STNB1 and PFN2 as OCT1-targets among them. Immunohistochemistry revealed that both STNB1 and PFN2 are highly expressed in human AR-negative PC tissues. Knockdown of SNTB1 and PFN2 by siRNAs significantly inhibited migration of AR-negative PC cells. Notably, knockdown of PFN2 showed a marked inhibitory effect on tumor growth in vivo. Thus, we identified OCT1-target genes in AR-negative PC using a patient-derived model, clinicopathologial analysis and an animal model.Androgen and androgen receptor (AR) targeted therapies are the main treatment for most prostate cancer (PC) patients. Although AR signaling inhibitors are effective, tumors can evade this treatment by transforming to an AR-negative PC via lineage plasticity. OCT1 is a transcription factor interacting with the AR to enhance signaling pathways involved in PC progression, but its role in the emergence of the AR-negative PC is unknown. We performed chromatin immunoprecipitation sequencing (ChIP-seq) in patient-derived castration-resistant AR-negative PC cells to identify genes that are regulated by OCT1. Interestingly, a group of genes associated with neural precursor cell proliferation was significantly enriched. Then, we focused on neural genes  Since androgen receptor (AR) signaling persists in most cases of castration-resistant PC (CRPC), second-generation AR signaling inhibitors are commonly used to treat CRPC6. However, with increasing use of AR signaling inhibitors, new mechanisms of resistance have emerged, including loss of AR expression, via lineage plasticity7.Although androgen deprivation therapy (ADT) is initially effective for the treatment of prostate cancer (PC), inevitably castration-resistant tumors emerge8. AR-collaborating TFs act on the AR-binding region condensed and packed by nucleosomes to support AR-binding, resulting in the enhanced expression of androgen-responsive genes. Among these TFs, GATA binding protein 2 (GATA2), forkhead box A1 (FOXA1), and octamer transcription factor (OCT1) were known to be significantly enriched along with functional AR in 68% of AR-binding regions9.AR signaling involves co-factors and AR-collaborating transcription factors (TFs)10. Comprehensive analysis of OCT1 signals revealed that acyl-CoA synthase long-chain family member 3 (ACSL3) is the most highly expressed gene regulated by AR and OCT1 in hormone-responsive PC, LNCaP cells12. Moreover, we observed increased expression of OCT1 in CRPC tissues compared with hormone-sensitive PC13. The genome-wide analysis of OCT1-target genes in 22Rv1 cells, a model of AR-positive CRPC, identified another set of target genes distinct from LNCaP cells that accelerate PC cell proliferation by promoting cell cycle, including aniline-actin binding protein (ANLN) and DLG-associated protein 5 (DLGAP5)14. These data raise the hypothesis that the set of genes targeted by the OCT1/AR complex changes with PC progression.We previously demonstrated that high expression of OCT1 is correlated with poor outcome of PC patients15. However, the selective pressure of long-term androgen deprivation therapy (ADT) can eventually induce the development of NEPC16 or double (AR and NEPC marker) negative PC (DNPC). They arise in approximately 36% of patients treated with AR inhibitors17. Yet, the role of OCT1 in the transition of tumors to an AR-negative phenotype is still unknown.On the other hand, AR-negative PC with neuroendocrine characteristics (NEPC) is initially a rare histological type that accounts for approximately 1% of PC patients, but it has highly malignant features18. We have previously established new PDXs of CRPC that were resistant to conventional ADT, second-generation AR-directed inhibitors, and chemotherapy, one of which was an AR-negative CRPC model19. In the present study, we used this PDX model to elucidate the genome-wide network of OCT1 in AR-negative CRPC.Although PC3 and DU145 recapitulate AR-negative CRPC, they do not encompass the heterogeneity of CRPC. To address this challenge, efforts are underway to develop new in vivo, ex vivo, and in vitro models from samples of patients who have been treated. This includes patient-derived xenografts (PDX) which typically retain the histological and genome characteristics of the original patient’s tumor13. We demonstrated that OCT1 recruitment around AR binding sites (ARBS) is enhanced by androgens, and OCT1-regulated genes differ between castration-sensitive PC and AR-positive CRPC cells13. However, the role of OCT1 in AR-negative CRPC is unknown; hence we conducted ChIP-seq analysis to identify genome wide activated histone marker, histone H3 lysine (K) 27 acetylated (AcH3K27) sites, and OCT1-binding regions in PDX 201.2A-Cx . PDX 201.2A-Cx is a patient-derived model of AR-negative CRPC that was established from a rapid autopsy sample of a lung metastasis from a PC patient who failed treatment with AR signaling inhibitors19. OCT1-binding regions were detected by calculating the enrichment of OCT1 compared with the input using the MACS software. In total, 12,005 binding regions were identified as OCT1 enriched sites and 9333 regions were identified as AcH3K27 enriched sites  , we observed reduced histone acetylation and Oct1 bindings in promoter/enhancer regions of AR and other Oct1/AR target genes in the AR negative CRPC model (201.2A-Cx) compared with AR positive 22Rv1 cells 21, suggesting the changed transcriptional program and Oct1 target in the transition of AR positive state to AR negative.We previously reported the distribution of OCT1-binding regions throughout the human genome in AR-positive PC cell lines, LNCaP, VCaP and 22Rv122 revealed enhancers and putative super-enhancers using ChIP-seq signals for AcH3K27 in PDX 201.2A-Cx cells, and identified 288 putative super-enhancers , Fibroblast Growth Factor Receptor 1 (FGFR1), N-Myc Downstream Regulated 1 (NDRG1), P53 Apoptosis Effector Related To PMP22 (PERP), profilin 2 (PFN2), RAD21 Cohesin Complex Component (RAD21), Retinol Binding Protein 1 (RBP1), Spermidine/Spermine N1-Acetyltransferase 1 (SAT1), and Syndecan 1 (SDC1).We used our previous RNA-seq data23. We extracted a list of the top 100 most highly expressed genes among putative super-enhancer and OCT1-regulated genes. We found that these genes are associated with various annotation groups and are significantly enriched in the Wnt signaling pathway, head development, chondrocyte differentiation, and neural precursor cell proliferation , SOX2, Syntrophin Beta 1 (SNTB1), and MDM2 Binding Protein (MTBP). To validate the expression level of these genes, we performed qRT-PCR using AR-positive and -negative PC cell lines as well as PDX 201.2A-Cx cells. All genes were more highly expressed in PDX 201.2A-Cx cells than the cell lines, except for SOX2 , which was used as negative control . We confirmed that these siRNAs significantly reduced the expression of endogenous SNTB1 and PFN2 in DU145 and PC3 cells  dataset , AR-positive PC cells can adapt into AR-negative phenotype, becoming independent of AR expression or signaling27. These data suggest that the type of TFs recruited into the AR-binding region change in accordance with lineage plasticity. On the other hand, OCT1 is widely expressed, including in the placenta, rectum and testis (Human Protein Atlas available from http://www.proteinatlas.org), in the human body among the eight OCT proteins, and known to be associated with the master regulator of pluripotency, octamer-binding transcription factor 4 (OCT4), in stem cells30. We recently reported that OCT4 associates with Nuclear Respiratory Factor 1 (NRF1) in AR-negative PC and consists an important component of the TF complex in CRPC31. Interestingly, OCT1 binding sites were enriched in a series of genes that are regulated by MYC in MYC-driven lung adenocarcinomas32, suggesting that OCT1 and MYC may co-regulate a series of androgen-responsive genes in PC. Consistent with these results, our PDXs are shown to express high levels of MYC19. We have previously reported that OCT1-regulated genes that overlap with AR signals differ between LNCaP and 22Rv1 cells14. Here, using a PDX model of AR-negative PC, we demonstrated the enrichment of OCT1-bound genes associated with proliferation of neural progenitor cells, which may be independent of the AR network. Interestingly, some of the genes we focused on in this study were mildly repressed in an androgen-dependent manner in LNCaP and 22Rv1 : CVCL_0395], 22RV1 (RRID: CVCL_1045), PC3 (RRID: CVCL_0035) and DU145 (RRID: CVCL_0105) were purchased from American Type Culture Collection . LNCaP, 22RV1, PC3 are cultured using RPMI-1640 and DU145 using DMEM medium, respectively, and both are supplemented with 10% FBS, 50 U/mL penicillin and 50 μg/mL streptomycin, in addition, some of LNCaP and 22Rv1 cells are treated with 100 nM of dihydrotestosterone (DHT)  for 3 days14. Short tandem repeat (STR) analysis was performed to authenticate the cell lines used in the present study42. Also, these cells have been checked for Mycoplasma contamination using real-time PCR performed by Funakoshi Co., Ltd. .PDX 201.2A-Cx was provided by the Melbourne Urological Research Alliance (MURAL)13. The signal score for OCT1 binding was calculated using Model-based analysis of ChIP-seq . The threshold for binding sites was set at P < 1.0e−4. The dataset was examined using the Integrative Genome Viewer. Genes located within 1000 kb of the upstream and downstream of the binding site were extracted with the Genomic Regions Enrichment of Annotations Tool (GREAT) version 4.0.4 to be candidates for OCT1-target genes43. Motif search (50 bp around the peaks obtained by ChIP-seq) was performed using HOMER44, and the samples used for ChIP-seq were further validated for binding to some regions by qPCR as described below. To identify putative super enhancers, we used Rank Ordering of Super-Enhancers (ROSE) downloaded from Young Lab (http://younglab.wi.mit.edu/super_enhancer_code.html)22.OCT1 and Acetyl-Histone H3 (Lys27) (AcH3K27) ChIP-seq with organoids from PDX 201.2A-Cx was performed as in previous studies using an Illumina HiSeq 2500 45. The expression level of each gene as a ratio to the expression level of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was calculated by the ΔΔCt method46. The primers used in this study are shown in the Supplementary Table 47.Total RNA extraction of all PC cell lines and PDX 201.2A-Cx, first-strand cDNA synthesis, and qRT-PCR were performed. Total RNA was obtained using RNeasy Mini kit . First-strand cDNAs were generated using the PrimeScript RT reagent kit  according to the manufacture’s protocol. The expression level of genes was measured by qRT-PCR using the SYBR green mix 11. PC3 cells were transfected with 1000 ng OCT1-pcDNA3.1-FLAG (PC3-OCT1) or without plasmids for control cells (PC3) using X-tremeGENE HP DNA transfection Reagent  according to manufacturer’s protocol.We used an OCT1 pcDNA3.1-FLAG construct as previously reported10, Mouse monoclonal anti-β-actin monoclonal antibody 10.PC3 and PC3-OCT1 were thawed on ice and whole protein lysates extracted from these cells using RIPA lysis buffer with protease inhibitor . Lysates were mixed with NuPAGE™ Sample Reducing Agent (10X) and NuPAGE™ LDS Sample Buffer (4X)  and loaded on Bis–Tris Gels (Thermo Fisher Scientific), separated by electro-phoresis. Samples were transferred to Immobilion-P Transfer Membranes . Membranes were incubated with primary antibodies overnight and then were incubated with secondary antibodies. Chemiluminescence was achieved with Chemi-Lumi One Super . The following antibodies were used in this study: Rabbit polyclonal anti-OCT1 antibody 19. Prostate cancer tissues obtained by prostate biopsy were stained by the streptavidin–biotin amplification method48. The use of prostate cancer tissue for immunohistochemistry has been approved by the Institutional Review Board and the Research Ethics Committee of the Nihon University School of Medicine . Briefly, anti-SNTB1 and anti-PFN2 polyclonal antibodies  were applied, followed by Histofine Simple Stain MAX-PO . The antigen–antibody complex was visualized with 3,30-diaminobenzidine (DAB) solution . Immunoreactivity (IR) score (0–8) was obtained as the sum of the proportion and the intensity of immunoreactivity. Proportion , Intensity .Immunohistochemistry was performed on PDX tissue using the Leica BOND-MAX-TM automated system (Autostainer) with BondTM epitope retrieval (ER)-1 for anti-ACSL3 Abnova  and ER-2 for anti-OCT1 antibodySNTB1  and PFN2  from ThermoFisher Japan .We transfected cells with 10 nM of siRNA using Lipofectamine RNAi MAX  according to the manufacture’s protocol. We purchased Silencer Select Negative Control #1 siRNA  and Silencer Select siRNAs (#44427037) targeting 3) in the upper chamber. After 24 h of incubation, the cells on the lower side of inserts were fixed, then stained with Giemsa solution . The cells that migrated on the lower surface were counted in four randomly selected fields under a microscope at a magnification of × 40.Migration assays were performed by using the Cell Culture Insert with 8.0-μm pore size polyester filters (BD Biosciences). We added 700 μL of cultured medium for PC3 or DU145 cells in the lower chamber and 300 μL of cultured medium containing cells transfected with siRNAs -3-(4-nitrophenyl)-5--2H tetrazolium, monosodium salt (WST-8), Cell Count Reagent SF  according to the manufacturer’s instructions. Assays were performed in four wells and data were presented as average and SD.6 cells) were injected subcutaneously into the right flank of 5-week-old male nude mice  . Tumor size was monitored by caliper measurements every 3 days, and the volume of tumors was calculated by the following formula: V = 0.5 × maximum diameter × intermediate diameter × minimum diameter. When tumor size reached approximately 100 mm3, 5 μg of siNegative control, siPFN2, or siSNTB1  mixed with RNAi MAX Transfection Reagent was injected into the tumor twice weekly for 2 weeks. Xenografts were harvested from mice anesthetized with isoflurane and stained with SNTB1 and PFN2 antibodies, and homogenized in ISOGEN  solution to extract RNA for cDNA.In vivo study was approved by the animal ethics committee of Nihon University School of Medicine . All animal experiments described adhere to policies and practices approved by the Institutional Animal Care and Use Committe (IACUC). The study was performed in compliance with the ARRIVE guidelines (2010). PC3 cells 26 and Oncomine databases (https://www.oncomine.org/)49. Using data from the Cancer Genome Atlas database, GEPIA performed the Log-rank test to analyze overall survival (OS) based on gene expression.We compared the transcriptional expression of Cell proliferation, cell migration assays, and xenograft experiments were evaluated using Student’s t-tests and One-way ANOVA with Dunnett’s multiple comparisons test. Statistical assessments were implemented in Graphpad Prism for Mac 8.0  and JMP 14 software  and p-values of less than 0.05 were considered statistically significant.Supplementary Information.


A cerebrovascular accident, or a stroke, can cause significant neurological damage, inflicting the patient with loss of motor function in their hands. Standard rehabilitation therapy for the hand increases demands on clinics, creating an avenue for powered hand rehabilitation devices. Hand rehabilitation devices (HRDs) are devices designed to provide the hand with passive, active, and active-assisted rehabilitation therapy; however, HRDs do not have any standards in terms of development or design. Although the categorization of an injury’s severity can guide a patient into seeking proper assistance, rehabilitation devices do not have a set standard to provide a solution from the beginning to the end stages of recovery. In this paper, HRDs are defined and compared by their mechanical designs, actuation mechanisms, control systems, and therapeutic strategies. Furthermore, devices with conducted clinical trials are used to determine the future development of HRDs. After evaluating the abilities of 35 devices, it is inferred that standard characteristics for HRDs should include an exoskeleton design, the incorporation of challenge-based and coaching therapeutic strategies, and the implementation of surface electromyogram signals (sEMG) based control. Victims of cardiovascular diseases often experience deterioration of their motor function . Two maiRehabilitation therapy is defined by three main forms: passive, active, and active-assisted therapy. Passive rehabilitation therapy is when the only force applied for the patient to complete their exercise is external, meaning the patient inputs no effort. This allows patients with more limited functions to begin their rehabilitation therapy. Active therapy is when no external force is used to complete an exercise, and patients need to exert all their effort to complete the exercise. This step is crucial for the patient, as active exercises strengthen the hand muscles and solidify their neuroplasticity. Active-assisted therapy combines both forms, providing the patient with an opportunity to strengthen their muscles much more efficiently. Rehabilitation requires all three phases to return the patient to proper motor function. By performing all three stages, patients can connect their muscle gain to their neural paths, satisfying the conditions for neural plasticity. As the population grows, the demand for rehabilitation therapy and assistive devices will increase. Currently, the demand for physical therapists outpaces the number of trained professionals available ,14. FurtRehabilitation therapy progress is frequently measured using scales to determine the severity of motor function loss, the capabilities of the affected limb, and the change in functional exercises. Judging progress for rehabilitation has no global uniformity, but generalized examinations have been created by professional medical associations. First, a patient’s stroke severity is determined by the Chedoke-McMaster Stroke Assessment (CMSA) . The CMSFurthermore, Krakauer studied several stroke patients and their progress through their rehabilitation and noted that patients would not meet a benchmark of eleven by the fourth week of rehabilitation. They are only 6% likely to recover full motor function by six months . Since tThe need for rehabilitative or assistive robotics is high. The market for powered rehabilitation devices in North America in 2020 is approximately USD 500 million , which iPowered prostheses have been studied since the early 1900s and have since evolved into more robust machines . AlthougSince their initial designs, these devices have advanced, employing more sensing capabilities, actuation devices, and overall weight . PoweredIn this paper, the discussion is focused on the design, actuation mechanisms, control, and applications for hand rehabilitation devices. The study’s primary purpose is to create a basis for an at-home rehabilitation device capable of conducting passive, active, and active-assisted exercises with a neurological feedback system. This device would help post-stroke patients rehabilitate their hands for improved strength and motor function. The organization of the manuscript is shown in The literature reviewed in this paper was limited to rehabilitation devices for the hand. Devices were researched using six databases such as Google Scholar, National Library of Medicine, IEEE Xplore, MDPI, PubMed, and Scopus. Only papers written in English are included while excluding devices with little technical information to narrow the search. Keywords such as hand rehabilitation device, active, passive, and active-assisted rehabilitation therapy, hand exoskeleton, and hand orthosis were used to compile these powered devices into a list. These devices were further categorized based on their mechanical design, actuation mechanisms, control methods, and interfaces.To properly conduct a literature review, criteria for the rehabilitation device must be defined. The papers retrieved were further filtered to devices for upper limb rehabilitation. Within this category, hand, wrist, elbow, and complete arm devices were discovered. Devices that did not primarily rehabilitate the hand and fingers were removed from the search. Moreover, only rehab devices categorized as orthoses, exoskeletons, or end-effector devices were considered for this search. After producing 326 papers meeting the criteria, 113 were removed since they did not apply to hand rehabilitation or did not incorporate passive exercises. Of 213 papers, 36 were crucial for this study. Although active rehabilitation is integral, medical devices have advanced far enough to incorporate both forms of rehabilitation. Furthermore, the study focused on devices that have been trialed by patients or are available commercially.In the human hand, all fingers, excluding the thumb, contain three phalanges, known as the distal phalange, middle phalange, and the proximal phalange. The thumb contains only two bones and no middle phalange. To design an exoskeleton rehabilitation device for the hand, the device’s link lengths and degrees of freedom (DoFs) should correspond to the anatomical configuration of the finger joints. Excluding the thumb, the phalanges comprise three joints, the metacarpophalangeal (MCP) joint, the proximal interphalangeal (PIP) joint, and the distal interphalangeal (DIP) joint. The thumb comprises only two joints, MCP and DIP joints. The MCP joint of the fingers has 2 degrees of freedom. It provides abduction and adduction with flexion and extension motions, whereas the PIP and DIP joints only have one degree of freedom and solely provide flexion and extension motions. The axes of rotation Where,iX, from axis iZ to axis i+Z1;Link Length Tii−Using Equations (1)–(3), the individual homogeneous transfer matrices that relate two successive frames  of the iSimilarly, using the Equations (1)–(3), the individual homogeneous transfer matrix that relates two successive frames  of the tThus, the homogenous transformation matrix that relates the fingertip frame n = 3 for the thumb, but n = 4 for the other fingers), The studies of dynamics discuss the rigid body’s motions and the forces and torque that cause them. The