription, and translation of inflammatory factors.Subsequently, 151 intersective target genes of THD and AR were obtained. Base on the PPI network analysis and topology algorithms in Cytoscape software, AKT1, TP53, IL6, TNF, CASP3, MAPK3, HIF1A, VEGFA, ESR1, and MYC were considered the hub target proteins in the treatment of AR. The activation of PI3K/AKT/mTOR pathway promotes abduction autophagy of macrophages. After RAGE activation, the elevate of reactive oxygen species (ROS) products and then the oxidative stress response was activated, which means that numerous intracellular structures, such as cellular membranes, proteins, lipids, and DNA were disrupted. Endothelial response to fluid shear stress (FSS) is a critical element of vascular homeostasis. Multi-directional and chaotic FSS caused curved and branched arteries more and this areas with unstable flow were more susceptible to infection and inflammation.GO annotation and pathway enrichment analyses showed that the major biological processes contained response to hormone, cellular response to organic cyclic compound, cellular response to lipid, membrane raft, membrane microdomain, DNA-binding transcription factor binding, and nuclear receptor activity et al And indicated it may be possible to delay the development of AR by preventing these biological processes form taking place. In the KEGG enrichment analysis of hub genes, the effect of THD against AR may be related to lipid and atherosclerosis, AGE-RAGE signaling pathway in diabetic complications, and fluid shear stress and atherosclerosis. The activation of AGE-RAGE signaling pathway led to increased RAGE expression and oxidative stressors, and blockaded of RAGE signal transduction may be a key measure for the prevention of deleterious consequences of oxidative stress, particularly in chronic disease.The binding mode and binding capacity of active components in THD to potential targets in AR were probed by molecular docking. Our results showed that the active compounds in THD had low binding energy and high binding capacity to TNF, TP53, ESR, and MYC, and the docking scores were mostly < -5kcal/mol which indicated that these protein may be potential binding targets of compounds.It is necessary to state the present several limitations:Firstly, our conclusion was based on these reviewed and predicted data from online databases, this may have led our results being incomplete without unproven and undocumented compounds or targets. Secondlym absorption pathways, metabolic forms of bioactives in THD should be studied. Lastly, our study could only initially explained the mechanism of THD to treat AR based on the theoretical results of network pharmacology and molecular docking. The experiments in vivo and vitro were needed to further verify the main regulatory targets and pathways of action about THD’s treatment in AR.In summary, our analysis identified TNF, TP53, and MYC as central genes associated with THD anti-AR and validated the reliability of predicted central genes using molecular docking techniques. These hub relevant targets may through its function of regulating cell growth, cycle, apoptosis, and angiogenesis, promoting mucous cell hyperplasia, and decreasing inflammatory cytokines release and through AGE-RAGE signaling pathway in diabetic complications, and fluid shear stress and atherosclerosis pathway to played its role in relieving inflammatory, anti-oxidative stress response, and promoting cell proliferation to improve AR. This conclusion proved that THD had the characteristics of combined action of multi-targets and multi-pathways, and provided new directions for exploring the potential mechanism of THD’s treatment in AR. However, our study had some certain deficiencies and the hub genes and its pharmacological mechanism of THD in the treatment of AR still need to be validated by in vitro and in vivo experiments.Conceptualization: Jiani Wu.Funding acquisition: Zukang Qiao.Investigation: Zukang Qiao.Methodology: Fang Zhang.Resources: Fang Zhang.Software: Jiani Wu.Supervision: Zukang Qiao.Visualization: Fang Zhang.Writing – original draft: Qu Shen.Writing – review & editing: Zhiling Che.


Anterior cruciate ligament is one of the most common ligaments to get injured especially in athletic population. It is a band of dense connective tissue which arises from the anteromedial aspect of the intercondylar area on the tibial plateau and passes upwards and backwards to attach to the posteromedial aspect of the lateral femoral condyle. There is an increasing rate of its reported injuries among athletes in Nepal and surgeons report increased consultations among athletes regarding adequate intervention strategies. Factors like overuse, inadequate recovery time, playing surface, fitness incompatibility are involved in the increase of anterior cruciate ligament injury among athletes in Nepal. The treatment approach for anterior cruciate ligament injury is ever-evolving with regular studies and innovation, but constant guidance and rehabilitation in an institution-based setting have shown positive feedback in recovery and return to play. It occurs most frequently in those who play sports involving pivoting . Injuries can range from mild  to severe (completely torn ligament). Both contact and noncontact injuries can occur, although non-contact tears and ruptures are most common.3The anterior cruciate ligament (ACL) is a band of dense connective tissue which attaches femur to the tibia in anterior joint line.3 ACL is primary structure that restrains anterioposterior and rotatory stability of knee joint in lower flexion angles. Primary cause of ACL tear is restraints to anterior tibialdisplacement when the knee is kept at 90 degrees of flexion and secondary restraints to tibial rotation & varus-valgus angulation at full knee extension.5The ACL is comprised of two bundles named as per insertion sites on the tibia: anteromedial (AM) and posterolateral (PL), at the lateral wall of the intercondylar notch, two prominent osseous ridges marks the borders of the femoral ACL insertion site: the lateral intercondylar ridge demarcates the anterior border of the ACL, while the lateral bifurcate ridge, running perpendicular to the lateral intercondylar ridge, separates the femoral attachment sites of the two bundles.6If a person comes to a sudden stop or makes an abrupt change in direction, it may force the tibia to move forward causing a tear. This is known as non-contact injury. An example would be an athlete who comes to a sudden halt while running.6When the knee is forced into hyperextension , during valgus deformation of knee, or due to head-on collision , the ACL may tear or rupture which is termed as contact injury. These patients usually present with poly-trauma associated with other life-threatening injuries.6 It occurs most frequently in those who play sports involving pivoting .An ACL rupture is a serious injury that can be career-ending for athletes. A re-rupture after primary ACL reconstruction occurs in 1 % to 11 % of all athletes. Injuries to the ACL are relatively common knee injuries among athletes.In Nepal incidence of ACL injuries either it is tear or even a rupture is increasing rapidly. In present day, there have been increased cases of ACL rehabilitation following repair, reconstruction and even conservatively managed. In past 6 months there has been 6-14 documented case of rehabilitation following ACL reconstruction in a single rehabilitation center (Orthoplast Rehabilitation Center).In our experience, athletes are unaware of the role of physiotherapy in sports and injury-prevention. Some might even be oblivious to the role physiotherapy plays in training, fitness, injury care, and rehabilitation following surgeries.Cause of increased incidence in NepalThere is a need to establish the current status and reasons of increasing injury rates in sports in comparison to previous years and how is rehabilitation trending in sports conditioning. As mentioned earlier, ACL injuries have increased in the last couple of years. Some reasons for this rise could be an increase in the number of sports competitions and tournaments, increased participation of female athletes in each sport, increase in the game time compared to recovery period. Another interesting reason could be a lack of knowledge on adequate training, diet planning, importance of warm-up and cool-down, or the impact of ACL in players.A common