A comprehensive, accurate description of workforce capacity is important for health service planning, to ensure that health services meet local needs. In many low- to middle-income countries, the government’s service planning ability is barred by the lack of accurate and/or comprehensively-described workforce data. In these low-resource settings, lack of appropriate planning leads to limited or no access to rehabilitation services. Variability in the definitions and scope of rehabilitation professionals further complicates the understanding of rehabilitation services and how it should be planned and delivered. Another challenge to describing the primary rehabilitation workforce capacity, is the lack of standardised and agreed-upon global metrics. These inconsistencies highlight the need for a comprehensive understanding of current practices, which can offer guidance to countries wishing to describe their rehabilitation workforce. This study aimed to scope the range of descriptors and metrics used to describe the rehabilitation workforce and to compare the workforce across countries that used similar descriptors in published reports.A scoping review was conducted according to the five-step framework first developed by Arksey and O’Malley. The review included a broad search of literature regarding the rehabilitation workforce and how countries quantify and describe the rehabilitation workforce.Nineteen studies on rehabilitation workforce capacity were identified. All but one  were database reviews. The main descriptors and indicators used to describe the rehabilitation workforce capacity were profession type, age, gender, distributions between urban/rural, level of care, and private/public sectors, absolute count totals, and population-adjusted ratios.This scoping review provided an overview of descriptors and indicators used to describe the rehabilitation workforce capacity internationally. The study is a first step towards developing standardised descriptors and metrics to quantify the rehabilitation workforce capacity, that will allow for comparison between different settings.This scoping review protocol has been registered with the Open Science Framework (http://osf.10/7h6xz).The online version contains supplementary material available at 10.1186/s12913-022-08531-z. A comprehensive and accurate description of workforce capacity is important for health service planning to ensure that health services meet local needs . Health The limited access to rehabilitation services in LMICs is widely reported in the literature , 3, despDefinitions of the rehabilitation workforce vary across countries due to differences in the classification of rehabilitation professionals , 7, 8. TDescribing the primary rehabilitation workforce capacity is also challenged by a lack of standardised and agreed-upon global metrics , 7. The To respond to the WHO’s recommendation for a country-specific description of the rehabilitation workforce, the selection of appropriate and commonly used metrics is an important preliminary step towards service planning . TherefoA scoping review was conducted according to the five-step framework first developed by Arksey and O’Malley . These sThe research objectives assisted in determining the eligibility criteria, guided the scope of the review, and determined an effective search strategy.Understand the data collection methods or data sources used to collate rehabilitation workforce capacity information (descriptors and indicators),Synthesise which descriptors and indicators were used to describe (or quantify) national or regional rehabilitation workforce data .To achieve the overall study aim, the following objectives were completed:A broad and comprehensive three-step search strategy was undertaken to identify published studies in five databases . These databases were chosen in consultation with a librarian as they yielded the most relevant results. Databases such as Africa Wide and EBSCOHost were accordingly excluded. As a first step, an initial limited keyword search was conducted in PubMed, using key terms related to ‘rehabilitation workforce’, ‘physiotherapy’, ‘physical therapy’, ‘occupational therapy’, ‘speech therapy’, ‘speech-language therapy’, ‘audiology’, ‘allied health’, ‘rehabilitation workforce’, ‘human resources’, ‘human resources for health’, ‘staffing’, ‘supply’, ‘population needs’ and ‘demographics’.This was followed by an analysis of the text words of the titles and abstracts of potentially relevant articles, and keywords used to index articles. A second search was undertaken, which incorporated the identified additional or refined index and keywords across all databases. The preliminary search string that was developed for PubMed is provided in Addendum All database search outcomes were transferred to Rayyan V0.1.0 software  . DedupliThe scoping review included peer-reviewed primary studies, published in English, on rehabilitation workforce. We considered descriptive, cross-sectional and cohort designs. Grey literature and studies published before 2000 were excluded. Studies where the full texts were not available, were also excluded. No geographical limitations were applied.We considered rehabilitation workforce capacity demographics , and rehabilitation workforce capacity indicators . Studies only reporting on forecasting were excluded.Only literature that included the rehabilitation workforce, or at least one of the professions that are classified as rehabilitation professionals in the relevant countries , were considered .Following deduplication, one reviewer (TC) screened all titles and abstracts retrieved and determined eligibility for inclusion. Eligible titles and abstracts were included for full-text review, which was again screened against the review eligibility criteria. If the reviewer (TC) was unsure of a study’s eligibility, a discussion with the second (QL) and third (KB) reviewers ensued for consensus. Reasons for excluding ineligible studies were discussed with the second (QL) and third (KB) reviewers and were documented.Based on a discussion between the reviewers , a draft data extraction form was developed in Microsoft Excel to ensure that all relevant data about the study objectives were included in the form. The form was piloted by two reviewers (TC and QL) using five randomly-selected eligible articles. Amendments were made by incorporating additional unforeseen data arising from the articles that were deemed important in terms of contributing to the review objectives. The data from the final sample of included articles were extracted by one reviewer (TC), using the final version of the data extraction form Addendum .Descriptive information  was summarised quantitively. Information on data collection methods and data sources that were used to collate the rehabilitation workforce capacity information were described narratively. Demographic and work setting-related descriptions  of the rehabilitation workforce data were described similarly. Metrics used to describe/quantify the national or regional rehabilitation workforce data were described and synthesised. To enable comparison and ease of interpretation of the findings regarding the workforce supply, percentages were calculated and, where data were available, ratios per 10 000 of the population were determined. Where ratios were reported per 1 000 or 100 000, the ratio was adjusted to 10 000 population. In cases where studies conducted retrospective analyses, the most recent year’s data were reported.The search produced 539 initial hits. Based on title and abstract screening, 500 records were excluded (213 duplicates and 287 that did not comply with the inclusion criteria). Full texts of the remaining 39 studies were screened and four further studies were identified via PEARLing. After full-text screening, a further 24 studies were excluded, and 19 studies remained for analysis  were published in the last five years. The total number of countries reported on the eligible studies, was 41 countries; with one study [Among the four LMICs included, South Africa , 18 and n = 14, 73.7%) [One of the studies compared physiotherapy between Canada and the USA . The dat, 73.7%) , 32–38, , 73.7%) –36, 38.Two 10.5%) studies , 37 desc0.5% studn = 11, 57.9%)) used data from professional associations [n = 3) [n = 7) [n = 1) [n = 9) [n = 2) [The data analysed by the included studies were retrieved from various publicly-accessible resources. More than half of the studies  –36, nati [n = 7) , 31, 38  [n = 9) –36, 38 o [n = 2) , 18. Nin [n = 2) , 36, 38  [n = 2)  of the iTwo (10.5%) , 36 studSix (31.6%) of the included studies reported on the age and/or gender of the rehabilitation workforce , 36, 38.Five (26.3%) studies , 36–38 rn = 14; 73.7%), of which nine reported on physiotherapy only [Most studies reported on physiotherapy  studies –36, 38. .8% studiFour (21.1%) of the 19 studies reported on the distribution of the rehabilitation workforce in urban versus rural areas Table  29, 32,, 36. TwoFive (26.3%) studies reported quantitative data: three studies on the distribution of the rehabilitation workforce per level of care , 20, 38 n = 14; 73.7%) of the studies [n = 879) who serve the population who are most likely to have hearing impairments in Arizona, USA [n = 119) of general inpatient beds [n = 643) in Saskatchewan, Canada [n = 6900) in New South Wales, Australia [n = 15 772), the USA (n = 167 810) and Ireland (n = 3172) for physiotherapy [n = 1150) [n = 5180) and audiology and speech therapy (n = 3266) workforce in South Africa [Most  . Two stuand n = 32 for phyThirteen 68.4%) of the studies reported on the population-adjusted ratios % of the , 35, 38.https://data.worldbank.org/indicator/SP.POP.TOTL)).Figure Figure Figure Figure To our knowledge, this is the first scoping review that examined descriptors and indicators of the rehabilitation workforce capacity across core rehabilitation professions and on a global level. Although only four LMICs were included in the review, the main descriptors and indicators identified are arguably applicable across contexts and settings. Our findings indicated that the following descriptors and indicators were most commonly used to quantify the rehabilitation workforce across countries: profession type, density, supply, distribution between rural and urban regions, distribution between public and private sectors, and age and gender.n = 150) of occupational therapists [The most common way in which the rehabilitation workforce was indicated, related to profession type. Reporting the rehabilitation workforce by profession is important, as multidisciplinary rehabilitation is reported as being the most effective for delivering quality rehabilitation services , 3, 6. Ierapists . CountriA quarter (26%) of the included studies , 34, 36 In many countries, gender equity is an important goal and gender should thus be considered in the descriptors to track gender distribution. About 26% of the profession included gender in the description of the rehabilitation workforce , 30, 36.The distribution of the rehabilitation workforce between rural and urban settings was reported in about a fifth of included studies Seven included studies (37%) –36, 38 rThe included studies also reported on quantitative metrics to describe the rehabilitation workforce. These metrics included absolute values and population ratios. The population-adjusted ratio is the most general measure of workforce supply in a specific area, region or population . AlthougOur review shows that HICs could have a therapist density of up to 40 times higher than LMICs. The stark difference may be due to better financial resources and because HICs have integrated rehabilitation into their policies, which prioritise funding for rehabilitation. In many LMICs, rehabilitation remains under-recognised as an essential healthcare strategy. The triple burden of non-communicable and communicable conditions and trauma evident in LMICs, are all pressing needs, which often utilise most of the health resources and funding. Consequently, rehabilitation remains underfunded and not well integrated into service and human resource planning.A single reviewer performed the searching and screening of titles and abstracts, which may have introduced bias. The review included only published primary studies; this may have led to the omission of unpublished information contained in the grey literature. Only studies published in English were included, which may have led to language bias and the potential exclusion of studies from some LMICs. The included studies were limited to studies reporting on rehabilitation workforce capacity, this excluded studies that were on rehabilitation workforce but did not include the capacity thereof – however, studies that did not report on capacity descriptors/metrics fell outside of the scope of this review. In line with scoping review methodology and the purpose of providing a comprehensive summary of the descriptors and metrics , no critical appraisal of the included studies was performed .The study findings can contribute to further research on rehabilitation workforce capacity and/or inform a systematic review on rehabilitation workforce. The data and information on rehabilitation workforce capacity in LMICs are lacking, and there is therefore a need to increase reliable and accurate data in LMICs to inform policies and finances for rehabilitation workforce. Future studies should adopt a more in-depth search strategy, including grey literature, to include a broader range of data (descriptors and metrics) at regional and national levels .This study aimed to scope the range of descriptors and metrics used to describe the rehabilitation workforce and to compare the workforce across countries that used similar descriptors. Despite the lack of a common definition or scope of the rehabilitation workforce capacity across countries, this review found the six most included descriptors in the eligible studies. The descriptors were profession type, density, supply, distribution between rural and urban regions, distribution between public and private sectors, age and gender. These descriptors enabled us to compare the capacity of the rehabilitation workforce across countries, keeping in mind the local context and economic status. These comparisons show that there is a large disparity in the rehabilitation workforce capacity between HICs and LMICs. With many LMICs already having poor access to rehabilitation services, this lack of workforce capacity means that access to rehabilitation services for the most vulnerable populations will be exacerbated. There is a need for reliable and appropriate data on rehabilitation workforce capacity, especially in LMICs, to strengthen rehabilitation into policies and promote the integration of rehabilitation in the local healthcare system.Additional file 1. Addendum 1. PRISMA Extension for Scoping Reviews checklist.Additional file 2: Addendum 2. PubMed Search String.Additional file 3: Addendum 3. Data extraction forms 1 and 2.