dynamic modeling of the finger using the iterative Newton-Euler formation can be expressed by the well-known rigid body’s dynamic equation as follows :(15)τ=Mθfound in . After iF is the applied force and torque vector at the fingertip.The most important design requirements are the assistive force and range of motion needed for each joint. Several healthy patients were tested with 11 activities of daily living (ADLs) to determine healthy ROM of the MCP, PIP, and DIP joints ,35. FromHand rehabilitation devices (HRDs) can be characterized as devices or braces designed for any stage of rehabilitation therapy for the hand. Rehabilitation therapy for the hand has been defined in set stages of exercises as outlined by the University of Kentucky’s Healthcare department (UKHC) . Here, UHRDs are classified as orthoses, exoskeletons, or end-effector devices. Each form provides crucial benefits to the rehabilitation process. Orthoses provide essential support and operate like most hand braces. Exoskeletons and end-effector devices add a necessary component to rehabilitation therapy: passive exercises. These powered devices offer crucial support and actuation of the phalanges using varying actuation mechanisms, including pneumatic and linkage-based systems, and control methods, including PID  and admittance control. Several rehabilitation devices for the hand employ solely active or passive exercises. Since active rehabilitation is accomplished without external force, devices providing solely active rehabilitation therapy are primarily orthoses.Exoskeletons and End-effector devices provide patients with both active and passive rehabilitation, combining multiple solutions into one device. Incorporating actuation into rehabilitation devices increases motor recovery and rehabilitation compared to standard in-person rehabilitation with a physical therapist ,39. WhilExoskeletons are devices designed to fit over the target area in a similar way to an orthosis, in that exoskeletons provide safety and support; however, exoskeletons have additional components that provide powered functions to the end-user. Exoskeletons are designed as wearable electromechanical devices that enhance the physical performance of the wearer . For hanExoskeletons provide solutions unique to their design. Since exoskeletons encompass each individual finger, actuation over individual joints while also providing support is crucial for patients with advanced injuries. Furthermore, exoskeletons provide portable solutions necessary for elderly or remote patients. Major drawbacks with exoskeletons include complex control algorithms and the adjustability of the device. Since an exoskeleton will actuate each individual appendage over each joint, controlling positioning requires complex strategies. Moreover, exoskeletons must be tailored to fit a patient’s hand. With end-effector devices, the mechanical designs are focused on end-point control and can adjust to varying hand dimensions.l, and the deflections at the tip A mathematical model for a hybrid-driven exoskeleton  for a haEnd-effector devices differ from exoskeletons because the actuation over the joints is based on end-point control, or control over the DIP joint, rather than the entire finger ,75. TypiOne main advantage of end-effector devices is the high level of control and feedback. Using linear rails and a control system that reads and displays neurological responses during the exercises, the Amadeo can actuate and rehabilitate the hand for patients of all ages and severity . The HapClinical trials have already been completed for the reviewed exoskeletons and end-effector devices. Amadeo, Gloreha, HEXORR, and My-HERO reported an increase of at least 7 points on the FMA scale, outperforming control groups of standard rehabilitation therapy ,78,79,80End-effector devices provide key advantages over exoskeletons. End-effector devices incorporate much simpler control mechanisms without sacrificing overall rehabilitation progress. Since the FMA scores aren’t significantly different, end-effector devices provide high levels of control and safety without complicated mechanical designs. Another advantage is the increased amount of user feedback. Devices such as the Amadeo can display neurological profiles of a patient’s hand while the exercises are conducted. However, end-effector devices are not able to constrain each individual appendage. Since the end-point control only actuates from the end of a finger, the risk for malalignment increases .Devices categorized as orthoses are devices created to protect and support the hand ,87. TablSome orthoses employ resistive therapies because they provide strengthening exercises without any powered components. SCRIPT and Saebo orthoses employ spring cords to provide resistive training in their device ,89. ResiActuation mechanisms describe mechanisms used in devices to translate power transmitted from actuators in exoskeleton or end-effector devices. Mechanisms employed by devices reviewed in this paper are categorized into four main classifications: pneumatic actuation, linkage-based actuation, cable-driven systems, and gear-motor actuation. Pneumatic actuators require sealed tubes or conduits to actuate the devices, whereas linkage-based actuation requires only direct connection from the actuator to the finger. Cable-driven systems translate actuation using cables connected throughout the finger. Gearmotor actuation employs gearmotors and gear trains primarily for increased torque transmission for the hand. Typically, pneumatic devices are powered by air pistons, using pneumatic tubes or pathways to translate the actuation for total flexion of the MCP, DIP, and PIP joints. Pneumatic actuation provides ample torque and control for rehabilitation. Pneumatic devices include the Rutgers Master II and the Power Assist Glove ,53. A keThe main drawback of pneumatic devices is the space required. Pneumatic and hydraulic systems are dependent on multiple components, including the compressor, separate chambers, pumps, and additional power sources. Low-weight options are available, but pneumatic devices may impede exoskeleton designs with a greater need for telerehabilitation and precise control . FurtherLinkage-based actuation is a popular choice for remote rehabilitation. Using links, either 3D printed or machined, linear actuators and varying motors translate the powered actuation. Devices that employ this method include the Hand of Hope, CyberGrasp, and HEXORR. These devices employ linkages to provide planar movement for each finger, securing the range of motion and preventing patients from flexing or extending out of the plane . LinkageLinkage-based actuation does have a disadvantage. Motors and the necessary translational linkages can add weight to the system, even though the motion is simple . To provCable-driven exoskeletons employ servo or rotary motors to provide enough torque to rehabilitate the hand. Systems such as the WearME, SEM Glove, and the glove designed by Delph et al. use cables for low-weight solutions. Implementing cable-driven systems allows the device to shift the weight of the actuation components away from the hand ,57,74. AA major disadvantage of cable-driven systems is the loss and control issues. Since the system depends on translating the actuation via cables, the actuation experiences transmission losses as the device work through the exercises . Cable-dGear-motor actuation mechanisms include any translation of power and motion using a combination of gear motors or gear trains. Devices such as the Exo-K’ab use gear motors for precise control over the joints. This mechanical control over the rotation is beneficial to actuation design since it provides safe and accurate control over 360°. Although the MCP, PIP, and DIP joints do not require 360° motion, the fluid motion provides beneficial rehabilitation.Gear-motor actuation falls short in terms of cost and implementation. Gear motor actuation is often an expensive approach to actuation. With a human hand, several gears and gear trains would be employed to provide actuation. Moreover, designs using gear-motor actuation run into similar weight issues experienced by linkage-based actuation. Both forms require heavy components to provide the safety and security pneumatic actuation can provide. Current forms of robotic therapies aid beyond normal passive and active movements. Several devices incorporate passive-assistance in addition to fully passive motion to aid patients with more severe injuries. Devices such as Amadeo and CyberGrasp also incorporate games to better interact with the patient using the device. These games not only help engage patients with repetitive tasks, but also provide challenge-based goals to help progress rehabilitation. In this section, the only devices compared are those with clinical trials with proven FMA score improvements.Assistive strategies provide assistive actuation based on user intention and end goals. Devices that implement this level of control have set goals for the patient to accomplish, such as certain hand signs or grasping and pinching motions. When users plan on closing their hand but lack the strength to drive their hand, the assistive control methods then aid the patient in completing the exercise based on need ,85. ThisHaptic strategies are an emerging strategy for hand rehabilitation. Haptic control is defined as a method for the patient to use a virtual system to replicate sensation or motion. The Hand of Hope and Rutgers Master II were trialed with patients to test their implementation of haptic control. The two devices performed well and were able to improve the FMA scores of the patients ,96. AddiChallenge-based strategies are implemented by requiring the end-user to accomplish an intuitive goal. This can be accomplished by having patients participate in exercises or games to encourage the patient to solve the challenge. Challenge-based strategies work well since the gamification of exercises increases patient involvement and practicing challenges improves motor function faster than simple steps . Some deCoaching is a crucial strategy and is necessary for other forms rehabilitation. Coaching refers to the rehabilitation device not providing assistance or resistance, but simply measuring motion and user intention using the device’s sensors and providing feedback to the user . Since cRehabilitation has now incorporated videogames and exercises to engage patients further in the rehabilitation progress . AllowinThe main obstacle facing telerehabilitation is accurate position control. Since the rehab devices already employ highly accurate control features, designs of the SCRIPT or HEXORR, some devices created for telerehabilitation are completely safe ,106. MosControl methods are applied to manipulate HRDs to provide different forms of rehabilitation therapy, including passive, active, and active-assisted therapy. Various controllers are employed to achieve different goals during the rehabilitation exercises, such as position control, force control, or torque control ,112,113.The earliest control method for prosthetics