problem we encounter is that the clients we treat have little knowledge on fitness regimen, do not have a well-planned training schedule, do not give importance to their nutrition, and do not opt for rehabilitation following any surgical intervention.In our experience, athletes that are supported by organizations or sports clubs adhere to institution-based rehabilitation more than those who do not. When subsidised by these organisations, rehabilitation time is adequate, and complications like an incomplete range of motion (ROM) in knee, reduced strength of knee stabilizers, fear of avoidance to activities of daily living (ADL's), or mental and physical incompetence to return to sports are lower. Treatment approach for ACL is ever evolving with regular studies and innovation, but constant guidance and rehabilitation in an institution-based setting has shown positive feedback in recovery and return to play.ACL cases have been rising day by day in Nepal and surgeons report increased consultations among athletes regarding adequate intervention strategies. Surgeon's report, in previous year's awareness about ACL injury without anyone informing about the symptoms were limited whereas in the present day with peer review, social media, increased rehabilitation units in Nepal, consultation has increased for understanding management approach.Non-operative/Conservative management- One of the least approached method that is poorly tolerated by both young active adults and in the skeletally immature ones. This often leads to recurrent instability and the development of osteochondral defect and meniscal injuries.5Repair- Poor outcomes have been associated with repair in comparison to ACLR from various reports.2 Recently, there has been an increasing interest in ACL preservation as an option to perhaps better restore native ACL anatomy, biomechanics, and neurosensory function.5Reconstruction- Most widely used method with higher success rate compared to other techniques by using grafts such as hamstring tendon (HT), bone-patellar tendon-bone (BPTB), or quadriceps tendon (QT) to reconstitute the anatomy and function of the native ACL.5 This tissue can be harvested from either patient (autograft) or from a cadaver .Basic principal followed all over the world for the treatment of ACL is as follows:Gain good functional stabilityRepair muscle strengthReach the best possible functional levelDecrease the risk for re-injury10Open chain and Closed chain exercises are managed accordingly in rehabilitation.13Structured rehabilitation of ACL ruptures is similar for any treatment option, either reconstruction or nonoperative management with rehabilitation programs including cryotherapy (ice), gravity-assisted motion or continuous passive motion (CPM), protective bracing, electrical neuromuscular stimulation, and exercises aimed for strengthening, balance, proprioception, and reducing inflammation.Rehabilitation in Nepal depends upon physiotherapy settings present, such as:Hospital based setting provides In-patient service for 0-1 week post-op, followed by 2-3 weeks OPD basis or else weekly follow-up basisClinic based settings-long term rehabilitation is adhered to focusing on pain, range of motion and strength but lacks adequate tools and methods for sports specific rehabilitation.Rehabilitation centre based setting-long term rehabilitation provider with adequate tools to return to sports, but rare in a single province.Home based rehabilitation as many players also return to home after surgery and they are prescribed with home based exercise protocol with regular follow-ups.Pros:Evidence based practised has emerged immensely in few years.More equipped Sports Injury centres are being established.Specific orthopaedic surgeons as Arthroscopic surgeons are performing sports injury surgeries in large numbers which itself is another scope of rehabilitation.Consultations with arthroscopic surgeons has been rising, athletes are concerned about injury status and remedy to return to sportsCons:Lack of enough well equipped centres.Transportation facilities.Official authorities have less knowledge about rehabilitation that indeed is driving force in professional associations to guide players.Hospital based rehabilitation approach has not been uniform for ACL rehabilitation as multispecialty hospitals tend to provide high equipped care whereas other hospitals provide follow-up based and home based care, private clinics provides long term rehabilitation but patient are unable to afford its cost.Players are not getting aids or supports from clubs or country for 6-9 months of continuous rehabilitation.There are very few sports rehabilitation center having regular contact with surgeons and physiotherapist working together under one project.In the last one year there have been few documented cases that have been successfully rehabilitated and returned to sports following six to nine months of intensive rehab and two months of field-based rehabilitation. Primary factors reported are multidisciplinary approach in ACL management, inadequate support to players from organizations or clubs that can help players financially to continue rehabilitation for required time span. One of the major things to rectify is establishment of sports specific rehabilitation centres that can provide evidence based, protocol-based approach in rehabilitation and return to sports.


The need for rehabilitation therapy has increased dramatically with the aging of the population, the prevalence of non-communicable diseases, and the increase in the number of disabilities. Rehabilitation therapists are crucial to provide high quality rehabilitation therapy; however, there is a significant shortage of these professionals in China. One of the effective strategies to address this challenge is using the norm of the workforce for rehabilitation therapy, which is an index for assessing the personnel required in a facility. This research aimed to create a rehabilitation therapist-required norm under institutional perspective in Shandong Province, China, based on the Workload Indicators of Staffing Needs (WISN) method, which was created by the World Health Organization (WHO) in 1998 to analyse staff utilization at various levels of the health care system.We conducted descriptive and quantitative research from October to November 2020 in the rehabilitation department of a tertiary hospital in Weifang City, China. Focus groups, online interviews, and document reviews were conducted to gather data and calculations of the WISN method performed.Admission assessment, pre-treatment evaluation, rehabilitation therapy, post-treatment evaluation, and health education for patients were identified as the main priority group activities. Interviews and analysis of documents summarized five factors related to rehabilitation therapists' health service activities. In this study, the annual working time of each therapist was 1,776 h per year. The WISN method calculations showed that the norm of rehabilitation therapists in this tertiary hospital was 23 therapists. As the department had 13 therapists, there was a shortage of 10 therapists based on the WISN calculation, with a ratio of 0.57, which represented the actual compared to the ideal number of therapists.Workload pressure was high for therapists in this tertiary hospital. This model revealed a demand for ten more therapists in the rehabilitation department. The WISN method can help hospital administrators in therapist workforce monitoring, including in regard to therapists. Therefore, the WISN method should be embraced as part of hospital human resource planning and recruitment strategies to meet increasing rehabilitation needs. According to the World Health Organization, approximately 15% of the world's total population has had some type of disability . RehabilOne of the health targets of Sustainable Development Goal 3 (SDG-3) and a global strategy for the health workforce is to increase training and retention of health personnel, a central element of health services . As an iChina is a developing country with the second largest economy worldwide and is facing multiple challenges, including an aging population, high incidences of chronic diseases, and an increased number of people with disabilities (PDs); therefore, the need for rehabilitation services is rapidly increasing . At the The Workload Indicators of Staffing Need (WISN) approach could provide a