Abyssal seafloor communities cover more than 60% of Earth’s surface. Despite their great size, abyssal plains extend across modest environmental gradients compared to other marine ecosystems. However, little is known about the patterns and processes regulating biodiversity or potentially delimiting biogeographical boundaries at regional scales in the abyss. Improved macroecological understanding of remote abyssal environments is urgent as threats of widespread anthropogenic disturbance grow in the deep ocean. Here, we use a new, basin-scale dataset to show the existence of clear regional zonation in abyssal communities across the 5,000 km span of the Clarion–Clipperton Zone (northeast Pacific), an area targeted for deep-sea mining. We found two pronounced biogeographic provinces, deep and shallow-abyssal, separated by a transition zone between 4,300 and 4,800 m depth. Surprisingly, species richness was maintained across this boundary by phylum-level taxonomic replacements. These regional transitions are probably related to calcium carbonate saturation boundaries as taxa dependent on calcium carbonate structures, such as shelled molluscs, appear restricted to the shallower province. Our results suggest geochemical and climatic forcing on distributions of abyssal populations over large spatial scales and provide a potential paradigm for deep-sea macroecology, opening a new basis for regional-scale biodiversity research and conservation strategies in Earth’s largest biome. Analysing seabed imagery data spanning 5,000 km and >50,000 megafaunal specimens across the Clarion–Clipperton Zone abyssal plain in the northeast Pacific, the authors identify two distinct biogeographical provinces in which taxa that are dependent on calcium carbonate structures are restricted to depths above 4,300–4,880 m. This abyssal seabed consists of plains and hills that extend across ocean basins, interspersed with seamounts and subdivided by mid-ocean ridges, ocean trenches and fracture zones1. Lacking sunlight, energy in this environment is highly limited, with detrital particles sinking from surface waters providing the main source of food2, while temperatures are steady at 0.5–3.0 °C (ref. 3) and bottom currents are generally low (0–0.25 m s−1) (ref. 4). As a result, abyssal benthic communities typically exhibit low abundance and biomass compared with other marine environments5 but they support high species richness at regional to landscape scales7 and play an active role in the cycling of carbon8. Abyssal habitats are therefore considered to be reservoirs for biodiversity9 and sources of important ecosystem services10. Despite their remoteness and as a consequence of being energy-restricted and environmentally stable, abyssal habitats are also expected to be highly vulnerable to anthropogenic disturbances including climate change12 and emerging industrial activities such as polymetallic nodule mining14. To adequately conserve the biodiversity and services of abyssal seabed ecosystems, it is critical to consider and protect their full range of habitats and communities, which requires elucidating the patterns and processes controlling the distribution of abyssal populations over large, regional scales.The abyssal seabed lies between water depths of 3,000 and 6,000 m  bathyal seafloor ecosystems22, which encompass a variety of relatively well-known habitats, between 1,000 and 3,000 m depth, including continental slopes, submarine canyons and coral mounds. Consequently, while biogeographic provinces proposed for the deep ocean readily distinguish bathyal and abyssal provinces within oceanic basins24, potential variation within abyssal regions remains largely unresolved a decade after provincial boundaries based on surrogate environmental data were postulated24, since large-scale empirical studies  are lacking for remote abyssal ecosystems. As such, the processes regulating alpha- and beta-diversity across the scale of a seemingly connected abyssal plain remain unclear, particularly for the largest size-class of seafloor organisms, megafauna . Megafauna are a conspicuous component of the abyssal benthos and a common target for investigation in deep-sea spatial ecology27 because occurrences of these taxa can be determined across large spatial scales from seabed imagery28 collected by deep-sea robots29.Macroecological studies assessing spatial variation on regional to global scales in the deep ocean2 of abyssal plain in areas beyond national jurisdiction between the Exclusive Economic Zones of Kiribati and Mexico . Our dataset spans 5,000 km across the CCZ  encompassing >50,000 megafaunal specimens from 411 morphotypes  in 13 phyla, enabling investigation of ecological gradients  in seabed communities across the region to develop key understanding of macroecological patterns in