was simple motor control over the actuator . HoweverThe PID control technique is the most widely used control technique for industrial applications . It is sTherefore, this Equation (23) can be re-formulated as an error equation:The relation (25) is decoupled, therefore individual torque command for each joint would be as follows.Shown in To realize better tracking performance of an HRD, the dynamic model of the HRD (as well as the dynamic model of the human fingers) needs to be included in the control law. Therefore, the nonlinear CTC technique is often used for this. Its control law includes both the finger and HRD’s dynamic model. The dynamic behavior of an HRD can be expressed by the well-known rigid body dynamic equation: The layout of the modified computed torque control technique is depicted in From relations (27) to (30), we may write:Therefore, Equation (31) can be rewritten in the following form:In active, active-assistive, resistive rehabilitation mode, the HRDs assist/resist user finger motion/exercise based on the human-user interactive force measured from the force sensor or skin surface EMG signals. To do this, the controller partially modifies the desired trajectory/exercise of an HRD in relation to the force sensor/EMG input, as expressed by Equation (34).t to use .F is the force vector, Impedance control can be demonstrated using an impedance model provided by Ibarra’s review of impedance control . An impeWhere for both . Since tfor both .As with all medical devices, precise feedback control is critical. Without proper control or feedback from the device, the patient could experience tremendous pain/fatigue and potentially cause more damage to their hand ,93. The Devices available commercially employ surface electromyography sensors (sEMG). These sensors detect EMG signals transmitted through the forearm, wrist, and hand. A neurological connection between the rehab device and the patient is created using these signals. sEMG sensors allow the devices to accurately measure and profile force and power transmitted by each hand. sEMG sensors provide great readings for muscular rehabilitation. Joan Lobo-Prat proved that a powered device could be directly controlled using sEMG control . This stThe human hand uses several groups of muscles to extend and flex the appendages. Early devices used a binary switch to actuate the prosthetic, turning on when the EMG sensors received the signal from the arm . Since EForce sensors are the most popularly employed control system. Since the patient will always be exerting pressure on the device to actuate the fingers, force sensors provide a natural reading of the patient’s motion. Using a combination of force sensors and other devices to detect position, such as Hall Sensors or potentiometers, the control system becomes highly accurate.Devices such as the ExoHand, X-Glove, and HandMATE employ force sensors in conjunction with potentiometers and force-sensitive resistors to measure the input force from the patients ,138. OncIn addition, most devices use a closed-loop controller to predict force-sensing accurately ,139. ComSeveral devices have already been produced for commercial use, either in a clinic or at home. With the market share of assistive devices increasing, it is important to discuss the commercialization of these devices and their usability.As technology grows, interfaces that allow for smoother user control are imperative. To provide standalone service with minimal assistance from an external source, patients seeking telerehabilitation or at-home solutions need a smart and intuitive interface. Amadeo and HandyRehab employ mobile apps and video games to encourage patients to exercise more. The skill-based exercises have been proven to improve motor function and increase patients’ focus on rehabilitation . A simplAmadeo, Gloreha, and Saebo are a few companies that have created several commercial devices for a range of rehabilitation. Amadeo has created devices for lower extremity rehabilitation while also providing EMG-based control and smart interfaces . Saebo, After reviewing and classifying the varying forms of HRDs, a newer idealized model of an HRD can be inferred. First, the correct class of HRD must be chosen. Orthoses, exoskeletons, and end-effector devices provide different balances of rehabilitation benefits. Newer designs should combine the advantages of each into one device. Future research will need to be conducted as there is no uniform scale to judge rehabilitation devices. The analysis of this paper has focused the discussion on clinical trials of HRDs rather than simulated results. Results from patients provide a better understanding of a device’s efficacy. Thus, the idealized model of an HRD should be based on clinical trials with FMA score improvements.Orthoses primarily offer strictly active rehabilitation therapy, with some devices providing additional components to allow for resistive training. However, these braces’ low profile and costs inhibit them from competing with more developed exoskeleton devices. Exoskeletons provide the perfect combination of power and support. While the outer casing can be printed from low-cost plastics, exoskeletons can also be developed at high costs depending on the material needs. These devices provide all rehabilitation therapy exercises. Patients using exoskeletons report a greater improvement in their motor function recovery, as shown by the FMA, MAS, and CMSA scales. End-effector devices provide the same benefits while incorporating higher sensing capabilities and games to engage the patients. Although end-effector devices result in slightly higher patient scores, they are limited to a singular location and cannot be portable. Therefore, an exoskeleton device is preferred.As shown by the mathematical models, the actuation of the HRD does not have strict requirements. Using different combinations of gears or links, any exoskeleton or end-effector device can properly actuate the flexion and extension of the hand. Furthermore, the only limitation on actuation is the weight and cost of the HRD. Preferably, linkage-based or cable-driven systems would be employed to provide the best torque to weight ratio while still attaining high precision and accuracy.Several therapeutic strategies can provide key advantages for each rehabilitation device. Since the performance of the patients during the exercise is the most integral part, challenge-based and assistive strategies should be employed. With the highest FMA score improvements being recorded with devices that employ haptic and coaching strategies, future developments of HRDs should integrate these strategies. Furthermore, devices should respond naturally to patients, so sEMG control is crucial. Neuroplasticity is dependent on the patient equating the device’s motions to the neurological signals being sent and received. Incorporating force feedback would benefit the patient in this process. Therefore, the best control method to implement would be a combination of sEMG and force feedback controls.Interfaces greatly improve the patient’s engagement with the device. Most humans already struggle with basic chores and exercise, so rehabilitation therapy is often difficult since patients find issues motivating the exercise. Incorporating virtual reality, exercise games, and self-driven ADL exercises engaged more patients in the rehabilitation process. Telerehabilitation allows patients to receive proper rehabilitation without being inhibited by travel, wait times, or availability.An idealized HRD would therefore be an exoskeleton device actuated by either linear actuators or rotary motors. This device would also incorporate an assistive and challenge-based control strategy with force feedback. This encompassing model will allow the device to incorporate ADL exercises, games, and progress tracking in an easy-to-use interface.After reviewing several commercial and documented rehabilitation devices, the need for improvement is still clear. Patients in need of HRDs have dynamic demands, since each patient would recover in unique ways. There is no rehabilitation device capable of operating passive, active, and assisted physical therapies for all forms and stages of hand rehabilitation. The use of sEMG sensors is not widely used, despite its direct connection to neuroplasticity and the recovery progress. Further, advanced therapeutic strategies have been proven to aid patients. These strategies require advanced technology, such as sEMG sensors, user feedback, and smart interfaces. The only standard in hand rehabilitation is the categorization of the injury’s severity using the CMSA scale. Without proper standards for rehabilitation progress, HRDs do not have set goals or uses. This, in turn, creates tangents in the HRD design and development. Future research must advance and focus development to a standardized form for hand rehabilitation.


In hospitals, PCL reconstruction (PCL-R) is less frequently performed than other types of knee surgery. It is unclear whether there is consensus among surgeons on how to perform rehabilitation after PCL-R or if there are different, more individual approaches in daily routines. (2) Methods: Rehabilitation protocols and their main criteria  were retrospectively analyzed after PCL-R. (3) Results: Only 33 of 120 (27.5%) analyzed institutes use rehabilitation protocols after PCL-R. The applied protocols showed vast differences between the individual rehabilitation criteria, especially with regard to the progression of weight bearing and the range of motion. The only standardized recommendations were the obligatory use of knee braces and the general restriction of weight bearing and range of motion immediately post-surgery. Therefore, because of the lack of a consensus about a standardized rehabilitation protocol after PCL-R, no recommendation can be made on one particular protocol. (4) Conclusion: There is no acknowledged standardized rehabilitation protocol after PCL-R. In clinical practice, recommendations are influenced by, i.a., surgeons’ opinions and experience. The lack of scientific evidence on a particular standardized rehabilitation protocol after PCL-R suggests that rehabilitation protocols need to be tailored to the individual patient. The posterior cruciate ligament (PCL) extends from the lateral aspect of the medial femoral condyle, adherent to the articular cartilage, down to the PCL facet of the posterior tibia, approximately 1 to 1.5 cm below the tibial plateau. Its course is intrasynovial but extraarticular ,3. The mEven in patients with asymptomatic, isolated PCL injuries, abnormal knee kinematics can be found during functional activities such as stair ascent and running . In geneThe rehabilitation phase must be at least as important in the overall treatment of the patient and must be accompanied in a similar way as the surgery itself. Its purpose is not only to protect the surgical result, but also, among other things, to restore the proprioceptive, coordinative, and conditional abilities lost since the injury. During the month-long rehabilitation phase, the patient should