device to discuss the staffing norms or plans for rehabilitation therapists . The WISIn 1998, the World Health Organization (WHO) proposed a methodology for adjusting staffing levels to achieve equitable and optimal distribution of health facility staff from local to national levels . The WHOThis research was conducted from October to November 2020 in the RD of a tertiary educational hospital in Shandong Province, China. The RD is the key municipal department for rehabilitation in Weifang City. There are 12 beds and 10 physicians , 22 staff nurses, and 13 rehabilitation therapists .The RD activities comprised three main categories: neurological rehabilitation, rehabilitation of osteoarthritis, and other rehabilitation. Neurological rehabilitation, which accounted for 60–70% of the total RD visits, included rehabilitation for patients with conditions such as a stroke, traumatic brain and spinal cord injury, peripheral nerve injury, Parkinson's disease, and cerebral palsy. Visits by older patients with a stroke or traumatic brain and spinal cord injury accounted for 50% of visits in this category. Rehabilitation of osteoarthritis, which accounted for 30–40% of the total RD visits, included various types of osteoarthritis, cervical spondylosis, periarthritis of the shoulder, lumbocrural pain, scoliosis, post-fracture dysfunction, dysfunction after tendon and joint injury, sports trauma, rheumatism and rheumatoid arthritis, post-joint replacement, and so on. Other rehabilitation included rehabilitation for chronic pain, physiotherapy for acute and chronic inflammation , and sub-health consultations, rehabilitation, and non-surgical treatments.The annual number of patients who received rehabilitation therapy for the year 2019 was 21,840. If the same therapists perform the same activity multiple times throughout the day, the number of times that specific activity is performed is used to calculate the workload. We used the list of template tables provided in the WISN user's manual illustrated by the WHO . Quantitative data were obtained by surveying therapists in the RD using a questionnaire with WISN indicators; namely, activity standard, allowance factor, available working time (AWT), standard workload, and workload component were chosen to determine the staffing requirements of rehabilitation therapists for the selected tertiary hospital in Shandong Province, China. The data needed include the main activities by selected groups during daily duties at the various levels of health service. Two types of results—differences and ratios—are provided by the WISN method. The former is the size of the staff shortage or surplus for the particular staff category, and the latter represents the measure of the workload pressure of the individual staff member.A hospital administrator and experienced therapists who had worked for at least 5 years administered structured individual and group interviews with therapists to identify the health service activities, support, and additional activities performed by each therapist. The time taken by a therapist in the RD to perform each drafted rehabilitation therapy service activity was calculated by the head of rehabilitation therapy and a hospital administrator from the department of human resources. The time taken for each activity was observed by the research team and from self-assessments of experienced therapists in the RD. Because direct observation of support and additional activities was not possible, the time spent performing each related activity was calculated based on an approximation given by the therapist through online interviews. Administrative records were used to access annual service statistics by our team members.Analyses of the workload and the staffing requirements were performed based on the WISN approach .Public holidays represent the days when almost everyone in China is given time off from work. We accounted for 52 weekends; sick leave, which is recorded by the head of the rehabilitation therapist's team, represents the therapist's absence due to sickness, and other leave includes training, vacation, and personal leave. Using the formula, the predicted AWT for rehabilitation therapists was 222 days or 1,776 hours in 1 year .The activity standard is a unit of time for a rehabilitation therapy activity of a therapist, including period and average of time performing admission assessment, pre-treatment evaluation, rehabilitation therapy, and post-treatment evaluation. The service standards and allowance standards were defined as follows: the standards of services and activities reported in the annual service statistics were termed service standards, and the allowance standards applied to activities that were not reported. The unit of time for each rehabilitation therapy activity was counted using the information collected from observations and self-assessments by rehabilitation therapists to define the activity standards .There are two sorts of allowance standards: category allowance standards (CAS) and individual allowance standards (IAS) . The forThe time required to perform each additional activity was calculated and multiplied by the number of rehabilitation therapists (RTs) required to perform that therapy activity per year. The time required for all rehabilitation-related activities was then added to calculate the total IAS per year. Finally, the individual allowance factor was calculated by dividing the total IAS by the total AWT of each therapist .The total number of required RTs was calculated by multiplying the total number of personnel obtained above by the category allowance factor. Later, the individual allowance factor was added to the result. The total number of therapists required was calculated using the total required staff for rehabilitation therapist activities × CAF + year long total IAS/AWT. This is 20.12 × 1.10 + 0.65 = 22.78 = 23. Hence, 23 RTs are required for the RD in this tertiary educational hospital.* 100 and the classification ranges “low” (1–29%), “high” (30–40%), “very high” (41–60%), and “extremely high” (>60%)  , the worIn the aging context, the WISN tool was demonstrated to be useful in setting facility-level norms for health workforce. This WISN-based estimation did not consider other absences, such as maternity leave and therapists' participation in further learning in other hospitals. The WISN tool was previously used to help many countries develop evidenced-based staffing norms for their nurses, doctors, pharmacists, laboratory staff, and medical officers at the national, regional, or organizational level. When the WISN ratio is one, there is a balance between department needs and existing staffing; if it is higher than one, the department is stress-free, while if it is lower than one, the department is understaffed. Thus, the WISN ratio in this study showed that the therapists in the department were under severe pressure.Globally, the education and training of RTs began earlier than in China. Physical therapists, occupational therapists, and speech therapists all have their own educational systems and job classifications. However, in China, there is only one major—rehabilitation therapy. After graduation, the students are assigned to different paths when they enter facilities such as this studied hospital. Thus, in this research, RTs included all categories of rehabilitation.In the Evaluation Criteria for Rehabilitation Medical Service Model Hospitals  , producevia an online questionnaire, and some questions were self-evaluated. Thus, data collection systems should be improved in the future. In addition, the observation times were limited because of the COVID-19 pandemic; it was difficult to get long-term access to the hospital. Further, the WISN approach uses the statistics of health services from the prior year; accordingly, this approach counts the total needed therapists for the previous year , the Natural Science Foundation of Shandong Province (Grant No. ZR2020QG057), and the Postdoctoral Research Foundation of China (Grant No. 2020M681191).