The aim of this review is to discuss the role of androgens in the progression of endometrial carcinoma (EC) with particular focus on the different kinds of androgenic hormones, androgen receptor (AR) and intracrine androgen metabolism.A comprehensive literature search within PubMed was performed. Selected publications related to androgens and EC were reviewed.There are different kinds of androgenic hormones, and different kinds of androgens may have different effects. Elevated androgens  have been associated with an increased EC risk in postmenopausal women. 5α-reductases (5α-Reds) and 17β-hydroxysteroid dehydrogenase type 2 (17βHSD2) pathway may inhibit the progression of EC mediated by dihydrotestosterone (DHT), but aromatases stimulate further progression of EC. The most of studies accessing the prognostic value of AR have found that AR expression may be a favorable prognostic indicator.Androgens may have both oncogenic and tumor suppressive roles. Androgen-specific biases in metabolism and the expression of AR may contribute to the different prognosis of patients with EC. Endometrial carcinoma (EC) is the most commonly diagnosed gynecological cancer in women and ranked second in gynecological cancer-related deaths . Risks fEndometrial growth is mediated by circulating sex hormones including androgens. There are several kinds of hormones that can exert androgenic effects, including dehydroepiandrosterone-sulfate (DHEAS), DHEA, androstenedione, testosterone and dihydrotestosterone (DHT) in the order of high to low level. Among them, DHT exerts the most potency of androgen, while androstenedione and DHEA exhibit only 10 and 5% of the potency of testosterone .Some studies have examined the potential role of circulating androgens as risk factors for EC. In general, elevated serum testosterone level has been associated with an increased EC risk in postmenopausal women Table . HoweverThe increased EC risks with androstenedione (A4) were also found in most studies after menopause Table . After aTo date, very few studies focused on the dihydrotestosterone (DHT), more potent than testosterone, in the role of EC risk. DHT is metabolized by 5α-reductase pathway and the reaction is not reversible Fig. . ExistinThe link between endometrial safety and androgen treatment has been investigated in postmenopausal women treated with androgens for diminished sexual wellbeing. Recent data form a meta-analysis showed that androgen treatment did not increase endometrial thickness in postmenopausal women . HoweverOnce inside the cells, androgens and their precursors can be further metabolized and converted into bioavailable androgen in specific tissues containing the appropriate enzymes , 11. In One of the primary roles of steroid sulfatase (STS) is to hydrolyze DHEAS to DHEA. Also, STS acts on substrates like estradiol-S and estrone-S. STS mRNA and protein levels were detected both in cancer tissues and normal endometrium, but no significant difference was found , 15. A l3β-Hydroxysteroid dehydrogenase (3βHSD) enzymes catalyze the conversion of DHEA to A4 and androstenediol to testosterone. Little is known about it in the role of EC, with only one study suggesting no significant changes in EC compared with normal tissues . Correla2) is produced via 17β-hydroxysteroid dehydrogenase type 1 (17βHSD1). To date, the role of 17βHSD1 in EC has been investigated more in relation to the production of estrogen rather than androgen. An increase in the levels of 17βHSD1 has been shown to be associated with increased levels of E2 in EC [The most potent estrogen estradiol  is responsible for generating A4 from testosterone and the reversible conversion between estrone and estradiol. Studies assessing the clinical significance of 17βHSD2 in EC have suggested conflicting findings. A relatively well-designed cohort study identified that 17βHSD2 was significantly higher in tumors compared with normal tissues, especially in endometrioid type II cancers . FurtherIn contrast to the role of 17βHSD2, 17β-hydroxysteroid dehydrogenase type 5 (17βHSD5) is involved in the conversion of A4 into T.To date, 17βHSD5 expression in cancer tissues as opposed to normal endometrium is still uncertain. The largest published study identified a decreased 17βHSD5 level measured by immunohistochemistry (IHC) in 123 EC specimens compared with adjacent normal endometrium. Further survival analysis revealed that increased expression of 17βHSD5 in endometrioid endometrial cancer was associated with better cumulative and disease-specific survival . 17βHSD55α-Reductases (5α-Reds), which have three different isoforms-5α-Red1, 5α-Red2, and 5α-Red3, catalyze the conversion of testosterone to DHT. In EC, 5α-Red1 is the most widely investigated among them. 5α-Red1 was considered the main isoform in EC tissues and expressed more frequently than 5α-Red2. And the levels of 5α-Red1 expression were upregulated compared with matched tissues –29. Howe5α-Reds, especially 5α-Red1, are also involved in progesterone metabolism. As we know, progesterone can counteract the effect of estrogens within the endometrium. The suppressive effect of 5α-Red1 may be involved in androgens and/or progesterone actions in endometrium tumorigenesis, indicating the need for a better understanding of it to better define the role of 5α-Red1 in EC.The importance of 5α-Red2 and 5α-Red3 in EC is known little. Deceased levels of 5α-Red2 and increased 5α-Red3 expression were detected in EC , 30, altThe aromatases encoded by CYP19A1 gene catalyze the last steps of estrogen biosynthesis, which stimulates the cell proliferation in EC. This forms the basis for aromatase inhibition as a therapeutic strategy for EC. When aromatase inhibitors (AIs) reduce the peripheral conversion of androgens to estrogen, the levels of androgens increase in peripheral circulation and/or EC tissues. It has been reported that DHT could inhibit the proliferation of EC cells induced by estrogen . TherefoEvidence that the endometrium is an androgen-target tissue is supported by detection of AR in the tissue . Normal AR knockout (ARKO) mice are important for the study of AR in EC. In these animals, normal but smaller uteri and reduced uterine growth at oestrous or in response to exogenous gonadotrophins are found. Besides, AR appears to involve in the development of pups and placental. The number of pups per litter is significantly decreased before ovarian failure exists in ARKO mice. Placentomegaly and abnormal placental development are more frequent during pregnancy in these animals .Traditionally, EC has been categorized as type I or type II based on histology. In type II EC, high-level AR expression was restricted to serous cancer in concert with ER and PR expression. Although this study did not provided data on the association between AR and EC outcomes, the patients with AR-positive malignancies were older than those with AR-negative tumors . AR staiType I endometrioid adenocarcinomas comprise most cases. Most of the related studies focused on the relationship among AR levels in the primary tumor, clinical characteristics, and disease outcome. AR is widely expressed in EC and its expression in metastatic is significantly higher than that in primary tumors . Most ofIn mouse models of type I EC, short-term enzalutamide treatment, an inhibitor of AR signaling, reduced endometrial tumor burden and increased cancer cell apoptosis in a dose-dependent way. However, enzalutamide increased the incidence of invasive and metastatic tumor . This stIn the circulation, testosterone is highly protein-bound, with a small fraction dissolved freely. The rest of testosterone is bound to sex hormone-binding globulin (SHBG) and albumin. The SHBG-bound fraction is biologically inactive because of the high binding affinity of SHBG for testosterone . Total o2 [Another obvious influential issue is that hyperandrogenism is often combined with several components such as insulin resistance (IR) and visceral adiposity –50, whic2 . After a2 .Androgens exert their effects on many cellular targets, including cells of the inflammatory and immune system. A comprehensive review showed that inflammatory cytokines were associated with an increased risk of EC. And they could activate the PI3K/Akt/mTOR signaling pathway that is the most frequently altered pathway in EC . It has Unfortunately, we are unable to conclude that androgens are the killer or helper in EC. This condition is complex. There are different kinds of androgenic hormones, and different kinds of androgens may have different effects. Elevated androgens  in EC patients mean that they maybe the potential inciting factor of EC. However, androgen-specific biases in metabolism and the expression of AR may contribute to the different prognosis of patients with EC. For example, 5α-Reds and 17βHSD2 pathway may inhibit the progression of EC mediated by DHT, but aromatases stimulate further progression of EC. However, the downstream signaling pathways have remained unknown. Further experimental studies are clearly required to uncover the impact of related enzymes and AR on carcinogenesis in endometrium.