not only be accompanied by the orthopedic surgeon, but rather by a rehabilitation team, which, in addition to the patient and surgeon, also consists of a physiotherapist and at best people from the home environment . There should also be regular exchanges between the patient, the orthopedic surgeon, and the physiotherapist, not only to prevent possible undesirable developments in rehabilitation, but also to document progress and thus keep the patient motivated to continue. Because of a mostly relatively young, sportive patient group with high pre-injury activity levels, the aims of surgery and the following rehabilitation phase are set high. In principle, the pre-injury activity level of the injured person as well as the demand on the quality of life, including the participation in sports after the injury, should be considered when deciding on conservative or surgical therapy. The same principle applies to the rehabilitation phase. Adequate rehabilitation is the key factor for graft healing (particularly of hamstring grafts) and for improving patient outcome. Yet, standardized post-treatment protocols are often used to guide patients through the rehabilitation process and to instruct their physical therapists on weight bearing, the range of motion (ROM), and the begin of rehabilitative training. As recently shown, post-treatment protocols vary significantly, even for well-established and frequently used surgical therapies of the knee joint, such as ACL reconstruction  or cartiBased on this finding, the aim of this study is to answer the question whether there exists a standardized approach or if there are different and more individual approaches among orthopedic surgeons on how to perform postsurgical rehabilitation after isolated PCL-R in daily routines.Design—In a retrospective cohort study, the early rehabilitation after PCL-R was analyzed in 120 institutes for orthopedic surgery. The medical device company OPED  developed a tabular template for creating a post-treatment protocol after knee surgery (PCL R). This template was offered to orthopedic departments and orthopedic outpatient centers in German-speaking countries for free, so that associated orthopedic surgeons may create their own individual, but for their own institution standardized, post-treatment rehabilitation protocol using the criteria described in Participants—For this qualitative study, we analyzed early rehabilitation protocols after knee surgery (PCL R) that are currently used in daily routines in German-speaking countries . The protocols originated from 120 different orthopedic institutions, of which 63 were outpatient centers, 57 clinical centers, and 4 university medical centers.Measures—This study focuses on the early rehabilitation phase. This phase can basically be divided into three episodes, each with its own goals. Within knee surgery, these phases are quite similar and are not necessarily PCL-specific. The timing of the phases, in turn, varies individually. The first episode includes the period immediately following surgery. It is also called the acute, inflammatory, or early protective phase. The therapeutic goals are to relieve pain, reduce swelling, and maintain or increase the mobility of the knee joint, especially the patellofemoral joint. The second episode is a transitional phase. It is characterized by a progressive increase in all dynamic modules of post-treatment. This mainly concerns the modules of loading and ROM. In addition, there is the restoration of coordinative abilities. Therefore, the start of rehab training usually falls into this phase. At the end of the second episode, full weight bearing, and the full ROM should be achieved. The third episode of early rehabilitation is the remodeling phase. Its therapeutic goal is to strengthen the important muscle groups and increase endurance with a view to mastering everyday skills. Everyday motor skills should be restored at the end of this episode. During this phase, sport-specific training usually begins. The early rehabilitation protocols were analyzed with regard to the following rehabilitation criteria see : postope® . Data are presented as mean ±SD or absolute and relative frequencies. Continuous data between two or more groups were compared with analysis of variance (ANOVA). Categorical data were compared using the chi-squared-test of independence. In case of significance, further post-hoc tests (according to Fisher’s least significant difference) were calculated. A probability (p) value of ≤0.05 was considered to be significant for each test. Graphical illustrations were generated with GraphPad Prism®  and Microsoft PowerPoint 2013® .Data analysis—Statistical analysis was performed with SPSSIn total, 620 protocols from 120 different orthopedic institutions were collected. A total of 33 (5.3%) of the 620 protocols described the early rehabilitation phase after isolated PCL-R. Twenty (60.6%) of the institutions, one of them a university medical center, provided stationary health care, thirteen (39.4%) were ambulatory. None of the PCL-R rehabilitation protocols were identical.Of the 33 PCL-R protocols, 31 contained detailed information on how to proceed with weight bearing and range of motion (ROM) see . For theIn the first postoperative week, 11 (35.5%) of 31 protocols recommended 0° to 10° of flexion of the knee joint, 14 (45.2%) protocols up to 30°, and 5 (16.1%) protocols up to 60°. One (3.2%) protocol even allowed pain-adapted, but in principle unrestricted, flexion and extension from the beginning. The majority of orthopedic surgeons recommended a steady increase in ROM in steps of further 30° over the following weeks. After six weeks, the majority of protocols  recommended release of the full range of motion in flexion, whereas 7 (22.6%) protocols set the limit at 90°. This limit was finally to be lifted after 9 weeks in 12.9%, after 13 weeks in 6.5%, and after 17 weeks in 3.2% of the protocols.According to the post-treatment protocols, the restriction of ROM in case of full restriction of flexion was mostly ensured by the use of an adjustable knee brace or a posterior tibial support brace (PTS). Thirty (90.9%) of the thirty-three included protocols provided specific information on the type of brace and their wearing period. Each protocol that included information about braces (100%) recommended the use of a brace immediately after surgery, approximately one third  a PTS, and two thirds  an adjustable knee brace. The mean wearing period of a knee brace after PCL-R is 12.2 ± 2.2 weeks (range: 6 to 24 weeks).A total of 27 (87.1%) of the 33 protocols contained specific recommendations on rehabilitation and specific training after PCL. Rehabilitation training was recommended at the earliest after 8 weeks in four (14.8%) protocols and at the latest after 4 months in nine (14.8%). The majority of protocols  recommended starting rehabilitation training between the 8th and 12th postoperative week. Two (7.4%) out of twenty-seven protocols recommended starting specific training at the earliest after 12 weeks and 10 (37.0%) after 6 months and later.p < 0.001) [The early rehabilitation protocols after PCL-R of various institutes did not correspond with regard to individual rehabilitation procedures. Some protocols contained comparable procedures, yet no standardized and more individual and personalized procedures. The main consensus found in over 90% of the protocols was on wearing a knee brace during early rehabilitation. The recommended duration of wearing a brace for an average of 12.2 weeks was almost twice as long as after isolated anterior cruciate ligament reconstruction  . This fiHowever, the main finding of our study was the wide range of different rehabilitation protocols after PCL-R, in particular regarding the progression of weight bearing and ROM of the knee joint. Previous researchers did also not find any relevant consensus when systematically reviewing post-treatment recommendations after PCL-R ,25,26. TThe fact that different post-treatment protocols—based on fixed postoperative time points—partly differ significantly in their respective rehabilitative criteria is not PCL-specific but also applies to other surgical therapies such as repair of the meniscus ,28, the Of course, the range of different recommendations seen from the results cannot be attributed solely to the presumption that an individualized approach is preferred. In this respect, the presented results cannot be generalized. One of the limitations that must be blamed for this is the fact that the investigated protocols do not take into account the time of indication for surgical therapy . Furthermore, due to the retrospective design of the descriptive analyses of rehabilitation protocols of different medical settings, individual clinical outcome or complications during the rehabilitation phase were not included in the assessment of rehabilitation protocols in the context of this study. The same applies to the lack of sociodemographic data such as sex, age, or the pre-operative activity level of the patients. Furthermore, there is no information about the surgical technique applied. However, this study shows the current clinical routine and daily practices of orthopedic surgeons and therefore the current status of postoperative care after PCL-R.Standards in rehabilitation should obviously not be presented in the form of timeline-based protocols and schedules that refer to the time since surgery; here, a much more differentiated approach seems to be required. The first step towards a patient-centered, personalized rehabilitation standard would be to disregard the notion that ‘time since surgery’ is a fixed criterion for reaching the next step, such as increasing weight bearing or the release of ROM. A scheduled rehabilitation protocol may suit one patient but may proceed too fast for another with a possible negative clinical outcome. Vice versa, however, professional athletes may achieve their rehabilitation goals more quickly than recreational athletes with a lower preoperative activity level. By setting rehabilitation goals rather than time points, a patient’s deficits and potentials can be adequately addressed. This way, post-surgical rehabilitation becomes more personalized and tailored to the individual patient. A similar approach has been proposed for the far more commonly performed reconstruction of the ACL  and meniThe only consensus in the currently existing rehabilitation protocols after PCL-R was on wearing a brace after knee surgery as well as the restriction of weight bearing and ROM immediately post-surgery. However, the wide range of different rehabilitation procedures, especially with regard to the progression of weight bearing and ROM, shows that a standardized post-surgical rehabilitation protocol is not available in clinical practice. Rather, individual rehabilitation seems to be the current solution in daily routine, depending on the time of indication, the surgical technique applied, and most importantly individual patient factors such as pre-operative activity level and the desired goal at the end of the rehabilitation phase.