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Physical aspects such as the type and severity of an injury are not the only factors contributing to whether or not a person can return to work (RTW) after a serious injury. A more comprehensive, biopsychosocial approach is needed to understand the complexity of RTW fully. The study aims to identify predictors of RTW 78 weeks after discharge from initial inpatient trauma rehabilitation in patients with severe musculoskeletal injuries using a biopsychosocial perspective.via stepwise variable selection based on the Akaike information criterion. The final model was validated for the training and the validation data.This is a prospective multicenter longitudinal study with a follow-up of up to 78 weeks after discharge from trauma rehabilitation. Data on potential predictors were collected at admission to rehabilitation using a comprehensive assessment tool. The status of RTW (yes vs. no) was assessed 78 weeks after discharge from rehabilitation. The data were randomly divided into a training and a validation data set in a ratio of 9:1. On the training data, we performed bivariate and multiple logistic regression analyses on the association of RTW and potential predictors. The final logit model was selected n = 561 male, 73.7%; mean age: 47.5 years, SD 12.3), primarily suffering from severe injuries to large joints and complex fractures of the large tubular bones, could be considered for analyses. At 78 weeks after discharge, 618 patients (81.2%) had returned to work. Eleven predictors remained in the final logit model: general health, current state of health, sensation of pain, limitations and restrictions in activities and participation (disability), professional sector, ongoing legal disputes, financial concerns (assets), personality traits, life satisfaction preaccident, attitude to life, and demand for pension claim. A predicted probability for RTW based on the multiple logistic regression model of 76.3% was revealed as the optimal cut-off score based on the ROC curve.Data from 761 patients (A holistic biopsychosocial approach is needed to address RTW and strengthen person-centered treatment and rehabilitation. Patients at risk for no RTW in the long term can already be identified at the onset of rehabilitation. The World Health Organization (WHO) reports intentional and unintentional injuries as the leading cause of death and disability, accounting for nearly 500,000 deaths in the WHO European Region in 2016  , with itThis paper presents the results of a longitudinal study—conducted as part of the icfPROreha project—that aims to identify predictors of RTW 78 weeks after discharge from initial inpatient trauma rehabilitation in patients with severe musculoskeletal injuries using a biopsychosocial perspective. The results of our study are based on a broad database with a comprehensive survey of potential predictors of RTW generated in 10 hospitals across Germany. They provide valuable insights that considering a biopsychosocial perspective is important for understanding RTW. In addition, our research sheds light on which functioning aspects and contextual factors are important for predicting RTW. These findings can help professionals working in rehabilitation to become aware of potential cases with a risk of delayed RTW at an early stage and to take the appropriate action.www.icf-proreha.de) is a joint project of the Chair of Public Health and Health Services Research–IBE of LMU Munich, the BG Rehabilitation Department of BG Unfallklink Murnau, and further nine cooperating rehabilitation departments all over Germany. The project aims to identify determinants  predicting RTW, time off work, and quality of life in persons with severe musculoskeletal injuries after inpatient trauma rehabilitation. In addition, an outcome prognosis and guidelines including recommendations have been established in icfPROreha, showing how to address the identified predictors in rehabilitation management to considerably reduce time off work and ensure a successful return to work.The research project “ICF-based prediction of outcomes in rehabilitation after trauma—icfPROreha” (The implementation of icfPROreha took place over 55 months (April 2017 to October 2021) and was divided into four phases .In phase 3, we conducted a multicenter longitudinal study in collaboration with the participating rehabilitation departments in which functioning aspects, contextual factors, and injury-specific and sociodemographic data were systematically recorded using a comprehensive ICF-based assessment tool. The assessment tool provides a database for carrying out predictive analyses of the outcome RTW 78 weeks after discharge from inpatient trauma rehabilitation.The study and its protocol were approved by the Ethical Committee of the Medical Faculty of LMU Munich  and the Ethical Committees of the participating rehabilitation departments. It was registered in the German Register of Clinical Studies (DRKS-ID: DRKS00014857). All included patients gave written informed consent to participate in the study.The study included severely injured persons being admitted as inpatients to rehabilitation departments of one of the participating hospitals from August 2018 to December 2019 and met the following inclusion criteria: (1) age 18–65 years, (2) diagnosis of severe musculoskeletal injury according to the German injury classification, such as severe injuries to large joints see  (18),  to initial inpatient rehabilitation in electronic form on a mobile device (tablet). Follow-up surveys on the status of RTW took place 12 (t3), 26 (t4) 52 (t5), and 78 weeks (t6) after discharge. Time points t3–t6 were conducted as telephone interviews; the end of data collection was 31 August 2021. In addition, the status of RTW was validated and—in case of missing values—complemented by routine data of the corresponding insurers. Only data on t1 (admission to rehabilitation) and t6 (78 weeks after discharge) were used here.n = 761). In these analyses, we considered whether the patient—as a result of the accident—has RTW or not (yes vs. no). Further aspects, such as type of job (full-time or part-time) or type of work activity (previous activities or modified activities), were not taken into account. Individual missing values in the potential predictor variables were replaced by mode or median based on the data of the finally included patients (n = 775). Initial descriptive analyses were performed.In the first step, all cases with a known status of RTW 78 weeks after discharge from inpatient rehabilitation were identified  and potential predictors. For the dependent variable, both bivariate regression models (logit models) and bivariate regression trees (classification trees) were calculated, i.e., models with a single predictor each. A number of metric variables were recoded based on the split values of the classification trees. Subsequently, we preselected potential predictors to be included in the multivariable analysis if they were associated with the dependent variable, i.e., showed a significance level of <0.1 for the bivariate logit models or <0.05 for the bivariate classification trees.Next, a multiple logistic regression analysis was performed on the training data set—including all preselected potential predictors—in which the final logit model was selected via stepwise variable selection based on the Akaike information criterion (AIC) . Afterwan = 561 male, 73.7%; mean age: 47.5, SD 12.3) could be considered for this publication , followed by complex fractures of the large tubular bones , were the most common injuries sustained. On average, patients were admitted to the first inpatient rehabilitation 37.4 days after discharge from the acute hospital, which lasted on average 6.2 weeks (median: 4.7 weeks).According to the diagnoses, severe injuries to large joints  than the proportion of men . However, bivariate analysis revealed no significant differences in RTW with regard to gender (p = 0.2482); thus, gender was not included in the multiple logistic regression analysis.At 78 weeks after discharge from rehabilitation, 618 patients (81.2%) had returned to work, whereas 143 patients (18.8%) had not returned to work. Of the 618 patients with RTW at the observed point in time, about half had returned within 16 weeks after discharge from the first inpatient rehabilitation . In terms of gender, the proportion of women having returned to work was 5.1% higher , professional sector, ongoing legal disputes, financial concerns (assets), personality traits, life satisfaction preaccident, attitude to life, and demand for pension claim.The identified predictors comprise aspects related to the health problem and functioning aspects and contextual factors, i.e., they refer to all components of the biopsychosocial