Background: Short- and long-term consequences after treatment for childhood fossa posterior tumors are extensively reported in the literature; however, papers highlighting physical function throughout rehabilitation and its correlation with Intelligence Quotient (IQ) are sparse. This study aims to describe the physical functioning and IQ of these survivors, their progression during rehabilitation, and the association with histopathological tumor classification. Additionally, the correlation between gross motor functioning and cognitive functioning was investigated. Methods: This retrospective single-center cohort study included 56 children (35 (62.5%) males and 21 (37.5%) females, with an average age of 6.51 years (SD 4.13)) who followed a multidisciplinary program at the Child Rehabilitation Centre, Ghent University Hospital in the period from 2005 to 2020. Descriptive statistical analysis was performed with the use of non-parametric tests and linear regression to determine the relationship between gross motor functioning and IQ. Results: This report shows impaired motor and intelligence performance in children with a fossa posterior tumor. Although multidisciplinary rehabilitation is beneficial, it is not able to counteract the further decline of several motor skills and intelligence during oncological treatment, more specifically in children with a medulloblastoma. A correlation between gross motor function and total IQ was found. Conclusion: Pediatric survivors of a fossa posterior tumor experience impaired physical and intellectual functions, with more decline during oncological treatment despite simultaneous multidisciplinary rehabilitation. In the pediatric population, one fourth of cancer diagnoses are brain tumors with an overall incidence between 2.65 and 5.7 per 100,000 children and adolescents . VariousDepending on the WHO classification of the tumor and protocol guidelines, total microsurgical removal of the tumor is often the first objective, followed by complementary treatments such as chemotherapy and radiotherapy. Previous papers have reported extensive short- and long-term consequences after treatment for childhood fossa posterior tumors. In the acute postoperative phase, there is often profound axial hypotonia and ataxia , which mWith regard to the neuropsychological outcome, short- and long-term neurocognitive dysfunctions, including memory impairment and IQ decline, have been reported . Risk faAs therapeutic interventions targeting motor skills and cognitive functions can be effective in this population, children with a history of a fossa posterior tumor usually start with multidisciplinary rehabilitation in specialized centers as soon as possible . Little (1)Physical functioning and the intelligence quotient (IQ) using a standardized measure and compared to normative data.(2)The progression of these aforementioned outcome values during a multidisciplinary rehabilitation program.(3)A possible difference in physical functioning and the intelligence quotient (IQ) between the different histopathological tumors .(4)Because cognitive function is related to motor function in small children and children with cerebral palsy, our additional goal is to search for a correlation between motor functioning and cognitive functioning in children with a fossa posterior tumor ,17.To better understand physical and cognitive outcomes in pediatric fossa posterior tumor survivors, this study aimed to investigate:(1)There is no difference in the outcomes of pediatric survivors of fossa posterior tumor and normative data.(2)There is no difference in outcomes when comparing the values at the beginning and at the end of the rehabilitation.(3)The histopathological tumor has no effect on physical functioning and IQ.(4)Motor functioning is not related to cognitive functioning.The null hypotheses of these goals are:A retrospective cohort study design was used, with data collected from the electronic patient record platform of the Children’s Rehabilitation Centre, Ghent University Hospital, Belgium. Children between the age of 0–15 years, diagnosed with a medulloblastoma, ependymoma or pilocytic astrocytoma in the fossa posterior, were selected in the period from 2005 to 2020. They were included in the study if they underwent a  neurosurgical tumor resection followed by a multidisciplinary rehabilitation program . ExclusiTo determine physical functioning at the onset and the end of the rehabilitation period, registered data were collected describing muscle strength and range of motion. Muscle strength was graded according to the Medical Research Council Scale. Range of motion was measured using a goniometer based on the neutral zero method. Furthermore, results of three norm-referenced tools to measure gross and fine motor skills in children were assembled: the Bruininks–Oseretsky Test of Motor Proficiency Second Edition (BOT-2), the Peabody Developmental Motor Scale (PDMS-2) and the Purdue Pegboard Test (PPT).The Bruininks–Oseretsky Test of Motor Proficiency Second Edition (BOT-2) delivers a comprehensive measure of gross and fine motor skills in children aged 4 to 21. The BOT-2 has 53 items organized into four composites: a fine motor manual control composite, manual coordination composite, body coordination composite and strength and agility composite. These composites are further divided into eight subscales ,19. The Peabody Developmental Motor Scale (PDMS-2) assesses the gross and fine motor skills of young children from birth through 5 years. This test is composed of six subsets, which include reflexes, stationary, locomotion, object manipulation, grasping and visual motor-integration. The PDMS-2 categorizes performance into 1 of 7 categories, with higher scores reflective of better performance ,21.The Purdue Pegboard Test (PPT) is an assessment of fingertip dexterity and gross movement of the arm, hand and fingers. The child is seated at a table with the testing board in front of him/her. The testing board consists of two vertical rows of 25 small holes down the center and 4 cups across the top with pins, washers and collars. The clinician administers the following subtests: place as many pins as possible on the row within 30 s with the right hand, with the left hand and with both hands. The last subtest is the use of both hands simultaneously while assembling as many pins, washers and collars as possible within 60 s.The Wechsler Intelligence Scale for Children (WISC) is a widely-used standardized tool to assess intelligence in children between the age of 6 and 17 years . DiffereThe Wechsler Preschool and Primary Scale of Intelligence (WPPSI)-III-NL is an intelligence test for children from the age of 2 year 6 months to 7 years 11 months .The assessment of intelligence in children with problems in the area of verbal communication  was performed with the Snijders-Oomen Nonverbal Intelligence test, Revised (SON-R). For the administration of this test, neither the examiner nor the child is required to speak or write. The SON-R 2½-7 is suitable for children between the age of 2, 5 and 7 years, while the SON-R 6-40 is used in older children . Descriptive statistical analysis was performed with SPSS version 27.0  and Excel (Microsoft Office) was used for the graphic illustrations. The comparison of the continuous variables between groups was performed using the non-parametric Wilcoxon (2 groups) or Kruskall–Wallis (more than two groups). The comparison of categorical variables was performed with the non-parametric chi square test. p-values lower than 0.05 were considered significant. Corrected The relationship between physical functioning and cognitive status was assessed by linear regression (Pearson correlation).Fifty-six children were included in our study in the time period of 2005–2020. Thirty-five (62.5%) males and 21 (37.5%) females, with an average age of 6.51 years (SD 4.13) when diagnosed. The average period of the multidisciplinary rehabilitation was 444 days, equaling 1 year and 2 months. Multidisciplinary rehabilitation was started immediately after the neurosurgical procedure and consisted of physiotherapy, occupational, speech-language and neurocognitive training, with a frequency of 3 to 5 times a week (2.5 h/day). The most common tumor histology was a medulloblastoma (50%), followed by a pilocytic astrocytoma (37.5%) and an ependymoma (12.5%).At presentation in the hospital, nearly 70% of patients needed an emergency surgery with the establishment of an external ventricular drain (EVD) for intracranial hypertension. p = 0.028), 19.6% died, most of them diagnosed with a medulloblastoma (10/11 children), and only one child (1/11) died from an ependymoma. Of the included children, 41.1% had a relapse tumor with a significant predilection for an ependymoma  as well as at the end of the rehabilitation period (p < 0.076). The range of motion in the upper limbs was seldom disturbed, however, a reduction in the range of motion in the lower limbs was often seen in children with a medulloblastoma. Moreover, this reduction in mobility in the lower limbs was unexpectedly more explicit at the end of the rehabilitation period compared to the beginning of the rehabilitation. The statistical significance (p) was calculated between this assessment and the different tumor histology  and the Peabody Developmental Scale (PDMS-2). The motor-area composite score distributions for “Body Coordination” and “Strength and Agility” were illustrated using boxplots and scatterplots . The norn = 18) at the start versus a mean of 37.8 (SD 8.189/n = 10) at the end.The composite scale, “Body Coordination” shows a positive tendency throughout the rehabilitation with a mean of 33 (SD 4.947/n = 16) and a final mean of 39.91 (SD = 11.149/n = 11). The heterogeneity of the data, together with missing data at the end of the rehab, did not allow statistical analysis of pre- and post-intervention.The composite score of “Strength and Agility” did not seem to improve during the rehabilitation with a starting mean of 40.53  at the beginning of the rehabilitation and 6.20 (SD = 2.864/n = 5) at discharge. Regarding the subscale “Object Manipulation”, a positive tendency throughout the rehabilitation was found with a starting mean score of 8 (SD = 2.366/n = 6) and at the end 13 (SD = 4.243/n = 2). Finally, the subscale “Stationary” showed no progress with similar scores at the start and the end of the rehabilitation, that is, 7.14 (SD = 2.410/n = 7) and 6.50 (SD = 3.536/n = 2), respectively , which is under the average value of 50. Throughout the rehabilitation there was an amelioration in the fine manual control, with an increase in the mean to 51.25 (SD 6.551/n = 4). The mean standard score of “Fine Manual Control” at the beginning was 41.286 (SD 7.544/n = 7).Additionally, the mean standard score of the subscale, “Manual Coordination” is located under the average value at the beginning of the rehabilitation, with a score of 37,857  at the beginning of the rehabilitation with a mean of 8 (SD = 4.082/n = 11) at the end. Although both mean scores lie within the average range, we noticed a small decrease between before and after the rehabilitation. The mean score of the subscale “Grasping” in our study was 9 (SD = 3/n = 11) at the beginning of the rehabilitation with a substantial decrease after the rehabilitation to 6.20 (SD = 3.347/n = 5), below the average range . After the end of the rehabilitation, there was no improvement in the percentile values with scores over the 50-percentile mark varying from only 10% of the children (scoring of the left hand) to a maximum of 18.2% (scoring of the right hand). n = 15) and for the Right Hand, the mean score was 27.857 (SD = 27.012/n = 14). Scoring for assembly and for Both Hands had a mean value of 35.0 (SD 29.439/n = 13) and 21.923 (SD 22.130/n = 13), respectively. The mean values of the ranks decreased at discharge from rehabilitation, with a mean value of 18.0 for the Right Hand (SD = 25.832/n = 11) and 19.546 (SD = 17.670/n = 10) for the Left Hand. The score for assembly had a mean value of 26.429 (SD = 22.678/n= 7) and finally, the mean score for the subset of Both Hands was 20 (SD = 23.452/n= 6). The mean value scores of the percentile ranks’ score before the