Offering cardiac rehabilitation to people who can benefit most could improve the outcomes in the context of limited availability. We used cluster analysis to distinguish three patient groups based on clinical and laboratory variables and then compared the outcomes of 6-month outpatient cardiac rehabilitation between these groups. The outcomes included blood pressure, blood lipids, fasting blood glucose, and uric acid concertation in serum. Group 1 consisted primarily of men with obesity, increased blood pressure, favourable lipid profiles and increased fasting glucose. Group 2 consisted of men or women with normal weight, normal blood pressure, favourable lipid profiles, and normal fasting glucose. Group 3 consisted primarily of women with overweight, normal blood pressure, unfavourable lipid profiles, and normal fasting glucose. After 6 months of cardiac rehabilitation, blood lipids improved in group 3, whereas blood pressure improved in groups 1 and 3, but the outcomes did not change significantly in group 2. We did not see any effect of cardiac rehabilitation on fasting blood glucose and serum uric acid concentration in any group. Concentrations of glucose and uric acid did not change significantly in any group. In conclusion, an adequate selection of patients should maximise the benefits of cardiac rehabilitation. Cardiac rehabilitation is a multifaceted intervention for patients with heart diseases. The pillars of cardiac rehabilitation include pharmacological management of the underlying disease and comorbidities, modification of lifestyle , and improvement of psychosocial well-being . TherefoMore and more people need cardiac rehabilitation because of the increasing prevalence of cardiovascular diseases and the continuing improvements in cardiac care, which often enable many patients to survive acute events, such as acute coronary syndromes or decompensation of heart failure . HoweverCluster analysis and other data-driven methods may help distinguish people who are most likely to benefit from health interventions and those who do not get any benefit ,10. TherThe study was carried out in 10 outpatient centres of cardiac rehabilitation in the Pomeranian Voivodeship, Poland between January 2020 and May 2021 . All participants signed informed consent before enrolment.Data analysed in this study were gathered before the first and six months after the last rehabilitation course. The following data were recorded at baseline: sex, age, education , smoking (yes vs. no), social situation , family history of cardiovascular diseases (yes vs. no), and medications for cardiovascular disease (yes vs. no). The following efficacy variables were measured at baseline and six months after the last rehabilitation course: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse rate, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, triglycerides (TG), fasting glucose, and serum uric acid. Exercise capacity, in metabolic equivalents of task (METs), was measured at enrolment and study completion with the use of a cycle ergometer according to the Bruce protocol.p < 0.05 was considered significant.Cluster analysis is an exploratory method in which objects  are allocated, based on object characteristics, to a set number of clusters. The clusters are distinguished by their centroids (most representative cluster points) and objects are allocated to the nearest centroid . Then, the values of centroids are modified, and objects are reallocated until they are no longer moving between clusters. We used cluster analysis based on k-means to distinguish three groups of patients based on baseline BMI, SBP, DBP, pulse rate, TC, LDL-C, HDL-C, non-HDL-C, TG, fasting glucose, and uric acid. For cluster analysis, all these variables were transformed into z-scores. The coefficient of determination (R2), Akaike Information Criterion (AIC), and Bayesian Information Criterion (BIC) were used to assess the performance of different models. The change in the efficacy variables for baseline to 6 months after the last rehabilitation course was compared between the groups with repeated-measures analysis of variance (ANOVA). An interaction term of group  x time (baseline vs. 6 months after rehabilitation) was used to assess whether outcomes changed differently in particular groups. The JASP software  was used for all analyses. A p = 0.440). Therefore, pulse rate was removed from cluster analysis, yielding an improved model with three groups . The initial result of cluster analysis based on baseline BMI, SBP, DBP, pulse rate, TC, LDL-C, HDL-C, non-HDL-C, TG, fasting glucose, and uric acid yielded three groups . Serial ANOVAs showed significant differences between the three groups for all the variables except pulse rate  = 7,20, p < 0.001; Repeated measures ANOVA showed that SBP and DBP decreased significantly from baseline to 6 months after cardiac rehabilitation in group 1 only , with a non-significant group x time interaction , overall, the change from baseline to 6 months after cardiac rehabilitation was non-significant  = 1.07, p = 0.342; p = 0.249; interaction term: F = 0.09, p = 0.918; p = 0.718; interaction term: F = 1.94, p = 0.144; data not shown).TC decreased significantly in group 3 . The BMI did not change substantially at the end of the rehabilitation course, with the mean changes not differing significantly between the three groups .The improvement in exercise capacity (METs) at the end of the rehabilitation course differed significantly between the three groups [F = 3.26; ment see . On postThis study, using a data-driven approach, showed that the benefits of cardiac rehabilitation are greater in certain groups of patients, whereas in others cardiac rehabilitation may provide no significant benefit. Of the three groups distinguished by cluster analysis, group 3 consisted mainly of women with overweight, normal BP, unfavourable lipid profiles, and normal blood glucose. In this group, blood lipids showed consistent improvement. Blood pressure improved in groups 1 and 3. Improvement in exercise tolerance was measurable in groups 2 and 3. We did not see any effect of cardiac rehabilitation on fasting blood glucose and serum uric acid concentrations in any of the groups. Cardiac rehabilitation is defined by the WHO as “the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they may, by their own efforts preserve or resume when lost, as normal a place as possible in the community.” . This gePrevious studies showed that cardiac rehabilitation significantly reduces SBP and DBP. Among 35 patients after myocardial infarction, Kargarfard et al. showed that aerobic training over 2 months significantly reduced both SBP and DBP . SimilarCardiac rehabilitation can improve blood lipids. Adeba-Garcia et al. showed that LDL-C decreased significantly 6 months after an acute coronary syndrome among 268 prospectively followed patients who received a multi-faceted cardiac rehabilitation . Lavie aThe availability of cardiac rehabilitation is very low globally, with only ~40% of countries offering cardiac rehabilitation programmes . In EuroOur study had limitations. The group of patients was heterogenous because we included patients with different cardiovascular diseases. Moreover, the use of a data-driven approach makes it difficult to interpret the results in clinical terms. The generalisability of our results is limited because of a substantial proportion of women in our sample, whereas secondary prevention of cardiovascular diseases is more common in men .In conclusion, developing criteria for an adequate selection of patients should maximise the benefits of cardiac rehabilitation in the context of limited availability.


Upper-extremity injuries and diseases rarely have life-threatening consequences, but failure to manage them properly can result in severe dysfunction. This article presents the current state of using virtual reality to support the rehabilitation process of patients with injuries and diseases of the upper extremities and points out their effects on upper-extremity functions. A scoping review was conducted to provide a comprehensive overview of the field of virtual reality for upper-extremity rehabilitation. PubMed, Web of Science, and the Cochrane Library were searched by two independent researchers between April and May 2021 to identify relevant publications and were examined according to inclusion and exclusion criteria. As a result of the literature review, 11 studies of various target groups were identified. Virtual-reality technologies were categorized into multisensory high-end systems and game-based systems. With respect to functional recovery, technologies based on virtual reality were not inferior to traditional rehabilitation. In addition, the users were highly motivated and satisfied. The results emphasize the need for stronger evidence-based virtual-reality technologies for rehabilitation of injuries and diseases of upper extremities. Injuries and diseases that concern the apparatus of movement and truss pose a long-term threat to both professional and individual performance, as well as participation in social life. In 2018, diseases of the musculoskeletal system were the most frequent reasons for outpatient rehabilitation among women (74%) and men (67%) in Germany [Rehabilitation is a multifaceted long-term process ranging from inpatient or outpatient rehabilitation up to subsequent rehabilitation services. Accordingly, the conservative treatment includes a multitude of interventions, such as physical therapy, psychological treatment, and activities such as swimming or yoga ,4. To maA technical innovation highly relevant for rehabilitation is virtual reality (VR). VR is the computer-animated simulation of a three-dimensional environment that can be used in real time . RehabilIn rehabilitation, VR represents a valid and reliable tool for joint and function . It is aThe effectiveness of VR in neurorehabilitation has been studied extensively in individuals with cerebral palsy  and espeThis scoping review was conducted using the framework of Arksey and O’Malley , describTwo independent reviewers judged the eligibility of retrieved studies by title and abstract, as well as according to inclusion and exclusion criteria. Duplicates were sorted out, and appropriate studies were included in a second screening. Thus, in the next step, the studies were assessed on the basis of full texts and with renewed consideration of inclusion and exclusion criteria. Studies that were not published in English or German, were available as abstracts only, or focused on neurological diseases solely were excluded. Studies that used rehabilitation approaches based on VR as a training tool, reported at least one outcome related to functional recovery, and were published in English or German between the years 2011 and 2021 were included. If disagreement existed, a consensus was reached through discussion.Authors,Country,Study design,Sample size,Study population,Intervention characteristics,Relevant outcomes and results.A standardized data extraction form was used to collect information related to the following aspects:These data were used for precise planning and preparation of the qualitative synthesis.The initial search procedure retrieved 681 articles. After duplicate removal and screening, 11 studies were considered eligible for inclusion see .Of the included studies, five studies were conducted as pilot randomized controlled trials ,22,23,24Consequently, there was heterogeneity in the parameters measured and assessment methods used in the studies, with a predominant focus on pain perception and dysfunction of the upper extremity. The most common evaluation methodology used was the visual analog scale (VAS) to assess pain and range of motion (ROM) to assess upper-extremity function.The VR technologies described in the studies can be divided into two categories. The first constituted multisensory high-end systems that enable complete immersion. In the pilot study of Chau et al. (2020), participants used the HTC Vive VR system, which consisted of a wired headset and two handheld motion controllers. Participants were approved for up to 10 sessions of VR therapy, with each session lasting approximately 45 min to 1 h. The sessions consisted of guided visualization exercises and interactions with the virtual environment. Activities included, for example, washing hands, sorting dishware, or arranging utensils . The BriN = 7) used game-based