Earth’s largest biome.To address these knowledge gaps, we compiled a new basin-scale standardized dataset to investigate patterns of abundance and diversity in benthic megafaunal communities across the Clarion–Clipperton Zone . The CCZ spans ~6 million kmico Fig.  and is t−1) but decreased in abundance by over an order of magnitude below 4,300 m (mean density ~100 ind ha−1), becoming virtually absent below 4,800 m (mean density <10 ind ha−1); (2) brittle stars (Ophiuroidea) were most abundant at shallow-abyssal depths , numerically dominated assemblages at intermediate depths  but decreased to low abundances below 4,800 m (mean density <40 ind ha−1); (3) anemones (Actiniaria) consistently increased in relative abundance with depth, first replacing soft corals as the dominant Cnidaria group below 4,300 m and then replacing brittle stars as the most dominant group in assemblages below 4,800 m , were absent below 4,400 m, where cirrate octopuses  became the only molluscan group in megabenthic assemblages. Changes in dominant taxa at the class or phylum level  sea0 m Fig. ; (5) shevel Fig.  clearly vel Fig. : a shallvel Fig. .Fig. 2VaOphiosphalma glabrum  and Thenea sp. indet.  were found exclusively in this deep zone, while 64 morphotypes (45 rare) out of a total of 283 were found exclusively in the shallow province. However, only 25 morphotypes (23 rare) from a total of 264 were found exclusively in the transitional zone. From the total of 175 (14 rare) morphotypes that were found in both shallow and deep communities, only two were within the ten most dominant taxa in both the shallow province (first- and third-most abundant) and in the deep province . Below the CCD, calcium carbonate (CaCO3) is undersaturated, which can energetically constrain the development and distribution of species highly dependent on carbonate structures such as in calcareous Foraminifera, a ubiquitous protozoan group showing clear depth zonation at intermediate scales in the abyss38. It is these groups, probably depending on CaCO3 structures, that exhibit the greatest variation in relative abundance or even presence with depth in our analysis and thereby contribute most to regional beta-diversity. For example, shelled molluscs  were absent below 4,400 m and soft corals (with scleroblast cells requiring CaCO3 to produce sclerites40) and bryozoans (most species dependent on CaCO3 exoskeletons41) were replaced by ‘soft’ anemones (Actiniaria) below 4,300 m. The echinoderm transition from ophiuroids to holothurians below 4,800 m, yielding the dominant taxon of the deep province, could be related to either differing CaCO3 requirements or metabolic efficiency, documented across echinoderms42. All of these shifts were observed within the depth range  of the CCD in the northeast Pacific36. However, our understanding of biogeochemical and metabolic cycles in abyssal ecosystems is still too limited to fully comprehend the specific role of the CCD and calcium calcite saturation, as a biogeographical driver in abyssal metazoans.The nature of the taxonomic shifts between provinces and the depth range at which these occur suggests that the carbonate compensation depth (CCD) plays a key role in the depth zonation we encountered. The CCD lies close to the seafloor depth in the northeast Pacificq = 0) ranged between 32 and 62 morphotypes per 200 specimens in the shallow-abyssal province and between 48 and 63 in the deep one but we found no evidence of a difference in richness across the three depth ranges  and Shannon diversity  with increasing depth  was up to an order of magnitude larger in the shallow than in the deep province , increasing towards southeast locations  in closer proximity to the high primary productivity related to equatorial upwelling8, with known capacity to regulate abyssal benthic processes46. Similarly, the benthic communities surveyed in northeasternmost locations —for instance, with the largest densities we observed in scavenging megafauna  where a previous top-down environmental assessment identified the potential for two abyssal provincesces Fig. , with mence Fig. . Nonethence Fig.  than depnce Fig. , especiance Fig. . In partnce Fig.  probably22, a reduction that is thought to reflect the wider geographic ranges of deep-sea species23. But our results suggest that more complex processes may control diversity in the abyss, helping maintain community richness with depth. These interpretations could be affected by the historical unbalance in the sampling conducted in abyssal ecosystems  compared to shallower deep-sea environments52. In turn, our results add to the existing evidence53 against a source–sink dependency from bathyal to abyssal communities in the Pacific54 and stress that, given the wealth of between-phylum species replacement we encountered with increasing