rehabilitation were below the average marker of 50. The mean score of the Left Hand was 31.667 . The results of the WPSI-III and WISC III/V edition are displayed in three categories, total IQ score, verbal IQ score and performance IQ score . RegardlWhen analyzing the IQ scores at the end of the rehabilitation, we see a negative tendency in all values  in children with a medulloblastoma, compared to the initial intelligence performance. The total IQ score decreased from 92.31 (SD 12.826) to 82.44 (SD 11.980). The verbal IQ score deteriorated from 96.07 (SD 12.899) to 88.33 (SD 12.510) and the performance IQ score decreased from 87.23 (SD 12.969) to 80.56 (SD 80.56). However, this negative tendency in intelligence performance was not seen in the small group of children with a pilocytic astrocytoma. Unfortunately, there was no IQ data available at the end of the rehabilitation of the children with an ependymoma.The relationship between IQ and gross and fine motor functioning before the start of the rehabilitation was investigated by using the Pearson correlation . p = 0.102/n = 11). A similar strong correlation was found between the Verbal IQ and the Body Coordination subset with a positive value of 0.528 (p = 0.144/n = 9). One relationship was strongly negatively correlated, namely, the verbal IQ and the Object Manipulation subset with a Pearson score of −1.000 (p < 0.001/n = 2); however, we have to be cautious with this conclusion because of the very small number of children. The other investigated correlations did not show a strong correlation (in a positive or negative way). The correlation between the IQ and fine motor functioning showed varying results, with a strong negative correlation between the Visual-Motor Integration (PDMS-2) and the performance IQ. However, as a result of the very small amount of data, no conclusions can be made.There was a strong correlation between the Total IQ and the Body Coordination score (BOT-2) with a positive correlation coefficient of 0.519  of the children in our study cohort was 90.94, with a mean verbal IQ (VIQ) of 95.11 and a mean performance IQ (PIQ) of 87.41 at the time of administration in the child rehabilitation center, which is low average in comparison with an age-appropriate standard population. Notwithstanding the fact that we cannot speak of excessive cognitive impairment in these children at the start of their rehabilitation program, we may presume a negative effect of initial increased intracranial pressure, the involvement of the cerebellum and the extent of neurosurgery . A growiIn conclusion, our study adds fundamental, but also contradictory information. An intensive multidisciplinary rehabilitation program in the post-acute phase during oncological treatment may only have a limited, certain effect on the neurocognitive and physical outcome in children with a medulloblastoma. Of course, although extremely interesting, a comparative age-matched study with fossa posterior tumor survivors who did not receive rehabilitation is not possible in our hospital due to ethical reasons. Chemotherapy and radiotherapy have a known suppressive effect on brain plasticity, cognitive development and physical performance ,39,40,41The limitations of this study need to be acknowledged. First, this study is a retrospective observational cohort study in which results were compared with normative data from the different assessments used. Since the inclusion time frame is a period of fifteen years, some measures were altered in different editions (for instance the WISC-III and WISC-V), which could interfere with our results. Second, there is a considerable amount of missing data, which made it difficult to obtain significant conclusions when we compared results at the beginning and at the end of the rehabilitation period. Therefore, our findings need to be interpreted with caution. A prospective longitudinal study in children with a fossa posterior tumor following rehabilitation would be more ideal to gain complete data sets.This report shows the impaired motor and intelligence performance in children with a fossa posterior tumor, and confirms the long-term detrimental effect of oncological treatment. Furthermore, our study indicates that multidisciplinary rehabilitation is beneficial, but is not able to counteract further decline in several motor skills and intelligence in the post-acute phase of treatment, more specifically, in children with a medulloblastoma. Although the efficacy of rehabilitation is moderate, we argue that rehabilitation in the post-acute phase of oncological treatment may increase participation in age-appropriate activity requirements. Longitudinal follow-up studies are warranted to assess the physical and neuropsychological outcomes in this population.


Augmented reality (AR) involves digitally overlapping virtual objects onto physical objects in real space so that individuals can interact with both at the same time. AR in medical education seeks to reduce surgical complications through high-quality education. There is uncertainty in the use of AR as a learning tool for interventional radiology procedures.To compare AR with other learning methods in interventional radiology.Systematic review of comparative studies on teaching techniques.We searched the Cochrane Library, MEDLINE, Embase, Tripdatabase, ERIC, CINAHL, SciELO and LILACS electronic databases for studies comparing AR simulation with other teaching methods in interventional radiology. This systematic review was performed in accordance with PRISMA and the BEME Collaboration. Eligible studies were evaluated using the quality indicators provided in the BEME Collaboration Guide no. 11, and the Kirkpatrick model.Four randomized clinical trials were included in this review. The level of educational evidence found among all the papers was 2B, according to the Kirkpatrick model. The Cochrane Collaboration tool was applied to assess the risk of bias for individual studies and across studies. Three studies showed an improvement in teaching of the proposed procedure through AR; one study showed that the participants took longer to perform the procedure through AR.AR, as a complementary teaching tool, can provide learners with additional skills, but there is still a lack of studies with a higher evidence level according to the Kirkpatrick model.DOI 10.17605/OSF.IO/ACZBM in the Open Science Framework database. In medicine, acquiring new abilities can lead to improvement in outcomes, as in the field of surgery, in which open surgical procedures have been replaced by minimally invasive procedures, and fresh devices are created to refine surgical abilities, and teaching processes as well.Learning is the process of acquiring new knowledge and skills, and this process has its difficulties and pitfalls. According to British National Health Service data, preventable injuries and deficient medical training are responsible for 10% of hospitalizations. In consonance, “warm-up” can be applied to students and experienced professionals, thus boosting performance and self-confidence. This could form another application for augmented reality (AR).The “learning before doing” concept is rapidly replacing the conventional “see one, do one, teach one” technique, in order to avoid potential mistakes. With AR, users visualize the real situation in which they are immersed along with a virtual projection of a 3D image. This immersion can be enhanced with sound, touch and smell through integrated external components. Increasingly, use of mobile AR (mAR) makes time and location flexible and expands training time.AR involves digitally overlapping virtual objects onto physical objects in real space so that individuals can interact with both at the same time. Virtual reality produces immersion of the user in a given environment, which may or may not be controlled, by depriving the perception of the local environment through use of a computerized scenario or one previously captured on video, and experiencing an environment as if it existed. Spatial and cognitive proprioception are the main difficulties identified during training. Acquisition of skills to use new devices is also a common issue, which can cause tragic outcomes, especially at the start of a career. Therefore, AR may improve medical teaching and enhance skills relating to given procedures. Preliminary studies comparing use of AR with traditional teaching methods have produced promising results.Interventional radiology consists of imaging-guided minimally invasive procedures that enable lower morbidity and shorter hospitalization time.There is no systematic review about augmented reality in interventional radiology.The aim of this study was to identify, systematically analyze and summarize the best available evidence comparing AR teaching techniques with various other methods in interventional radiology.The PICO technique  was used to define the study, as follows:P = Undergraduate healthcare students; postgraduate trainees; continuous professional development training – independent of the specialties.I = Augmented reality to teach interventional radiology.C = Traditional methodology versus AR.O = Improve ultrasound skills to achieve an accurate diagnosishttps://www.bemecollaboration.org/), and was registered in the Open Science Framework (https://osf.io/wn762). This study was exempted from institutional review as no live subjects were studied.This systematic review was executed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Best Evidence Medical Education  – in interventional radiology. No restrictions concerning the language, publication status of the study or population were imposed.https://rayyan.qcri.org).Eligible studies were identified using a two-stage method by two independent reviewers . Disagreements were settled by reaching a consensus. First, after eliminating duplicates, titles and abstracts retrieved through the search strategy were evaluated, thus yielding potentially eligible studies. Second, full-text evaluation of the pre-selected studies was performed to confirm eligibility; this process was carried out through the Rayyan platform  were analyzed using the quality indicators from Best Evidence Medical Education (BEME) Collaboration Guide no. 11  and those analyzing factors other than medical teaching, were excluded.Electronic searches were performed in the PubMed, Cochrane Library, Embase, ERIC, CINAHL, Tripdatabase and SciELO databases, using the following MeSH terms: Interventional Radiology; Virtual Reality; Augmented Reality; Video Games; Computer Simulation; Education, Medical; Teaching; and Simulation Training.References from the studies included and from the main reviews on the subject were also analyzed. The search strategies were carried out on July 29, 2020, for each database, and are shown in  did not evaluate the learning that resulted from the teaching methods and was excluded from the analysis.The search yielded 5189 articles; 50 of these were duplicates and were excluded. Through analysis on the titles and abstracts, 56 articles were selected for full-text evaluation, out of which four were included . Among t and used a pre-experience questionnaire; the other two were from the United States and used both a pre-experience and a post-experience questionnaire. We found that heterogeneity was present among both the participants and the procedures analyzed. All of these studies were RCTs in which, differently from the intervention group, the control group did not have access to an AR device; while the remaining instructions and other materials (books and didactic lessons) were equal for the two groups.Two of the four studies were from CanadaAll of these four studies reported that changes in perspective or judgment occurred in the groups of participants, concerning teaching and learning (Kirkpatrick evidence level 2B). one study evaluated the lumbar puncture procedure and one investigated injection into the interfacetal joint. Although a diversity of issues were analyzed among these trials, the performance achieved through the technique was the main outcome in all of them. Regarding the populations investigated, the participants comprised respiratory therapists, sleep technicians, pre-medical and medical undergraduate students, emergency medicine and surgery residents and anesthesiologists. In three of the studies analyzed, it was concluded that AR could increase students’ skills in interventional radiology.Regarding procedures, two studies analyzed central venous catheter placement,AR is used in a variety of areas of medicine and no systematic review or clinical trial has been carried out using a homogenous population. Because of the heterogeneous nature of the populations studied, different AR devices analyzed and different medical procedures used in these four RCTs, we did not perform any meta-analysis.  