systems for upper-extremity rehabilitation [On the other hand, there are commercially available game-based systems, such as Nintendo Wii and Xbox Kinect, which are designed to be lower-threshold and less expensive. The majority of the studies included in this work  performed a protocol of active, active assistivem and passive ROM exercises for six sessions using Microsoft Kinect, where the movements attempted to match the movements of an avatar, which was displayed on a screen. Participants in the control group received similar exercises for six sessions but without Microsoft Kinect and with minimal therapeutically support 14 perfor. SimilarIn the study of Yohannan et al. (2012), all participants received three consecutive sessions of traditional passive ROM and joint-specific exercises for 15 min. This was followed by an additional 15 min of Nintendo Wii exercises consisting of games such as wall finger climbs, overhead ball toss, or bouncing a physioball for those in the intervention group or 15 min of a therapist-chosen exercise for those in the control group. In the control group, although therapy was tailored by interventional therapists, the movements were comparable with the intervention group. Interventional therapists were guided by scripts to provide standardized therapy . The stuIn two studies, participants using the VR technology received continuous support from trained professionals ,26. In aThe results of the pilot studies in pre–post design showed significant improvements with regard to pain and upper-extremity function ,27. The p = 0.0019) favoring the intervention group using the VR technology, while no statistically significant differences were detectable in range of motion [p < 0.001) and “pain” (p = 0.002) of the Jebsen–Taylor hand function test (JTT) [Varying results were obtained in the randomized controlled trials. Rarely, the VR technologies in the included studies were associated with measurable benefits related to pain perception and upper-extremity function. For example, the study results of Parker et al. showed significant improvements in pain (f motion . In contst (JTT) . Pekyavast (JTT) . Four stst (JTT) ,21,23,24Beyond that, results related to user satisfaction and motivation were mostly consistent. Overall, users were satisfied with the interventions used ,23,30 anNumerous reviews ,17,31 haExisting evidence of VR technology effectiveness in patients with upper-extremity injuries and diseases is inconclusive yet promising. Findings from this scoping review indicate that VR-based interventions are not inferior to traditional rehabilitation and might have an added advantage for functional recovery and pain reduction. Future studies of high quality are necessary to reach a more solid conclusion.The number of studies that used game-based VR technologies is remarkable. The integration of low-cost game-based VR technologies can allow healthcare specialists to precisely create, deliver, and control complex and dynamic environments for user interaction. Although such systems were not explicitly developed for rehabilitation, they might be motivating and cost-effective alternatives. As such, game-based VR rehabilitation exercises that are easily adapted to individual user needs will become a valuable adjunct to conventional therapy in inpatient, outpatient, and home-based care settings. However, limited options for customizing and adapting game-based contents to the needs of particular injuries or diseases could also be a disadvantage. Furthermore, visualization of content includes many different elements and stimuli, which might be overwhelming. Additionally, movements to be performed are often too nonspecific and incompatible with therapeutic goals .Future research directions should consider the potential of VR-based systems to increase the efficiency of training in terms of human resources . With VRMost of the VR technologies used in the studies included motion detection systems, in which the virtual environment is presented on large screens. Thus, the user sees the simulated environment and can interact with it. An advantage of this is that the system might encourage users to perform movements naturally. Consequently, VR-based rehabilitation is an effective way for people with upper-extremity injuries and diseases to cope with their motor impairment and regain the ability of performing activities of daily living (ADL) and self-care, which refer to the activities carried out to live an independent life, e.g., grooming or preparing food . ExampleIt is important to note a few limitations. First, only articles in the English and German language were included. Furthermore, studies that assessed neurological disorders were excluded. Because of this, only 11 studies could be identified, which again highlights that the potential of VR technologies for the rehabilitation of upper-extremity diseases and injuries is still underexplored. The heterogeneity of endpoints and assessment tools, as well as the small sample sizes in the studies, limits the comparability and interpretation of the results. Additionally, it was not possible to obtain conceptual or concrete content-related details of VR technologies.In conclusion, this scoping review showed that especially game-based VR systems are highly prevalent in the context of rehabilitation and seem to be gaining importance to enhance motivation and support therapy. As presented, the literature to date strongly suggests that these technologies are poised to have a major impact on evaluation and intervention for motor and functional rehabilitation because of the unique attributes of VR-based therapy. These attributes make it highly suitable for the achievement of many rehabilitation goals, including the encouragement of active learning, the provision of challenging but safe environments, the flexibility of individualized and graded treatments, the power to motivate patients to perform to their utmost ability, and the capacity to record objective measures of performance.VR systems are being directed at the rehabilitation of motor deficits to help provide recreational opportunities for people with upper-extremity dysfunction. VR-mediated rehabilitation has yielded significant improvements in upper-extremity recovery, especially regarding range of motion and pain reduction. VR systems show promise for training in activities of daily living, including use of a virtual kitchen, street-crossing, and wayfinding environment. Evidence from this scoping review suggests that VR technologies have the potential to become an effective tool in the rehabilitation of upper-extremity functions. Although the results do not indicate VR systems to be significantly more beneficial than routine physiotherapy, VR systems are comparable with existing traditional rehabilitation procedures and can be used as an alternative or adjunct for the rehabilitation of upper-extremity injuries and diseases. Advantages are mainly seen in the increased motivation to perform therapy tasks and the simulated and risk-free training of functional exercises with a stronger intensity than traditional rehabilitation.Overall, VR offers a unique medium in which rehabilitation can be offered within a functional, purposeful, and motivation context, which can be readily graded and documented. Especially game-based VR technologies are becoming more accessible and cost-effective; however, they are not yet fully provided in regular care. The successful and extensive implementation of VR technologies in rehabilitation might be possible when the technologies are easily integrated in the everyday life of patients and professionals. For this purpose, it will be necessary to design and evaluate VR technologies in a participatory and user-oriented way. It remains exciting to learn about the effects that future developments will report, including user-specific perspectives.


Prostate cancer (PCa) relies in part on AR-signaling for disease development and progression. Earlier, we developed drug candidate galeterone, which advanced through phase 2-clinical trials in treating castration-resistant PCa (CRPC). Subsequently, we designed, synthesized, and evaluated next-generation galeterone-analogs including VNPP433-3β which is potently efficacious against pre-clinical models of PCa. This study describes the mechanism of action of VNPP433-3β that promotes degradation of full-length AR (fAR) and its splice variant AR-V7 besides depleting MNK1/2 in in vitro and in vivo CRPC models that stably overexpresses fAR. VNPP433-3β directly engages AR within the cell and promotes proteasomal degradation of fAR and its splice variant AR-V7 by enhancing the interaction of AR with E3 ligases MDM2/CHIP but disrupting AR-HSP90 binding. Next, VNPP433-3β decreases phosphorylation of 4EBP1 and abates binding of eIF4E and eIF4G to 5′ cap of mRNA by depleting MNK1/2 with consequent depletion of phosphorylated eIF4E. Finally, RNA-seq demonstrates modulation of multiple pathways that synergistically contribute to PCa inhibition. Therefore, VNPP433-3β exerts its antitumor effect by imposing 1) transcriptional regulation of AR and AR-responsive oncogenes 2) translational regulation by disrupting mRNA-5′cap-dependent translation initiation, 3) reducing AR half-life through enhanced proteasomal degradation in vitro and AR-overexpressing tumor xenografts in vivo. Notwithstanding the revolutionary advancements in biomedical research and patient healthcare, metastatic castration-resistant prostate cancer (mCRPC) poses a major challenge and remains the second leading cause of cancer-related death in men in the United States and the second most frequently diagnosed cancer among males worldwide ,2,3. DysPreviously reported full-length AR signaling inhibitors abiraterone and enzalutamide have significant effects on CRPC and prolong the survival of the patients. Although abiraterone inhibits the enzyme CYP17A1 and blocks residual androgen synthesis and AR signaling ,13, enzaThe setback suffered in current treatments of CRPC is partly due to the perpetuation of AR signaling even in hormone-refractory disease and therefore AR remains essentially a preferred therapeutic target . HoweverWe have recently developed galeterone , a potent drug that concurrently targets AR and Mnk1/2 . Though In this study, we report the mechanism of VNPP433-3β, a potent degrader of AR. VNPP433-3β decreases the steady-state availability of AR protein substantially by reducing its half-life through accelerated proteasomal degradation. RNA-seq studies further support the antitumor effect due to the shift in transcriptional activity in favor of PCa inhibition. Furthermore, VNPP433-3β depletes Mnk1/2, thereby inhibiting the phosphorylation of eIF4E. The key advantage of VNPP433-3β is its ability to target multiple signaling and metabolic pathways  that play crucial roles in the development and progression of PCa.2. Gal and VNPP433-3β were synthesized in-house as previously described [The human PCa cell lines, CWR22Rv1 and LNCaP were procured from ATCC  and cultured in phenol red-containing RPMI-1640 media supplemented with 10% heat-inactivated standard fetal bovine serum  and 1% penicillin-streptomycin  at 37 °C and 5% COescribed  and dissThe crystalline structure of the human AR ligand binding domain (LBD) available in the protein databank PDB  was empD values were derived using ‘one-site specific binding’ function in non-linear regression of GraphPad Prism. All experiments were done in triplicates independently.Fluorescence spectral measurements were carried out using recombinant human AR LBD  in the Tecan Spark microplate reader  as described previously . Brieflyg for 20 min at 4 °C to pellet down the cell debris, precipitated, and aggregated proteins. Supernatant fraction containing the soluble protein was subjected to immunoblotting and the relative intensity of the bands was quantified using Image lab  and plotted as a function of temperature to yield the apparent melting curve.Thermal stabilization of protein upon ligand binding was quantitatively measured using Cellular thermal shift assay and detected using western blotting as described previously . BrieflyCells were lysed with radioimmunoprecipitation assay (RIPA) buffer supplemented with 1X protease inhibitors , phosphatase inhibitors , 1 mmol/L EDTA and 1 mmol/L PMSF (Sigma) and immunoblotting analyses were performed as described previously ,38. For CWR22Rv1 and LNCaP cells were hormone-starved for 48 