depth, assessments including multiple phyla might be best suited to investigate biodiversity and macroecological patterns in abyssal regions.The results of this study represent the largest multiphylum assessment of beta-diversity patterns to date conducted across such a vast abyssal seabed extension , provide key insights to our view of abyssal ecosystems and biodiversity and challenge some current paradigms in deep-sea macroecology. The maintenance of high taxonomic richness with increasing depth by phylum-level replacements (in presence or dominance) was surprising. Diversity, especially that of the largest-sized fauna, is commonly expected to decrease with depth and nutrient flux in the deep sea38), although more physiological research is needed to better understand how CaCO3 saturation affects different phyla. Greater understanding of CaCO3 saturation as a biodiversity driver is especially important as the CCD is expected to shoal with increased CO2 levels in the ocean associated with climate change55. In the light of our results, shoaling of the CCD could have much larger implications for abyssal biodiversity than previously expected, especially in regions like the northeast Pacific where the seafloor depths transcend the current CCD11. A CCD shoaling of tens of metres in abyssal ecosystems, given their vast area, could lead to shifts in the environmental conditions  across thousands of km2 of seabed worldwide. This could trigger large shifts in community structure and species distributions or even extinctions of highly specialized abyssal taxa, adding to the cumulative impacts of deep-sea mining and other emerging anthropogenic disturbances56 that might concur on Earth’s largest biome in the coming years.The presence of such a clear and unexpected boundary zone demarking the limits of provinces has not been previously documented in abyssal metazoans, opening questions for further macroecological research in the deep ocean. We suggest that the CCD may control the location of the environmental boundaries between shallow and deep-abyssal provinces for megafauna, as appears to occur in protozoans  lies close to the seafloor in the northeast Pacific35, deepening north to south between 4,400 and 4,800 m (ref. 36). Surface sediments in the northeast Pacific are relatively well-oxygenated and generally dominated by either siliciclastic clay and radiolarian ooze in the northern and central parts of the CCZ, or by biogenic calcareous oozes and fine-grained sediments in southern sites45. These are supplied by extremely low sedimentation rates, regionally varying between 0.2 and 1.15 cm per 1,000 years61. These conditions are thought to promote the (extremely slow) formation of polymetallic nodules35, yielding growth rates of ∼1–12 mm per million years in the abyssal Pacific31. Nodules can vary in size, shape and abundance61 and are extensively distributed across the northeast Pacific31 but are not exclusively found there. Vast abyssal nodule field areas are present in the southeast Pacific , the southwest Pacific  and in the Central Indian Ocean Basin31. Nodule fields form an unusual mosaic habitat, where the hard substratum provided by nodules acts as keystone structure increasing local seabed complexity63, promoting the occurrence of some of some of the most biodiverse benthic assemblages surveyed in the abyss27. But the biodiversity of the CCZ is poorly known, for example 90% of the species identified in the region are thought to be new to science51 and substantial levels of dark biodiversity have been predicted34. In addition, a general lack of standardization of intercalibrated taxonomic standards for the identification of benthic fauna50 has historically hampered comparability between biological studies64 and thereby the assessment of regional, macroecological patterns across the northeast Pacific basin.The CCZ is an extensive abyssal plain and hill ecosystem, interspersed by seamount areaswaters59 . In turn2; (4) no overlapping frames included in image-based studies; (5) scalable stills collected vertically facing the seabed . Imagery data were collected within 14 sites managed by the International Seabed Authority across the CCZ , and by reference to existing literature69—though developed before the major higher taxonomic revision recently undergone by Octocorallia70. The catalogue follows the ref. 33 open nomenclature to report the taxonomic resolution reached in each morphotype but all taxa identified from the catalogue (411 morphotypes in this study) were deemed as sufficiently different morphologically by taxonomic experts to be confidently considered separate species. Specimens with uncertain classification at the morphotype level  but identifiable to a certain higher taxonomical level (like phylum or class) were retained only for density