enrolled 32 adult novice central line operators  with no visual or auditory impairments. Comparisons were made between simulations using AR reality glasses and conventional instruction; the AR glasses used were Brother AiRScouter WD-200B AR glasses . The authors did not comment on the cost of the teaching techniques. The AR simulation group undertook a five to ten-minute hands-on instructional course on the AR device; the mean time taken for AR head placement was 71 seconds. No significant difference in the median time taken for internal jugular cannulation or in the median total duration of the procedure was found between the groups. Most participants  were successful in cannulating the internal jugular upon the first attempt (12 in the AR group versus 11 in the non-AR group). A significant difference in adherence level between the two groups  was detected. In the post-exercise questionnaire for the AR group, more than 80% of the participants stated that the instrument did not cause any fatigue and was not too heavy to be uncomfortable. Nonetheless, 30% admitted that the equipment affected their action skills and that it was not easy to regulate. On the other hand, 94% reported that the hand, head and foot interactions were undemanding and 80% stated that the information presented on-screen was suitable and reacted fast enough.Huang et al. 20 medical students and 20 emergency medicine residents were compared with regard to learning central venous catheter positioning. All the participants watched a video explaining how to use Google Glass and how to place an internal jugular central venous access catheter under ultrasound guidance in a simulation task trainer. The participants were randomized into two groups: with and without Google Glass. The ultrasound machine setup was the same between the groups; the intervention group participants were asked to execute the procedure by viewing ultrasound images displayed on their Google Glass screen, while the control group executed the procedure by viewing ultrasound images shown on the ultrasound screen. The Google Glass group took longer to perform the procedure, with longer times spent looking at the patient and monitor and greater numbers of needle redirections, at both training levels . This may have been due to unfamiliarity with Google Glass, thus requiring more attention throughout the procedure. The responses to the post-exercise questionnaire showed that the majority of the participants were not previously familiar with AR or with wearable computing technology ; however, 73% reported having some degree of knowledge about Google Glass. Nonetheless, 87% of the participants randomized to Google Glass reported that the instrument was comfortable to use for the procedure.In the study by Wu et al., evaluated the effectiveness of Perk Tutor  in relation to a phantom, as a teaching method among anesthesiology and surgery residents for lumbar puncture procedures. Perk Tutor is a training platform that was designed to display ultrasound images along with real-time three-dimensional images, using wearable technology. The authors did not comment on the participants’ experience levels regarding AR. There were 24 participants, who were divided into two groups (ten anesthesiologists and two surgeons): Perk Tutor with phantom and phantom alone. All the participants received a short presentation on spinal anatomy, ultrasound basics and how to use the device. They were also trained to perform ultrasound-guided procedures on three different lumbar spine models. The participants were then tested using conventional ultrasound guidance on an abnormal spinal model that they had not previously seen, for ten minutes at most or until positive fluid backflow ws observed at the needle hub. The potential tissue damage, needle path in tissue, total duration of the procedure and time taken to insert the needle were measured. Eleven participants in the phantom group and all participants in the Perk Tutor with phantom group performed the task successfully. The potential for tissue lesion was significantly lower in the Perk Tutor with phantom group (39.7 [range 21.3-42.7] square centimeters (cm2) versus 128.3 [50.3-208.2] cm2). Moreover, the needle tissue path was shorter (426.0 [range 164.9-571.6] millimeters (mm) versus 629.7  mm), as also was the time taken to insert the needle (30.3 [14.0-51.0] seconds (sec) versus 59.1 [26.0-136.2] sec). The total duration of the procedure was similar (203.8 [range 135.1-274.9] sec versus 266.9 [221.6-416.2] sec).Keri et al. compared the performances of 26 pre-medical undergraduate students (with no prior needle insertion experience) in a task of injection into the interfacetal joint. Participants were divided equally into two groups: Perk Tutor with phantom and phantom only. The authors did not comment on the cost of the teaching techniques. Both groups received a ten-minute introductory class on anatomy, procedure, ultrasound image interpretation and needle handling techniques. Afterwards, both groups had a ten-minute practice session on ultrasound-guided facet joint injections on the phantom; the Perk Tutor group had access to ultrasound and Perk Tutor, while the phantom group only had access to the ultrasound machine. The Perk Tutor and phantom group had a mean success rate of 61.5%, while this rate was 38.5% in the phantom only group; the total duration of the procedure was longer in the phantom only group (73 ± 8 versus 66 ± 6 seconds). The total needle distance travel (inside and outside of the phantom body) was greater in the phantom only group (1803 ± 290 versus 1366 ± 185 mm), but the inside distance traveled was shorter (25 ± 3 versus 42 ± 16 mm) in this group. Moreover, within the phantom body, the needle tip time was greater in the Perk Tutor and phantom group (296 ± 45 seconds versus 243 ± 28 seconds).Moult et al.All of these results are summarized in The objective of our study was to examine the current evidence on training using AR in interventional radiology and its performance, along with the impact of AR on educational outcomes and skills, and its main advantages, disadvantages and challenges during the teaching-learning process. AR combines virtual and real-world through use of wearable technology that provides a live feed from computer workstations (i.e. from an ultrasound device). Images and information are shown in the user’s line of sight through the device.New teaching techniques such as virtual reality (VR), AR or mixed reality (MR) are being introduced in medical education. However there is still a lack of research regarding the competence of this technology.Everyday use of mobile devices facilitates implementation of this instructional tool in teaching processes, which permits access to learning at any moment. Furthermore, the pressure imposed on healthcare systems during the COVID-19 pandemic has hastened implementation of new technologies, thereby accelerating the learning of healthcare professionals.AR methods have stood out in the surgical environment over recent years, through providing educational simulation practice free from potential ethical/hygiene concerns. Teachers can avail themselves of this familiarity to upgrade teaching methods and aids, so as to encourage students. Kotcherlakota et al. evaluated the utility of clinical simulation through applying AR technology to education outcomes for nurse practitioners in pediatric asthma management. The students showed high motivation, satisfaction and confidence scores. A systematic review by Barteit et al., on AR, VR and MR in several medical specialties, showed similar outcomes that revealed that these techniques were at least not inferior to traditional teaching methods. Moreover, these technologies offer opportunities for scalability and repetition without risk to patients.Students are now used to dealing with technologies such as the internet, 3D video games, cell phones and others. However, with regard to anatomy education, Bölek et al. concluded from a meta-analysis on five studies with a total of 508 participants that AR did not have any meaningful advantages or disadvantages for students’ education, compared with several traditional educational tools.A systematic review by Rad et al. demonstrated that, in thoracic surgery, AR-enhanced intraoperative knowledge of anatomy decreased preoperative preparation time and workload. Küçük et al. found that neuroanatomy learning using AR with a smartphone provided support for students, through reducing cognitive effort and increasing educational pleasure. According to our systematic review, the results regarding AR are similar in several medical specialties.AR could form a viable tool within traditional anatomy teaching in more technological environments. AR simulation provides the possibility of repetition to boost self-confidence, within a safe method.The main purpose of AR involves the concept of “practice makes perfection”, given that efficient performance in procedures requires experience. Teaching with AR aids could result in lower morbidity, hospitalization time and costs.Over five million central venous catheters are fitted each year in the United States. The complication rates are 5%-8% higher per procedure when these are handled by novice professionals.Comparison of learning between novice physicians and experienced interventional radiologists could enable evaluation of whether AR has the capacity to accelerate learning. Studies comparing different kinds of AR in one specified procedure need to be performed in order to determine which technology is better for that particular procedure. From the current information available, AR is a useful additional tool for teaching interventional radiology, but not a substitute for the traditional methodology.From the students’ perspective, AR can contribute to mastery and confidence in a new procedure, through enabling students to memorize details, thus decreasing the tension in real-life situations. Regarding classroom ambience, AR may enable a shift from the monotonous routine of expository classes, thus providing evolution of the learning experience. Assembling education with technology would engage young people, thereby transforming learning into a pleasant experience and improving learning, as well as clinical practice. Numerous procedures are involved in interventional radiology, but in the four studies evaluated, only three different procedures were investigated: central venous catheter placement, lumbar punctures and interfacetal joint injection. Two different types of AR devices were tested: Perk Tutor and AR glasses. Different AR devices could be compared in the future. Moreover, the small samples used in the studies represented another limitation, thus hampering generalization.One limitation of this systematic review was that only two studies analyzed the same procedure.Another limitation was the lack of evaluation among experienced professionals. The participants included in these studies were novice physicians or non-physicians; none of these studies investigated radiology residents. Our searches did not retrieve any studies with educational evidence at level 3 , 4A  or 4B . Despite the current interest in using simulators, it remains to be delineated which types of simulation and simulator should be used, and what population this teaching method will be applied to. Hence, a higher level of evidence is needed.The level of evidence of the studies was also a limitation: all of them were classified as 2B in the Kirkpatrick model. These technical difficulties could be resolved by the smartphone industry. Use of faster networks enables a shared environment through cloud services and shared real-time information. Introduction of artificial intelligence to AR-based learning programs can also provide more positive learning.Hardware needs are also a concern, considering that running the application produced intense energy usage as well as device heating.The costs of AR devices are expected to decrease along with the evolution of production and increased market competition, thus bringing these technologies to low-income countries. Moreover, AR-based medical training could facilitate teaching for people with reading limitations and could also facilitate remote teaching.It was demonstrated through this study that AR, as a complementary tool, can add skills to learners and thus can improve the teaching-learning process. It needs to be noted that only level 2B studies were found in this systematic review and, thus, that a higher level of evidence is required. Moreover, comparison of beginner physicians and expert interventional radiologists could enable appraisal of the hastening of the learning curve through AR, as well as investigation of which set of AR tools is most adequate for each procedure.