h, treated with VNPP433-3β (10 µM) for 4 h. Immunoprecipitation was performed using Dyna beads conjugated to Protein A in accordance with the manufacturer’s instructions . Briefly, 50 μL Dyna beads conjugate was incubated with 3–5 μg of antibody for 10 min. Dyna beads-Ab complex was then washed in washing buffer and subsequently binding buffer. Cell lysate containing 1mg protein was added to the Dyna beads-Ab complex and incubated for 10 min. The complex was washed thrice using washing buffer and resuspended in elution buffer followed by immunoblotting with the appropriate antibody. To study protein-protein interactions, hormone-starved CWR22Rv1 and LNCaP cells were treated with VNPP433-3β (10 µM) for 4 h and the cell lysates were incubated with Dyna beads-Ab complex following the manufacturer’s instructions and immunoblotted.7GTP (C10-spacer)-Agarose beads  was added to 500 μg of total proteins and incubated at 4 °C for 2 h with constant shaking. Samples were then washed with cap-binding buffer, quenched with sample buffer, and subjected to immunoblotting.CWR22Rv1 and LNCaP cells seeded in 6-well plates 24 h prior to drug exposure were treated with VNPP433-3β (10 and 20 μM) for 24 h. Cells were then washed with ice-cold PBS and total cell lysates were prepared in cap-binding buffer containing 150 mM NaCI, 50 mM Tris, pH 7.5, 50 mM NaF, 10 mM Na-pyrophosphate, 1 mM EDTA, and 2.5 mM Na-orthovanadate supplemented with protease inhibitor cocktail (Sigma) at 4 °C for 15 min. Subsequently, 25 μL of γ-Aminophenyl-mCWR22Rv1 cells were treated with 10 μM VNPP433-3β for 24 or 48 h in triplicates. Cells were then washed with PBS and RNA was extracted using RNAeasy Plus mini kit . The concentration and quality of total RNA samples were assessed using Agilent 2100 Bioanalyzer, and a RIN (RNA Integrity Number) threshold of 8 or above was employed for all samples. RNA-Seq libraries were prepared with the NEB Ultra II Directional RNA library prep kit. The libraries were assessed for quantity and size distribution using Qubit and Agilent 2100 Bioanalyzer. Sequencing was performed on an Illumina NovaSeq S2 PE100 bp lane at Maryland Genomics, Institute for Genome Sciences, University of Maryland Baltimore. Phred quality score (Q score) was used to measure the quality of sequencing. More than 90% of the sequencing reads reached Q30 . QIAGEN Ingenuity Pathway and Gene Set Enrichment analyses (GSEA) were carried out to reveal canonical cellular pathways modulated by VNPP433-3β.Specific siRNA targeting the gene of interest and scramble siRNA (siControl) were purchased from Ambion . CWR22Rv1 and LNCaP cells were grown in 6-well culture plates and transfected with specific siRNA using lipofectamine RNAiMax transfection reagent  in Opti-MEM reduced serum medium  for 48 h following the manufacturer’s instructions. Scrambled siRNA was transfected as control and knockdown was confirmed by immunoblot analyses.6 22Rv1 cells that stably overexpress full-length AR were subcutaneously injected into the left flank of mice. After three weeks of inoculation and upon reaching the tumor volume of ~100 mm3, the mice were randomized into five groups of five animals. Mice-bearing tumors of 22Rv1 cells that are transfected with an empty plasmid vector served as transfection control and mice bearing AR-overexpressing 22Rv1 tumor xenografts served as treatment control. Both the control groups of mice were orally administered with vehicle . The other three groups of mice bearing AR-overexpressing 22Rv1 tumor xenografts were orally administered with galeterone  or VNPP433-3β , five days a week for 17 days. The animals were monitored daily for general health and body weight was recorded three times a week. The tumor size was measured thrice a week using digital calipers and tumor volume was calculated using the formula length × width 2 × 0.5 (mm3). Upon reaching the tumor length close to 20 mm in control groups (17th day), the experiment was terminated, the animals were euthanized, and tumors were excised for further immunoblot and histology analyses as described previously [The castration-resistant prostate cancer (CRPC) cell line 22Rv1 that stably overexpresses full-length AR and inherently expresses fAR and AR-V7 was used to induce tumor xenografts in immunodeficient male NRG mice. The mice (age 5–7 weeks) were procured from the Veterinary Resources, University of Maryland School of Medicine , housed under sterile conditions, and fed with sterile pellets and water ad libitum. After a week of acclimatization, 5 × 10eviously . All in t test using GraphPad Prism 5.0 software . A probability value with * p < 0.05, ** p < 0.01 and *** p < 0.001 were considered statistically significant. As specified in the figure, values in data are expressed as the mean  ±  SEM of three or more independent experiments.Statistical comparisons were made by one-way ANOVA followed by Student’s RNA sequencing and transcriptome analyses in CWR22Rv1 cells reveal that VNPP433-3β triggers significant changes in the cellular transcriptome A. The 10D) in vitro by fluorescence spectroscopy. Changes in relative fluorescence upon AR LBD-VNPP433-3β interaction, ΔF was plotted as a function of the concentration of AR (D) of 360 ± 30 nM.As the primary studies indicated that AR is the prime target of VNPP433-3β A, we furon of AR D. VNPP43We next validated the in-silico and in vitro findings of AR-VNPP433-3β interaction by performing a cellular thermal shift assay (CETSA) in LNCaP cells. The protein level of AR was monitored by western blot E and relPhysiologically, the non-ligand bound AR is degraded by a proteasome-dependent pathway, but its stability is increased by androgen binding . This prFurther, to ascertain whether the effects of VNPP433-3β were direct and due to AR binding the ligand, we tested if dihydrotestosterone (DHT), the natural ligand of AR could prevent the decline in AR protein. Interestingly, we observed that DHT could partly impede the VNPP433-3β-mediated decrease in AR level in CWR22Rv1 E and LNCNext, we overexpressed fAR in CWR22Rv1 and LNCaP cell lines and assessed the effect of VNPP433-3β and Gal in AR-overexpressing cell lines. We found that overexpression of AR did not significantly alleviate the effect of VNPP433-3β or Gal as the levels of fAR and AR-V7 were decreased significantly I,J.Considering ubiquitin-dependent proteasomal degradation is the major and well-known pathway of AR degradation, we then investigated the role of major proteins operating in the pathway and how VNPP433-3β modulates their activity. Firstly, MDM2 or CHIP was knocked down in CWR22Rv1 and LNCaP cell lines using siRNA prior to treating with 10 µM VNPP433-3β for 24 h. Strikingly, the degradation of fAR and AR-V7 by VNPP433-3β was impaired when either of these E3 ligases was downregulated in CWR22Rv1 A and LNCIntrigued by these results, we then investigated if these proteins physically interacted with AR and if so, this interaction was modulated by VNPP433-3β. To study this, a series of co-immunoprecipitation (co-IP) experiments were carried out. IP of fAR followed by western blot shows that MDM2 and CHIP were co-precipitated with AR, wherein VNPP433-3β treated cells resulted in enhanced interaction of AR with MDM2 and CHIP compared to the vehicle control in CWR22Rv1 C and LNCHeat shock protein 90 (HSP90) is a molecular chaperone that aids other proteins to fold into native conformation. It stabilizes the client proteins against various stresses in the cell and is a key regulator of proteostasis. The HSP90 is found to interact with AR, thereby enhancing the stability of non-ligand bound receptors. Inhibitors of HSP90 such as 17-AAG prevent HSP90-AR interaction, subsequently leading to AR degradation . This prThe co-immunoprecipitation (Co-IP) with AR confirmed the VNPP433-3β-mediated augmentation of interaction between fAR/AR-V7 and E3 ligases MDM2 and CHIP while disrupting the interaction between fAR/AR-V7 and HSP90, thereby compelling fAR/AR-V7 to enter the ubiquitin-dependent proteolysis pathway. This model of AR degradation is consistent with the previous reports of small molecule-induced AR degradation through ubiquitin-dependent proteasomal degradation ,45. As t7GTP-Agarose pull-down followed by western blot analyses of eIF4E and eIF4G. Interestingly, the treatment with VNPP433-3β significantly disrupted the mRNA-5′cap-binding ability of eIF4E and eIF4G in a dose-dependent manner in both the cell lines tested , the very first step of translation is tightly regulated. Eukaryotic translation initiation factor 4E (eIF4E) is a vital effector molecule and its availability is a rate-limiting factor in the initiation of protein synthesis F, the ve. It binds tested A,B. ThisPhysiologically, eIF4E is sequestered from binding the mRNA by another key protein 4EBP1. However, when 4EBP1 is phosphorylated (p-4EBP1) at one or more of the seven residues known to be phosphorylated by mTOR or yet-to-be-identified other kinases, it gradually loses affinity for eIF4E and liberates eIF4E, which can bind the mRNA 5′-cap, thereby initiating translation . The hypSince the biochemical, cytological, and molecular data demonstrated AR as the prime target of VNPP433-3β, we sought to evaluate the effect of VNPP433-3β in AR-overexpressing tumor xenografts in vivo. The tumor xenografts from AR-overexpressing 22Rv1 were larger in volume and heavier in final weight than the empty vector-transfected 22Rv1 xenografts. However, when treated with galeterone  or VNPP433-3β , five days a week for 17 days, the tumor growth was significantly impaired A–C. InteThe goal of this study is to investigate the mechanism of action of VNPP433-3β in combating PCa. Our in vivo studies suggest that VNPP433-3β is more potent than galeterone in combating PCa . In thisMore notably, VNPP433-3β also triggers a significant reduction in the Mnk1/2 protein level. However, we are further investigating the mechanism of VNPP433-3β-induced Mnk1/2 depletion. Our findings are consistent with previous studies that showed phosphorylation of eIF4E by MNK1/2 is critical to promoting EMT and metastasis via translational control of SNAIL and MMP3 . VNPP433Recent RNA-seq studies in PCa suggest that AR-V7 acts as a transcriptional repressor of tumor-suppressor genes . TranscrCollectively, our data suggest that VNPP433-3β directly targets AR within the cells and inhibits mCRPC. VNPP433-3β also precludes eIF4E phosphorylation by depleting Mnk1/2 besides dodging binding of eIF4E and eIF4G to mRNA 5′ cap thereby impeding the reckless translational activity of the PCa cells. Finally, VNPP433-3β obstructs cell proliferation, colony formation, invasion, and EMT in PCa cells and enforces apoptosis. Transcriptome analyses by RNA-seq further substantiate the biochemical findings and reveal several pathways relevant to PCa that are modulated by VNPP433-3β. Notably, VNPP433-3β acts at multiple levels and modulates more than 20 cellular pathways to halt PCa progression and redirect the cells to undergo apoptosis. Based on the results of the present study, we propose that VNPP433-3β exerts the antitumor effect by imposing (1) transcriptional regulation of AR and AR-responsive oncogenes via degrading AR, (2) translational regulation by depleting Mnk1/2 thereby impeding phosphorylation of eIF4E and subsequent mRNA-5′cap-dependent translation initiation, (3) reducing AR half-life through enhanced proteasomal degradation and (4) modulating transcription of several genes relevant to PCa. As VNPP433-3β exerts its therapeutic effect at multiple levels, it could potentially be developed for clinical trials in mCRPC patients.VNPP433-3β modulates AR-responsive oncogenic transcription by directly targeting AR and augmenting its degradation. VNPP433-3β-bound AR loses affinity for HSP90 and preferentially interacts with Mdm2 and CHIP resulting in its ubiquitination and subsequent proteasomal degradation. Further, it perturbs eIF4E phosphorylation by depleting Mnk1/2 besides disrupting the binding of eIF4E and eIF4G to mRNA 5′ cap, thereby upsetting reckless translational activity of the PCa cells. Finally, it modulates the transcription of several genes and activates more than 20 cellular pathways, that synergistically contribute to PCa inhibition. As VNPP433-3β effectively disrupts multiple cellular pathways that drive PCa development, progression, and metastasis, it could possibly thwart therapy resistance, making it an excellent candidate for clinical development.