perspective according to the ICF .p = 0.0221; CI ), and patients who stated higher levels of pain at rest  had a 55% reduced odds  of having returned to work 78 weeks after discharge, respectively.According to our analyses, the current state of health and sensation of pain (in particular pain at rest) at admission to inpatient rehabilitation are strong predictors regarding RTW 78 weeks after discharge. Patients who rated a state of health >53  had an 82% higher odds  for RTW compared with patients not in this sector. Furthermore, individuals who stated financial concerns at admission to rehabilitation and persons who reported ongoing legal disputes related to the accident were less likely to be able to work 78 weeks after discharge .The professional sector, or more precisely, working in the construction, architecture, surveying, and building services engineering, is a strong predictor related to RTW. Among our study collective, being in this professional sector is associated with a 53% reduced odds , whereas an increase of 1 in the Neuroticism score increased the odds of RTW by 36% .Of the five personality traits assessed by BFI-10, Conscientiousness and Neuroticism  remained significant predictors in the model. An increase of 1 in the Conscientiousness score reduced the odds of RTW by 31% .The bivariate regression tree revealed 53 as a split value regarding life satisfaction preaccident (score: 0–100). Patients who rated their preaccident life satisfaction better at admission to inpatient rehabilitation, i.e., who scored >51, had a 67% reduced odds for RTW compared to patients who rated their preaccident life satisfaction as ≤51  in the included study population.We identified demand for pension claims as a highly significant predictor for RTW 78 weeks after discharge. Confirming the statement “I think I will probably apply for / get a pension in the near future” resulted in a 93% reduced odds of RTW , while an alternative cut-off score of 85.1% led to high sensitivity of at least 80% on the training data set .For both cutoff scores, sensitivity, specificity, PPV, and NPV for the training data set and the validation data set are provided in This paper reports on the results of a multicenter longitudinal study conducted as part of the icfPROreha project. Our objective was to identify factors—taking into account a biopsychosocial perspective—relevant to the prediction of RTW of individuals with severe musculoskeletal injuries 78 weeks after discharge from inpatient trauma rehabilitation. Thus, we seek to contribute to a better understanding of the complexity of RTW after severe musculoskeletal injuries, detached from a purely biomedical approach.Studies have shown that whether someone returns to work after an injury does not necessarily depend only on the type of injury but on multiple factors , 27, 28.In this study, we assessed a wide range of factors as potential predictors of RTW at admission to inpatient rehabilitation to cope with the biopsychosocial understanding of functioning and disability. Considering our results, it is advisable to distinguish between modifiable and generally nonmodifiable predictors because appropriate interventions should primarily target modifiable factors to avoid prolonged delay of RTW. Based on our data, 11 predictors of RTW were identified, which not only refer to functioning but also include environmental and personal factors. Predictors that reduce the odds of RTW are lower general health, higher level of pain and disability besides working in the construction sector, having stated ongoing legal disputes, and reporting financial concerns. Furthermore, being a very conscientious person, showing a higher overall life satisfaction before the accident and assuming to receive or apply for a pension in the near future reduced the odds for RTW in our population. Predictors that increase the odds of RTW are a higher score in the current state of health as well as considering work as an important purpose in life and having a higher score in the personality trait neuroticism.p-value: 0.0015). From a clinical point of view, the result is very plausible, and it provides valuable evidence that even low-level pain at rest should not be underestimated. In close contact with the patient, pain can be addressed at an early stage, for example, through appropriate pain communication, the involvement of a pain therapist, the use of passive therapies, or the administration of pain medication.Our results regarding predictors for RTW related to functioning, i.e., sensation of pain and level of disability, are in line with scientific research on RTW following a traumatic injury , 15, 35.We further identified a number of contextual factors such as working in the construction sector , reportiTo ensure optimized care, it is particularly important to identify at an early stage those individuals who are at risk for prolonged or no RTW. Thus, the rehabilitative treatment and measures can be optimized, for example, by applying the appropriate interventions or by involving specific health professions. Our analyses revealed a predicted probability for RTW at the admission of 76.3% as cutoff, i.e., in individuals with a predicted probability of RTW less than 76.3%, the predicted status will be “no RTW,” and conversely, in individuals with a predicted probability of RTW greater than 76.3%, the predicted status will be “RTW.” By assessing the identified predictors at admission to the first inpatient rehabilitation, 65.6% of the patients who will not RTW at 78 weeks after discharge from rehabilitation will be detected (sensitivity). Using the alternative cutoff of 85.1% would lead to an increase in the proportion of individuals being correctly identified as not going to RTW up to 80.5%. However, by doing so, the PPV would decrease from 46.4% to 35.2%, which means that of those receiving increased attention, only 35.2% would have an actual need. A PPV of 46.4% (or even 35.2%) may not seem particularly meaningful. However, it should be taken into account that the PPV cannot be close to 1 if the prevalence of the outcome is rather low ; accordingly, it is difficult to get a high PPV . As we aThe study is subject to certain limitations. Due to the extensive assessment, sufficient knowledge of the German language was required for participation in the study. Thus, a substantial proportion of patients who were not fluent in German had to be excluded. In particular, injured patients with a migration background and/or language comprehension problems, but also Germans with  illiteracy, pose special problems for rehabilitation facilities and treatment providers. As predominantly clinics run by the employers' liability insurance association participated, mainly patients after occupational accidents were included. The payer is usually the German Social Accident Insurance (DGUV), which, in contrast to statutory health insurance, has a broader legal mandate and aims for rehabilitation “by all appropriate means.”The particular strength of our study lies in the large number of patients included in the participating hospitals and the broad database available for the analyses. Due to the small number of missing values, both for the potential predictors and the outcome RTW, the data of almost all included patients could be considered in our analyses.In general, there is still a lack of studies that comprehensively examine functioning and contextual factors related to RTW in individuals with traumatic injuries. Our study results support, however, the need for a holistic biopsychosocial view on functioning and contextual factors to further strengthen person-centered treatment and optimize guided rehabilitation , 30–32. Thus, knowing the relevant predictors allows recommendations for action to be developed to address these factors influencing RTW. Health care professionals to develop targeted interventions and strategies to prevent no RTW at an early stage. Recommendations for strategies can not only refer to the phase of inpatient rehabilitation but can also start at an early stage, e.g., after completion of acute care. Insurer specialists such as rehab managers can identify cases at risk of delayed RTW in good time and initiate the appropriate measures. In the interaction of all those involved in care, it is thus possible to prevent the accident victim, who wants to recover as quickly as possible, from becoming chronically ill.