Anterior knee pain (AKP) is a common knee injury resulting from overuse, and impact negatively on the quality of life of many runners. Runners with AKP in under-resourced poor communities present with poor health outcomes.To determine the experiences and rehabilitation needs of runners in under-resourced communities in Ekurhuleni, South Africa.The study was qualitative, based on the focus group interview method. Interviews were conducted with 12 runners. They were aged from 18 to 45 years and had a history of AKP. Permission was obtained from club managers and consent from each participant. An interview schedule with predetermined questions was used to collect the data. Two researchers conducted the interview, a facilitator and moderator. The interview session lasted for 80 minutes. Audio recordings of the interview session were made, transcribed verbatim and notes taken, with the final result provided in a written report. The data approach was thematic and deductive in nature.All 12 recruited participants participated. The participants were comprised of six females and six males, eight youths and four adults; seven had ≤5 years of running experience and five had 10 years. The following themes and subthemes emerged: 1) The negative impact of AKP on health ; 2) Limited rehabilitation services ; 3) Rehabilitation needs .The study showed the negative impact of AKP on health and the problem of the paucity of rehabilitation services. A community based rehabilitation programme is therefore recommended for runners. This condition is most common among runners, accounting for between 15–45% of the cases of AKP globally. In a previous study, Kunene et al. found that 40% of the runners in under-resourced communities in Ekurhuleni, South Africa, presented with AKP. This condition is was found to be more prevalent in females, the youth, and runners with a limited number of years of running experience (less than five years).Anterior knee pain (AKP) has a negative impact on the quality of life (QOL) of many athletes, tight hamstring and iliotibial band muscles, weak quadriceps muscles, weak gluteal muscles (resulting in poor hip control) and patellar tilt problems, were found to contribute significantly to AKP. Other factors may include tight iliopsoas muscles, tightness of the gastrocnemius complex, foot pronation, general joint laxity, leg length discrepancy, patellar glide abnormalities, and patellar hypermobility.,5 Kunene et al. also found that a heavy training load, lack of warm-up exercises during training, poor condition of running shoes, and downhill running significantly contribute to AKP among runners.Various factors were found to contribute to this condition. According to Kunene et al. These factors may include paucity of health services, limited access to coaching professionals, and sports administrators available to organise and deliver sports events, and negative attitudes towards sports-related injuries. The lack of health services could be as a result of no formal health structures with their associated support facilities and of trained professionals to deliver these services. The lack of health resources is a serious challenge in many African countries, including South Africa. Most health facilities in the rural and peri-urban communities do not have access to full rehabilitation teams. Therefore, athletes do not receive the necessary holistic treatment that they require for their injuries. While it is ideal to have access to full rehabilitation teams and the services they provide in sporting clubs, owing to their financial constraints, poorer communities do not have access to these facilities. Thus many athletes end up training, and even competing, with their untreated injuries, which in turn lead to further complications. In fact, many runners may terminate their running careers due to injury complications.The incidence of sports injuries and their associated problems continues to increase among athletes, more especially among those in the poorer communities who live under unfavourable socioeconomic conditions.In professional sports, especially in urban communities, athletes are fortunate to have access to specialised sports rehabilitation services offered either by their clubs, or privately. In addition to the availability and accessibility of these rehabilitation services, there are also personal trainers and coaches for athletes in urban communities. Unfortunately, this is not so in the poorer rural and peri-urban communities.In the course of this research, which was conducted at running clubs located in communities with low socioeconomic status, it was noted that some runners had stopped running as a result of their injuries, while others were running with injuries that had not been addressed. There were no rehabilitation services for injured sportspeople in these communities.In order to design appropriate rehabilitation solutions for these runners, it was necessary to fully understand their experiences and rehabilitation needs. The purpose of this study was intended to determine the experiences and rehabilitation needs of runners in under- resourced communities in Ekurhuleni, South Africa.This study was a qualitative study involving focus group interviews. The focus group interview was used to trigger responses from participants in order to clarify their experiences and rehabilitation needs.,4,6 In these previous studies, the prevalence of AKP was determined by the use of the Kujala AKP questionnaire (a subjective tool) and confirmed by objective screening tests,4. Participants were members of six developing running clubs in under-resourced communities in Ekurhuleni, South Africa. Runners with degenerative conditions and traumatic injuries were excluded. The interviews took place in a quiet office at one of the training facilities.The twelve participating runners included long-distance, cross country, and those with a history of AKP as determined by a qualified physiotherapist. These were the runners who participated in these authors’ previous studies,4. The letter of invitation included information on the proposed date, time and venue for the interview.Ethical clearance to conduct this study was obtained from the University of KwaZulu-Natal (clearance number is BFC377/15) and permission to conduct the study was given in writing by the respective club managers. A letter of invitation was sent to each club manager from the six developing running clubs requesting the participation of at least two of their runners who were a minimum of 18 years old and in training, who had undergone physical screening for AKP in the authors’ previous studies.A focus group interview was scheduled by the researchers to collect detailed data from the participants with regard to their running experiences and rehabilitation. It was developed by the first author and validated for content by three physiotherapy experts with sports clinical and research experience. The schedule included predetermined questions about the participants’ experiences (injury and rehabilitation) and their rehabilitation needs. A pilot study was conducted to test the appropriateness of the data collection tool prior to the main study.The focus group discussion was facilitated by the first author (interviewer) and a research assistant, who presided over the process and also took care of the administrative aspects, which included the taking of notes and ensuring that all of relevant documentation was in order, e.g. information sheets, consent forms, interview notes etc. The discussion was undertaken using all 12 participants in one meeting. On the first day of data collection, the main author provided a statement of the purpose of the interview and allowed the participants to go through the study’s information sheet. All of the participants were requested to sign the consent form, and they also gave their permission for the interview to be audio recorded.The first author outlined the procedures of the meeting and encouraged everyone to participate in the discussion. The interview was conducted in English as it was the language best understood by all the participants. The first author then posed the questions as predetermined in the schedule. Follow-up probe questions were also used to garner in-depth insights into the information pertaining to the main question asked. Participants were encouraged to answer the questions and express their experiences freely, rather than to find consensus. The questions covered the following topics: injury experiences, rehabilitation experiences, and rehabilitation needs. The session lasted for 80 minutes. The audio recordings were transcribed verbatim and handwritten notes were taken.The names of the participants were coded numerically in the transcripts. The data were analysed thematically, the process being deductive in nature. The first author and research assistant reviewed the transcripts independently. They then compared their findings to reach agreement on the themes and subthemes from the data. The process included the following steps: 1) familiarisation with the data by reading and re-reading the original transcript, while listening to the audio recording, 2) development of themes and subthemes from the concepts and categories from the data, and 3) defining and naming the themes and subthemes. Three rounds of discussions took place between the first author and the research assistant, where they compared the findings from the interviews to improve the credibility of the process.All of the 12 participants took part in the focus group interview meeting. The participants included six females and six males: eight youths (18–35 years) and four adults (36–45 years). Seven of the participants had less than five years of running experience and five had between five and ten years of running experience .The participants’ injury and rehabilitation experiences, and rehabilitation needs are presented below, according to the selected themes and subthemes, together with their comments. The themes and subthemes are presented in All of the participants reported that they had experienced AKP injuries in the past as a result of their long-distance running, and that they were still suffering from these injuries. Their injuries had been confirmed by a qualified clinician. According to their descriptions, their pain was located on the anterior aspect of the knee below the patella. They received these injuries during training and exacerbated during races. These injuries negatively affected their health.‘I have had bad experiences in the past, and now too, with my knee problems. My pain has affected the way I run. In the beginning of the training or race I feel the pain, but as time goes on, the pain disappears but also comes back later as I run especially when I feel I’m getting tired .’ ‘I also have the same challenge as my brother. Mine is worse during training, especially on an uneven surface, especially here on our training ground’ The participants expressed their frustrations with knee pain when running. They indicated that the pain interferes with their running to the point that they are being forced to miss training sessions and races. ‘I sometimes get stressed when I think of how my knee problems have affected my performance as a runner, because running is my life’ .Some indicated that their condition negatively impacted not only on their physical health, but also on their emotional health. Some reported that they sometimes become stressed about their situation and ended up being demotivated and not wanting to continue with running. ‘Running is our way of life, it gives some of us the purpose for living. So, this knee problem I have really makes me very emotional and it takes away my sense of belonging, especially when I think of the possibility of being unable to run anymore because of it’ .All participants agreed that running is a social activity that keeps them connected with people, especially their friends. Some use running as a means to improve their physical appearance so that they are accepted among their peers. Therefore, sustaining injuries threatens not only the physical and emotional aspects of their life, but also their social life. ‘This place does not have a clinic or somebody who is helping us with the injury problems we are facing. The only thing you can get is pain tablets when you go to the clinic. They don’t even give you a bandage’ . Runners end up trying to find their own solutions to the injury problems they are facing. ‘What I’m using currently is Arnica oil. I sometimes ask someone to massage my knee and thigh muscle using Arnica oil. I sometimes use ice baths or rub my knee with ice. When I wake up the following day, I feel better. When I don’t massage, I feel stiff and have more pain’ .Participants reported that their communities do not have rehabilitation services to address their needs as is the case in more affluent urban communities. They indicated that the clinics in their vicinity only provide basic medical services but not rehabilitation programmes for sports-related injuries. ‘This thing of hospital, sometimes I don’t see a point of even trying to go there because it’s a too long process’ . Most participants reported that the means of transport to the hospital for rehabilitation services is scarce. Sometimes, because of the distance, they are required to take more than one taxi.Participants indicated that rehabilitation services can only be found at the district or regional hospitals, which are located far from their communities. Sometimes even the hospitals have limited services. Accessing these services is a long process. Participants reported that an injured person has to first visit the clinic in order to get a referral to a hospital in order to access the rehabilitation services offered there. When they finally get to the hospital, the athletes are required to stand in long queues. Sometimes athletes reach the hospital but do not immediately gain access to rehabilitation services. They are sometimes given an appointment for another day. ‘No, those people (private practitioners) are too expensive for people like us who do not have enough money. It is better to deal with your problems yourself than to lose money like that’ . Transport to clinics and hospitals is another factor that makes such services unaffordable to participants ‘I’m currently not working, and I don’t have money for transport to go to hospital and that is why I end up not honouring my appointments’ .Participants reported that most of the services at the public clinics and hospitals are free of charge, especially for people who are not working or who fall into the lower income bracket. Most participants agreed that private practitioners where too expensive for them which is why they do not even consider visiting them. ‘Big clubs are better than us because they have their own physiotherapists or doctors to take care of them, but us we don’t have anyone because of money issues’ .The majority were of the opinion that the rehabilitation services at the hospitals and clinics are unable to prevent injuries among the running population or to offer the necessary treatment. They indicated that the rehabilitation services offered by their sporting clubs are very limited – few and far between, as opposed to those offered by the professional athletic clubs in more affluent urban communities. ‘I would say yes, when you eventually get to see a physio in a public hospital, you get the help you need. But I still prefer services in private’ . They complained that the available healthcare centres do not have specialised practitioners to deal with running-related injuries .A few of the participants, especially those who could afford rehabilitation services, were positive about the standard of the services provided to them in hospitals and private practices. ‘Maybe if we can get some material with information so that we can help ourselves. In that way we would not need to stress a lot and go very far to get help’ . ‘We would like to have someone to advise us on the kind of shoes we need to use when we run because I think my problem with my knee is caused by the shoes I’m using’ .The interviews revealed that participants needed to be provided with the appropriate information regarding their injuries and how to manage them. Like in other big clubs, we also need help in terms of screening and treatment of injuries’ . ‘I would go straight to the point. I wish our club to can have a physiotherapist who can help us with screening and treatment of injuries. Even if that physio come once in a while, it’s still fine. It’s unfortunate that there are not physiotherapists who can volunteer to come and help us’ . Another intervention that they would like was the support of a person with coaching skills who could help them to improve their running performance. ‘We need trained coaches who will make us perform better, like other athletes in big countries’ . Other participants also indicated that their training facilities were not in a good state of repair and that they would like them to be improved. ‘If government can help us improve our running facilities..., we are struggling, our running tracks are not good and the grounds are not levelled’ .Participants agreed that they need the trained people in their clubs to intervene. Such an intervention would include the frequent screening of injuries; supplying information on prevention tactics to avoid injury, and providing treatment for and rehabilitation techniques to deal with, the injury. ‘ Maclachlan et al. also reported extensively on the impact of AKP on the psychological well-being of runners. They found that runners experienced stress, anxiety, depression, and fear of movement because of AKP. This suggests a need to diligently deal with AKP and its associated problems. Thus a comprehensive rehabilitation programme is required to address both the physical and non-physical features of this condition in order to improve runners’ quality of life.The findings of this study highlighted the negative health impacts of AKP on participants, namely, the physical, emotional and social aspects. These findings are similar to those found in the authors’ previous survey on the impact of AKP on the quality of life among 73 runners. particularly in socio-economically challenged communities. A low level of education, a problematical economy, and issues of crime, are some of the factors that contribute to this problem in South Africa.The study revealed that rehabilitation services are limited for the running population in the under-resourced communities of Ekurhuleni. Problems with availability, accessibility, affordability, adequacy, and appropriateness of rehabilitation services were reported. Furthermore, a lack of resources and limited skills, including health professional skills, is a serious challenge in South Africa,  As previously mentioned, a lack of resources and limited professional skills available to them, could be some of the main reasons for limiting their well-being. Thus the prevalence of anterior knee pain was reported to be greatest among runners in under-resourced communities, such as those in the Ekurhuleni communities.People who live in poor communities have been found to present with poor mental and physical health outcomes. However, they still need the services and support from trained professionals. Rehabilitation services should be made available, accessible, affordable, appropriate and adequate for athletes in rural areas and in township communities. Healthcare resources need to be equally allocated to both the more affluent in the urban areas and the disadvantaged, the latter being burdened with the additional challenges of living at a lower socioeconomic level.This study’s results highlighted the need to address the problem of limited rehabilitation services for the running population in under-resourced communities. A need to empower runners with the relevant knowledge and skills for self-help and a need for professional intervention were identified. According to Esculier et al., educating runners about the symptoms of AKP and how to manage this condition is found to be effective in dealing with this type of injury.Rehabilitation teams in the professional sports arena, including various practitioners such as sports physicians, physiotherapists, psychologists, nutritionists or dieticians, biokineticists, massage therapists, podiatrists and other healthcare practitioners, depend on the needs of the injured person. Furthermore, in addition to these healthcare practitioners, personal trainers and coaches/managers also form part of the rehabilitation team. Each member of the team uses his/her knowledge and skills appropriately for each phase of rehabilitation. Communication and cooperation between the rehabilitation team members is vital in ensuring the continuity of care for runners. While it is ideal to have full rehabilitation teams to provide services for running clubs, it is not always possible to provide them in under-resourced communities. Therefore, the transdisciplinary rehabilitation model may be the solution to issues of limited professional healthcare services in under-resourced communities. This model is client-centred and promotes an ethos of cooperation among the rehabilitation team members to provide worthwhile rehabilitation services. With this approach, the rehabilitation team members are cross-trained and multi-skilled in several areas besides in their own speciality, in order to provide a holistic rehabilitation service.,13,14,15 For this model to work effectively, rehabilitation team members are encouraged to consult with one another, to learn to be interdependent, to assume interchangeable roles and responsibilities, and to exchange information, knowledge and skills.Other studies have provided convincing evidence about the importance and effectiveness of the transdisciplinary approach.The study presented with some limitations. The researcher could not draw participants from a larger population due to restricted resources, thus the findings from the interviews cannot be applied more widely. Runners younger than 17 years and older than 45 years were not included in the study. Further studies may be necessary to include a larger, more diverse and more dispersed population to better understand the experiences of runners of various ages, gender and running experiences, and found in different environments.Anterior knee pain is a common but serious injury to the knee that is experienced by many runners. This study revealed that AKP negatively impacts on the physical, emotional and social health of runners in under-resourced communities. The study also showed that rehabilitation services are limited in terms of their availability, accessibility, affordability, adequacy and appropriateness, and therefore in the management of running-related injuries in these communities.Issues such as the need to push for the empowerment of runners through self-help knowledge and skills, as well as to bring them to the realisation that there is a need for professional intervention in order to manage their injuries, were identified. Therefore, a transdisciplinary rehabilitation approach is recommended as an intervention strategy to cater for the needs of runners in under-resourced communities.