analyses. Taxa living in a closed shell or tube  were excluded from analysis as it is not possible to determine whether these are alive in images. Several spatially blind reviews were conducted to the whole dataset to ensure a robust taxonomic alignment between sites, consisting in side-by side visualization of all specimens classified under the same catalogue label using the ‘Label Review Grid Overview’ tool in BIIGLE65; a process that was repeated many times by the same group of expert seabed image scientists, to minimize potential bias28. In addition, the likely feeding behaviour  of each morphotype was inferred from observational knowledge and by reference to similar organisms described in the literature. With a total of 53,512 megafaunal specimens in 13 phyla, our biodiversity dataset was compiled across a wide geographical span  at the abyss and is of comparable magnitude to the largest datasets that have been used to underpin our theoretical understanding in the deep-sea .Megafauna specimens >10 mm were detected and counted in imagery reanalysed from the selected surveys  within sites. This process divided the SSdat into 23 locations and the BDdat into 28 locations . In locations where surveys covered a large depth spectrum, data were further constrained to 200 m depth bins during replicate sample generation. Following recommendations of minimum sample size for accurate and precise estimation of local megabenthic community features47 and to minimize the potential effect of regional gradients in faunal abundance on diversity measures , we generated SSdat samples containing 450–500 specimens  and BDdat samples containing an exact number of 200 specimens (taxonomic resolution including only specimens identified to morphotype level). This process yielded a total of 84 samples standardized for density analyses (standing stocks) and 161 samples standardized for biodiversity analyses (richness and beta-diversity).We compiled invertebrate megafauna occurrences into two different subsets to investigate variations across space in different parameters. These were 1) standing stocks subset (SSdat): containing faunal count data at all taxonomical levels obtained only from scalable still images and thereby associated with a precise measure of the seabed surface area ; and (2) biodiversity subset (BDdat): containing faunal count data obtained from both image and video surveys but including only specimens identified up to morphotype level . Using ArcMap v.6.10 software, we interpolated each specimen across a 10 × 10 km standingorg m−2 yr−1) to the seabed derived by applying vertical flux attenuation59 to satellite-derived export flux data (2) of seabed surveyed in each SSdat sample; that is, for the whole assemblage, specific populations or faunal groups of interest  and (2) to examine the range of diversity characteristics, Hill’s diversity numbers of order 0 and 1 (ref. 43) were calculated in each BDdat sample as morphotype richness (S), the exponential form of the Shannon diversity index (expH’), for the whole assemblage.Depth and position (latitude and longitude) of specimens (or images) were averaged within each sample to investigate variations in communities across space and environmental gradients. Sample positions were interpolated with predictions of yearly POC flux  and two main environmental factors .Preliminary exploration of the interaction between different environmental factors  across study locations revealed substantial correlations between depth and longitude and also between POC flux and latitude .We followed a simple, data-driven, bottom-up approach to investigate the potential existence of biogeographic boundaries across the depth spectrum of the north Pacific abyss. First, using the whole dataset, we generated ridgeline plots depicting within-group geometric distributions of the total abundance sampled in the most dominant high taxonomic groups . On the basis of the results of this analysis, we assessed the potential variability within and between the megabenthic communities in tentative biogeographical provinces, by grouping samples in three different depth bins: shallow <4,300 m; transition 4,300–4,800 m; deep >4,800 m). Mean values and 95% confidence intervals were calculated for different ecological parameters  within each tentative province. To contextualize patterns in morphotype richness and the representability of the sampling conducted within each depth range, morphotype accumulation curves were calculated following ref. 77) taxon abundances. Non-metric multidimensional scaling ordinations were conducted to visualize the rate of dissimilarity (distance) between all pairs of samples; isotropic contour lines depicting broadly approximated depth ranges were fitted using generalized additive models78 in the resulting multidimensional