Androgen receptor (AR) signaling remains the key therapeutic target in the management of hormone‐naïve‐advanced prostate cancer (PCa) and castration‐resistant PCa (CRPC). Recently, landmark molecular features have been reported for CRPC, including the expression of constitutively active AR variants that lack the ligand‐binding domain. Besides their role in CRPC, AR variants lead to the expression of genes involved in tumor progression. However, little is known about the specificity of their mode of action compared with that of wild‐type AR (AR‐WT). We performed AR transcriptome analyses in an androgen‐dependent PCa cell line as well as cross‐analyses with publicly available RNA‐seq datasets and established that transcriptional repression capacity that was marked for AR‐WT was pathologically lost by AR variants. Functional enrichment analyses allowed us to associate AR‐WT repressive function to a panel of genes involved in cell adhesion and epithelial‐to‐mesenchymal transition. So, we postulate that a less documented AR‐WT normal function in prostate epithelial cells could be the repression of a panel of genes linked to cell plasticity and that this repressive function could be pathologically abrogated by AR variants in PCa. Androgen receptor (AR) is essential for prostate development and function, and also for prostate cancer (PCa) cell survival and proliferation. In this study, we show that the transcriptional repressive program of AR in PCa is a determinant of constrained cell plasticity and that this protective role is lost in the presence of pathological constitutively active AR variants or during androgen ablation therapy. ARandrogen receptorAREsandrogen‐responsive elementsAR‐WTwild‐type ARBioID2proximity‐dependent biotin identification‐2BPbiological processCCcellular componentCDH2cadherin‐2 (N‐cadherin) geneCRPCcastration‐resistant prostate cancerDHTdihydrotestosteroneEMTepithelial‐to‐mesenchymal transitionEtOHethanolFBSfetal bovine serumFCfold changeFDRfalse discovery rateGEOGene Expression OmnibusGOGene OntologyGSEAgene set enrichment analysisHRPhorseradish peroxidaseMFmolecular functionMSigDBMolecular Signature DatabasenAREsnegative AREsPCaprostate cancer1With an estimated 1.27 million newly diagnosed men worldwide in 2018, prostate cancer (PCa) remains the second most common cancer in men according to the GLOBOCAN project and is the fifth leading cause of death from cancer in men, which places it as a vitally important public health issue , 4.Androgen receptor is a ligand‐dependent transcription factor that belongs to the nuclear receptor superfamily , 5. In aAR gene rearrangements that result in the expression of constitutively active AR variants emerge as important molecular mechanisms that lead to CRPC  referring to AR ChIP‐seq from LNCaP cells cultured in complete medium provides 21127 AR binding sites (peaks). Samples GSM4462682, GSM4462683 and GSM4462684 [31] corresponding to three replicates of VCaP cells treated with 1nM of R1881 for 22h were first subjected to the bedtools intersect function from pybedtools library on python 3 to identify 30941 AR peaks common to the three replicates. Then, the Genomic Regions Enrichment of Annotations Tool (GREAT version 4.0.4) program was used to associate the AR binding sites to putative target genes with the single nearest method and 1000 kb as the maximum extension (http://great.stanford.edu/public/html). Intersection of these ChIP‐seq AR target genes with genes identified as differentially expressed in RNA‐seq data provided us a list of AR peaks associated with genes up‐regulated or down‐regulated by AR in LNCaP and VCaP cells. In order to proceed to motif analysis, sequences corresponding to AR binding sites (500 bp centered on the peak summit) were retrieved from human reference genome (hg19/GRCh37) and submitted to MEME‐ChIP webserver (https://meme‐suite.org/meme/tools/meme‐chip).Click here for additional data file.Fig. S6. Motif analysis of AR peaks in LNCaP and VCaP cells. The first two DNA sequence motifs found by the MEME‐ChIP program in AR binding sites associated to up‐regulated and down‐regulated genes by AR in LNCaP cells (A) and in VCaP cells (B).Click here for additional data file.Fig. S7. BioID cellular model to investigate difference in partner recruitment between DHT‐activated AR‐WT and constitutively active AR variants. (A) Western blot showing expression of myc‐BioID2 (Control) and myc‐BioID2‐AR in the presence of doxycycline (DOX) in stable transduced LNCaP cells. (B and C) Validation of functionality of myc‐BioID2‐AR‐WT construct in transduced LNCaP cells. (B) Streptavidin‐HRP labelling revealed protein biotinylation induced by myc‐BioID2 or myc‐BioID2‐AR‐WT in LNCaP cells in the presence or absence of doxycycline, and in the presence of 10 nM DHT. (C) Luciferase assay using the PSA61‐luc construct confirmed androgen‐dependent transcriptional activities of Myc‐BioID2‐AR‐WT fusion protein in LNCaP cells. In brief, 104 LNCaP cells were transfected in triplicates with 230 ng of PSA61‐luc  and 20 ng of Renilla‐luc  plasmids using the JetPEI transfection reagent (Polyplus transfection) and according to the manufacturer’s protocol. After 48 hours, luciferase activities were measured using Dual Dual‐Glo® Luciferase Assay System (Promega) following supplier’s instructions. Bar graph represents mean of 3 biological repeats.Click here for additional data file.Table S1. List of primers used for RT‐qPCR.Click here for additional data file.Table S2. Significantly regulated proteins in MS analysis.Click here for additional data file.Table S3. Gene Set Enrichment Analysis down‐regulated pathways.Click here for additional data file.


Fracture patients are frail and have high mortality. We investigated whether introducing a fast-track strategy during post-surgery care and including early rehabilitation protocols may shorten the length of hospital stay (LOS) while improving the overall clinical effectiveness. A training ground was built inside the inpatient area dedicated to trauma settings. Usual postoperative care consists of immobilization during the first day, but patients may start rehabilitation earlier, 24 hours after the surgical procedure, with a fast-track strategy. In general, gait speed, step length, and self-assessment in terms of mobility improve significantly in the first six postoperative weeks in fracture patients. As delayed postoperative mobility during hospitalization was observed, the established training ground may help with this concern. The expert physiotherapist may contribute to ameliorating the indicators showing great potential in postoperative rehabilitation regardless of fracture pattern. The primary outcome was postoperative physical functioning. Secondary outcomes included the patient’s assessment of therapeutic effect , perceived pain intensity, health services utilization, treatment side effects, and adverse events. Data were analyzed by univariate analysis and binary logistic regression showing a reduction of LOS of almost three days. Further, the optimized hip fracture program reduced the rate of in-hospital postoperative complications and mortality. Adding to the schedule, some PROMPTS (Patient-reported outcome measures) could further integrate the patient empowerment perspective into the quality set of values. For this reason, ‘fast track’ may define a crucial policy able to guarantee rapid rehabilitation, becoming a key factor to achieving a good clinical effect. Fast-track rehabilitation facilitates a shortened hospital stay and cost-saving and can be used to optimize the patient’s condition before admission to a rehabilitation facility• Early rehabilitation protocols may shorten the length of hospital stay (LOS) while improving the overall clinical effectiveness.• Human factors and patients empowerments may help.