When the coronavirus disease 2019 (COVID-19) pandemic manifested in South Africa, rehabilitation services were seriously affected. The consequences of these were wide-ranging: affecting service users, their families and caregivers, rehabilitation practices and practitioners as well as the integrity and sustainability of rehabilitation systems.This study aimed to explore the nature and consequences of disruption caused by the pandemic, based on the experience of rehabilitation clinicians who were working in public healthcare facilities in Gauteng.This was a phenomenology study that used critical reflection method. Trained and experienced in reflecting on barriers and enablers that affect their practices, a multidisciplinary group of rehabilitation clinicians captured their experience of working during the time of COVID-19. Data construction extended over 6 months during 2020. An inductive thematic analysis was performed using Taguette: an open-source qualitative data analysis tool.The main themes captured the disorder and confusion with its resultant impact on rehabilitation services and those offering these services that came about at the beginning of the pandemic. The importance of teamwork and leadership in rehabilitation also emerged as themes. Other themes related to having to approach work differently, working beyond professional scopes of practice and pandemic fatigue.The COVID-19 pandemic disrupted the way rehabilitation was being performed, creating an opportunity to reconceptualise, strengthen and improve rehabilitation services offered at public healthcare. The presence of effective leadership with clear communication, dependable multidisciplinary teams and clinicians with robust personal resources were strategies that supported rehabilitation clinicians whilst working during COVID-19. When disaster, in any form strikes, vulnerable individuals in a community suffer the most Pedersen . ChildreIn March 2020, when the COVID-19 pandemic surfaced in South Africa and a national state of disaster was declared  and other health statutory councils to meet challenges which our regulatory framework must accommodate.  provided ethical approval (Ref No N18/01/113) for the amendment and extension of the research. Gauteng Healthcare’s Research Committee approved the research with ref no: DRC Ref 2018-03-008, and the research was registered on the South African National Health Research Database (Ref. No GP201802022). Continuing Professional Development (CPD) points were awarded to participants who did not receive any other form of remuneration.n = 14) volunteered, were informed regarding the research, signed consent forms and provided demographic information. On conclusion of the data collection phase, eight rehabilitation clinicians (57% compliance) submitted reflections. Reasons for non-completion provided by the six participants who did not complete data collection, were inertia and feeling overwhelmed.Of the 75 participants who were invited, 19% (n = 4), Afrikaans (n = 2), IsiXhosa (n = 1) and Sepedi (n = 1). Professions represented were occupational therapy (n = 5), physiotherapy (n = 1), podiatry (n = 1), speech and audiology (n = 1). All had tertiary-level qualifications with an average of 18 years’ clinical experience (range 2–40). All participants worked in tertiary healthcare facilities: one performed only management functions, two combined management with clinical responsibilities, the rest were clinicians.Demographic details of the eight clinicians who completed data collection show a gender distribution of one male and seven females, the average age was 40 years (Range 26 – 58) and all were South African citizens. Reported home languages were English  an indicator of the origin of the quote e.g., date of the reflection or field notes which were undated summaries or notes made by participants or researchers; (2) participant code and (3), occupation – using the HPCSA identifier of such.Field notes by the first author, disclosed reasons why participants were working where they were and to what extent their work had changed. The most prominent reason for working in public healthcare was related to the type of service users they were seeing:H]ere I can be of the most benefit to the community and … to make a difference in the lives of vulnerable people.’ ‘t is not if we are going to get it but when.’ ‘ lied to us. I feel millions of Rands have been wasted for nothing. I feel this virus is no worse that TB, which kills more people in South Africa every single year than this virus ever will. I feel the majority of South Africa is really struggling to support their families and those that were already vulnerable have been pushed even deeper into their pit of despair. The knock-on effect, financially, will take years to recover if it ever does. I don’t know if it was really worth it.’ ‘I feel [The lifting of restrictions allowed for continuation of some familiar rehabilitation initiatives; this went a long way to reduce pandemic fatigue:‘Heritage Day, physio week, OT week and deaf awareness campaign all provided some much-needed distraction, respite from the COVID-19 onslaught and a glimpse into some form of normalcy. We have had to however keep reminding each other not to become complacent. Having attended some external meeting this month was probably one of the most healing interventions for my heart and soul. I didn’t realise how much I had really missed those interactions. I thrive on interacting with others especially those I regard as mentors and finally seeing these important people in my life was a blessing.’ cathartic. Another participant captured her views in an email as follows:Field notes taken during the conclusion of the research revealed that several participants experienced the systematic capturing of their professional reflections to be a positive experience. It helped them cope with anxiety and uncertainty. One participant referred to the experience as ‘Just finalising my last entry so I can submit. As much as I started this for the CPD points, reflecting on my experiences over the past few months have put things into some perspective. I was able to share some of these thoughts with colleagues and we could guide and pull each other up when we most needed it. Knowing that I was not alone in this and others were feeling the same makes me feel less isolated.’ Disorder and confusion, disruption of rehabilitation and the strain under which rehabilitation clinicians were, showed how the role of rehabilitation and its service to public healthcare users was challenged. The need to strengthen and improve rehabilitation services offered at public healthcare facilities was demonstrated. Different leadership experiences were reflected on showing how the presence of effective leadership with clear communication, dependable multidisciplinary teams and robust personal resources were strategies that supported rehabilitation clinicians whilst working during COVID-19. Similarly, the positive impact of well-informed clinicians implementing COVID-19 related policies in their practices illustrated the power of good leadership to yield positive outcomes, providing containment that made clinicians feel safe and cared for, reasserting their commitment to their work.The COVID-19 pandemic has offered an opportunity to learn from the experiences of rehabilitation clinicians, thus producing practice-based evidence that could inform policies or strategies to raise the level of preparedness for future disruptive events. In addition, the consequences of discontinued, restricted or disrupted rehabilitation led to a reappraisal of rehabilitation as an essential service. The findings further highlighted professional competencies, often considered ‘soft skills’, to be paramount in managing heightened demand for containment and mental health concerns of health professionals and their patients alike.Qualitative research does not necessarily require large samples to yield good quality findings. However, having only one participant for most of the professions completing data collection is considered a limitation. Conversely, none of the themes that emerged pertained to profession-specific issues, thus reducing the impact of this limitation. The prospective nature and eliciting practice-based reflections was a strength of the research, especially because reflections extended over 6 months. As such the way in which participants were affected by the progression of the pandemic was shown.The COVID-19 pandemic has created an opportunity to reconceptualise, strengthen and improve rehabilitation services in public healthcare.Effective leadership, clear communication, strong multidisciplinary teams and clinicians with robust personal resources, strengthened rehabilitation services offered in public healthcare.In Africa, the need to address epidemics, plagues, pandemics and other large-scale threats to health is not an uncommon event. The focus of intervention and planning for such event is often on the role of medical doctors, nurses and community health workers. Evidence that could inform the role of rehabilitation healthcare workers would be of value to public healthcare users, educators, policymakers and professional bodies. Interviewing 101 leading thinkers from a variety of fields, on what the world might look like after the corona virus, Najam concludes that the COVID-19 pandemic will leave nothing unchanged and that it brought about an opportunity for fundamental restructuring Najam .For rehabilitation, the pandemic has shown the negative consequences of diverted focus of policymakers and resources, leaving the service users of rehabilitation side-lined. Without strong rehabilitation-focussed leadership and clear policies, rehabilitation services will once again be left floundering with practitioners taking strain. An important lesson for rehabilitation practitioners was the need to move beyond an institution-based silo-practice mindset. Instead, rehabilitation professions should work together to develop collective strategies to ensure the availability of their services. Advocacy for continuation of rehabilitation as an essential service should be a priority of professional associations in preparation for future disasters requiring quick action and clear protocols. Further in-depth exploration involving larger groups of rehabilitation professions from a greater variety of clinical settings, could be valuable to inform restructuring and suggestions emanating from this research.