Person-centeredness in healthcare is a philosophical approach in which decision-making and caregiving is explicitly undertaken with, and not for the person, with their needs, values and preferences positioned as central to the care they receive . Person-Attard et al. contribute a discussion paper presenting a novel perspective to the conceptualization of person-centeredness relevant to rehabilitation and recovery. They illustrate how the concepts of SECI and Ba from Japanese epistemological traditions can provide novel processes that could facilitate children's involvement in decision-making about their care, rehabilitation and recovery within child and adolescent mental health services. They propose that creating opportunities within the system (Ba) for eliciting and integrating the tacit and explicit knowledge of stakeholders using the SECI model will provide platforms for developing person-centered practices to ensure that the values, beliefs and experiences of parents, children and staff are heard and given equal value within the system. Curnow et al. draw on another conceptual framework—the Person-Centered Practice Framework (Within this topic in Frontiers in Rehabilitation Science, we present a collection of papers that address some of the key issues in this emerging academic and practice-orientated field. ramework  to exploLeeson et al. explored how clinicians worked with people with traumatic brain injury to identify a goal focus for a community-based social activity within the context of a community connection intervention. They identified humanizing, empowering, and focusing as key strategies for building a relational approach to underpin their intervention, concepts with broad application to goal-setting within many rehabilitation contexts. Building on the importance of context to person-centered rehabilitation, Eggen and Thuesen interviewed eight people with rheumatic diseases about the changing relevance of goals and plans made within in-patient rehabilitation to their lives after discharge. They found that goals and plans made within rehabilitation were acontextual to their lives after discharge, with being back home described as a harsh reality. Consistent with recent person-centered models for rehabilitation (Person-centered goal-setting, in which meaningful goals are negotiated with recipients of rehabilitation and plans to achieve them are agreed upon, is considered fundamental to rehabilitation practice . Despitelitation  and carelitation , the stuWadams et al. is a systematic review of metacognitive treatment in acquired brain injury, explicitly evaluating its relevance to aphasia. Metacognitive therapy seeks to promote self-awareness and awareness of performance errors, thereby enhancing independence in goal setting and achievement, therapy participation and functioning. The review showed the intervention was effective across a range of outcomes, but the small number of studies examining its specific use in people with aphasia meant that it was impossible to determine effectiveness for that population, and more research is necessary. Metacognitive therapy is inherently person-centered and focuses on the individual and their specific goals and challenges. This important review provides another example of the expansion but relative immaturity of the field of person-centered rehabilitation.The development and testing of person-centered interventions is another indication of the growth of the field within rehabilitation. The final paper within this collection by Together these articles provide a snapshot of issues relevant within this growth area of research in rehabilitation. They provide a small but essential step in advancing knowledge to address some of the most challenging topics and in moving the almost universal rhetoric about person-centered rehabilitation within the field toward a steadfast reality.JM took the lead in writing the editorial. NK and BM reviewed drafts and provided critical feedback. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The treatment and rehabilitation for people with acquired brain injury is continually evolving, with increasing recognition of the importance of approaches that adopt a multi-disciplinary biopsychosocial perspective focused on improving adjustment, social participation, and wellbeing. However, there is significant variability as to how such approaches are delivered, across the various stages of recovery, rehabilitation settings, and within different healthcare systems.This paper had three aims. The first was to describe the neurobehavioral therapy (NBT) approach to brain injury rehabilitation adopted in our charitable organization. The second aim was to report how the NBT approach evolved in response to changes in referral patterns, and patient needs within a broader, longer-term clinical pathway. The third aim was to assess the effectiveness of the NBT approach by analyzing outcome data.Retrospective analyses of standardized outcome data were completed to investigate the effectiveness of our approach. Case vignettes are provided to illustrate the key components of the approach.Outcome data suggested that the approach is effective in delivering positive outcomes for patients. Furthermore, the data show differences in presentation between three clinical streams  within the NBT approach.This paper describes the adaption of the ‘traditional' neurobehavioral approach to brain injury rehabilitation into a model of delivery that can benefit a more diverse range of people living with the heterogenous and long-term consequences of brain injury. The Trust's first rehabilitation center, Thomas Edward Mitton House, established in 1991, had a strong behavioral ethos, which evolved to incorporate aspects of cognitive theory fundamental to human learning, informing all rehabilitation activities .At present the Trust has two hospitals, seven assessment and rehabilitation centers and eight continuing brain injury rehabilitation units. Since offering specialist brain injury rehabilitation in 1991, there has been an ongoing emphasis on shaping the rehabilitation provided to patients around a neurobehavioral approach. Originally, the approach was based on a “purer” behavioral model applied to the rehabilitation of persons with acquired brain injury, predominantly those with traumatic brain injury and behavioral difficulties. Over time, it has evolved to incorporate aspects of cognitive theory that are seen as fundamental to learning, and there is growing evidence that the approach may be indicated for anyone who cannot independently meet their own social or functional needs , 7.social outcomes, which occurs post-acutely, within a community setting. It is a transdisciplinary approach. The whole multidisciplinary team, which typically comprises neuropsychologists, clinical psychologists, occupational therapists, physiotherapists, and speech and language therapists, jointly focuses on behaviors or outcomes , rather than on improving specific areas of impairment . The approach recognizes and places centrally the neurological underpinnings of brain injury. For this reason, it is delivered within a structured environment which facilitates the consistent application of rehabilitation procedures to promote implicit learning, consolidation and generalization of habits and routines. The focus on feedback and on processes to evaluate outcomes facilitate the development of self-awareness, as well as the adaptation of rehabilitation procedures as the individual progresses. Through interactions with staff during rehabilitation in a variety of settings, patients learn by experience and work toward adjusting to life after brain injury. The key aspects of the approach are informed by neuropsychological principles and psychological formulation. Formulation incorporates how cognition, learning, and emotion together influence the person's adjustment, engagement in rehabilitation, and recovery. It is psychology-led; however, senior members of different clinical professions also contribute to the leadership of services and teams.Some of the general principles of neurobehavioral rehabilitation originally described by Wood and Worthington, and which remain relevant , includeevery suitable interaction, which facilitates opportunities for generalization of rehabilitation gains across environments. Furthermore, a novel aspect of the approach, the high frequency possible to achieve through support workers' contacts with patients, further facilitates learning and generalization through repetition. These everyday applications of the approach are guided by the psychology-led transdisciplinary formulations and treatment plans.Basic behavioral modification principles, for example reinforcement, modeling, feedback, and non-reinforcement, among others, remain key to the rehabilitation programmes across the Trust's rehabilitation centers and hospitals. A unique feature of neurobehavioral programmes is the concept that “every interaction is an opportunity to implement a small building block of the person's rehabilitation”. What that means in practice is that new learning is supported both by members of the transdisciplinary clinical team, who apply these principles in their sessions with patients, and on an everyday, 24/7 principle, by rehabilitation support workers and other floor staff. These floor staff encounter patients many times each day, and apply behavioral strategies, such as, for example, feedback and reinforcement in Every interaction is rehab.”), through for example our intranet, email signatures, and screensavers. The engagement and feedback on whether staff are aware of the monthly mantra, and how they have applied it are obtained to monitor learning and skills development. The overarching aim with this initiative is to consolidate an understanding of why rehabilitation is delivered in a certain way, and to ensure consistency in everyday practice. The initiative is also intended to ensure maximum penetration of the model's principles into every aspect of rehabilitation, thus increasing the ‘dose’ of therapeutic interactions by all staff, which is a novel aspect of the NBT approach.Skilling staff to understand and apply these transdisciplinary formulations is a key component of the approach. This is achieved in multiple ways, ranging from formal training on understanding brain injury, to bespoke tutorials introducing specific interventions or clinical guidelines, all developed to support recovery and the achievement of rehabilitation roles. More recently, the Trust has been piloting a new “Rehab Mantras” initiative as a novel way of ensuring the constant embedding of the core principles of the neurobehavioral approach into everyday operation and practice across all our services. This involves identifying and disseminating a “rehab mantra” each month to all staff  for example, has had a significant influence on the range of neuropathological conditions seen in the Trust's services. The other factor driving this development, has been the desire to have more complete, integrated multi-disciplinary clinical pathways to meet the needs of patients on the journey from sub-acute, to post-acute, to long-term health and care.Data from referrals spanning 2 years, including diagnostic information and routinely collected outcomes, were retrospectively analyzed to assess the effectiveness of the approach.Clinical effectiveness is routinely monitored by periodically analyzing data from global measures of outcome, which provides evidence about the effectiveness of rehabilitation and informs practice development, both clinical and research . These rSupervision Rating Scale [SRS ], a 14-pThe BIRT Independent Living Scales—Accommodation and Occupation , which Mayo-Portland Adaptability Inventory—IV [MPAI-4 ], is a wn = 9, 81%), observations and behavior monitoring , standardized clinical measures  and goal achievement scores .In addition to these measures, clinicians monitor the progress using a range of methods that are most suited to the person's individual goals, given that goal setting is associated with effectiveness of rehabilitation. Based on a survey of the Trust's psychologists, this usually includes patient feedback .This paper describes the overarching Brain Injury Rehabilitation Trust approach, and its clinical implementation, and application to three different ‘streams’ of service provision. These “streams” are illustrated with case vignettes. Quantitative outcomes achieved by patients who completed their programmes over the period between October 2019 and October 2021 were analyzed with R 4.1.2 , using dRecent referral data spanning just over 2 years (01 October 2019–31 October 2021) provide more detailed information of the gradual expansion of diagnoses accepted within the Trust's services. These data show that services provide, or have provided (where discharge has taken place), clinical services to persons with diagnoses other than traumatic brain injury, including several types of stroke . More spCluster analysis methodology has been used previously to inform and validate the development of three broad streams that match different profiles of clinical need within the NBT approach. This identified specific areas that distinguish between groups, including functioning, neuropathology, comorbidity, and the time since injury or illness onset . The finAccordingly, rehabilitation centers or hospitals are now configured and staffed to best meet the different needs of patients who require:Restoration, which is indicated for people who have significant needs in specific areas, for example self-care, communication, or mobility, because of a recent brain injury, and who are likely to benefit from approaches focused primarily on restoration of function. People who benefit from this stream will usually have good awareness of their injury, and how it has affected them. They also do not show any behaviors of concern , which wCompensation is for people whose needs may present as barriers to taking part in neurorehabilitation, and who are likely to benefit from approaches primarily focused on compensation of function. People in this group may need initial support, prompting, and feedback to become more aware of, and adjust to, the difficulties they face after brain injury. In some cases, they may have both cognitive and emotional difficulties, as well as physical health needs.Scaffolding and support is for people who are likely to benefit from ongoing clinical input and support to maintain function and prevent relapse or deterioration. Improvements as a result of functional skills training are achievable in this group , but thiData illustrating the three clinical streams are shown in Three case vignettes containing qualitative information, provide individual examples of these differences.Mr A was referred for 12 weeks rehabilitation 2 months after suffering a large left cortical ischemic stroke in the middle cerebral artery area. His stay in rehabilitation was later extended by a further 12-weeks due to the COVID-19 pandemic. The first part of his programme focused on comprehensive assessment and management of his cognition and aphasia. The programme then continued with intensive physiotherapy for 45–60 mins a day, 5–6 times a week. This was extended beyond the clinical sessions, through “self-led” exercise sessions where rehabilitation support workers ensured that the exercises were performed correctly within his everyday environment. Mr A also worked on improving problem solving, and motor planning skills with the physiotherapist, occupational therapist and speech and language therapist. In the last few weeks at the unit, the programme focused on stand and walk practice, and on learning exercises to do at home post-discharge. At the end of the programme Mr A was able to walk with a stick and manage his personal care by himself. Mr A's total standardized score on the Mayo-Portland Adaptability Inventory reduced by 12 points to 53, indicating moderate disability at the time of discharge, and clinically robust changes .W = 44,991, p < 0.001), which was large in the Restoration and Compensation streams, and medium within the Scaffolding stream. Comparable changes were found on the BILS Accommodation , indicating discharges into less structured community-based settings . Changes in occupation were more modest, but meaningful and significant , with 28% of the people discharged into an independent living setting engaged in an occupational role. The MPAI-4 scores revealed an overall significant reduction of disability in all domains of the MPAI-4 , but these positive changes were generally limited to improvements in social participation for those in the Scaffolding and support stream.The median scores on the SRS showed a statistically significant reduction of supervision needs . Furthermore, individuals who were discharged earlier than planned , were excluded from the analyses, as they would not have completed their rehabilitation programme. However, the data did include results for individuals who were discharged later than planned, which has been found to influence outcomes . Delays One of the main strengths of this paper is that it describes in detail a modified neurobehavioral approach, which may offer opportunities to develop rehabilitation programmes that lend themselves to addressing a wider (than behavior) range of difficulties patients may present. The outcome data reported here suggest that it is possible to achieve meaningful change with such modified programmes. The data provide preliminary evidence that treatments in the three streams of rehabilitation described can potentially benefit a wider group of patients with neurological injury or illness, over the longer-term journey of a more complete clinical pathway.sara.dasilvaramos@thedtgroup.org.The data analyzed in this study is subject to the following licenses/restrictions: access to data analyses can be requested from SR. Requests to access these datasets should be directed to Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.RC defined the topic, aims, scope of the paper, and wrote the first draft. SR conducted the statistical analysis, data presentation, sourced, and wrote up the case vignettes. Both authors contributed to the writing and development of subsequent drafts and approved the final version of the paper.The authors are grateful for the financial support received from their employer, the Disabilities Trust, for open access publishing of this paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Pediatric rehabilitation medicine is a discipline that enables children with acquired or congenital disabilities to reach their maximum physical, mental, social, occupational, and educational potential . PediatrIn this Special Issue, seven clinically significant publications are discussed ,6,7,8,9.As the editor responsible for this Special Issue, I am elated to contribute to the current body of knowledge on pediatric rehabilitation and to present the novel treatment discussed in these seven studies. I hope that this Special Issue will further advance pediatric rehabilitation research.