scaling plots to aid visualization of beta-diversity patterns across environmental gradients. All data processing and analysis were implemented in R v.4.2.1 (ref. 79), using standard analysis methods and functions from the packages: ‘vegan’80, ‘AICcmodavg’81, ‘ggridges’82 and ‘ggplots2’83. We report statistical evidence of variations in ecological parameters across environmental gradients  or between biogeographical provinces  using the simplified language of evidence84.Variations in community composition across locations, sites and potential biogeographical provinces were further explored using BDdat samples. Dissimilarity in faunal composition between all pairs of samples was calculated using the Bray–Curtis dissimilarity measure on square-root transformed (normalizedFurther information on research design is available in the Supplementary InformationSupplementary Methods, Figs. 1–5 and Tables 1 and 2.Reporting Summary


The aim of this study was to explore and clarify the role of nursing staff in geriatric rehabilitation on supporting patients in goal setting and achieving, through reflecting on rehabilitation interventions.A descriptive qualitative study was conducted.We conducted four online focus group interviews with 23 members of the nursing staff working in geriatric rehabilitation. They reflected on six interventions, preclassified into three types: setting goals in the admission phase, increasing patient participation in order to personalize the rehabilitation trajectory, and supporting patients in working on short-term goals. Data were analyzed using thematic content analysis.Setting goals in the admission phase is primarily the task of the multidisciplinary team rather than the nursing staff. Interventions to increase patient participation align with the coordinating role of nursing staff in the rehabilitation team. Working on short-term goals is of great value to patients.The connection between the patient’s personal goals and professional treatment aimed at functional recovery can be enhanced by strengthening the position of nursing staff working in geriatric rehabilitation.Members of nursing staff in geriatric rehabilitation see themselves playing a coordinating role in the multidisciplinary team, supporting the patient in goal work. Interventions aimed at advancing patient participation and providing support for short-term goals reinforce this role. Older people can recuperate in special rehabilitation wards in nursing homes following an acute or subacute decrease in function after a medical event such as a hip fracture or stroke . In 2019In Dutch healthcare facilities for older people, geriatric rehabilitation is relatively new. In 2015, the healthcare system was changed from a long-term care government-guided reimbursement system without financial incentive for “efficient” geriatric rehabilitation toward a more market-guided bundled payment system . This chGeriatric rehabilitation mainly takes place in nursing homes. Nursing staff in nursing homes in the Netherlands consist of registered nurses, but mostly certified nursing assistants . CompareThis descriptive qualitative design study used focus group interviews with nursing staff working in geriatric rehabilitation to explore perspectives on their role in working with patients on their rehabilitation goals. The study followed the 32-item Consolidated Criteria for Reporting Qualitative Research formulated by Participants were recruited through a purposive sampling strategy. Supplying potential participants with an invitation leaflet with information about the purpose and procedure of the focus groups, we contacted nursing home managers and senior staff members of two research networks (UKON and UNO Amsterdam) and a quality network (GRZ E-cademy). The managers and senior staff were asked to approach “outstanding” members of their nursing staff and encourage them to volunteer for the focus groups. “Outstanding” was described as “visibly concerned with their profession and preferably in the possession of a rehabilitation nursing diploma or similar qualification.” The other inclusion criterion was working in inpatient geriatric rehabilitation. To the participants who volunteered, four different dates for focus groups were provided. Participants chose a group based on their schedule. Participants received a €10 voucher for cosmetics.A semistructured interview guide was developed by all authors . The guide consisted of three questions: (1) Does this intervention/part of the intervention meet the needs of patients in your practice? (2) Does this intervention/part of the intervention fit the role of nursing staff? (3) Which preconditions are needed to use this intervention in practice? The interview guide was tested in a pilot session with one nurse and three nursing students on a geriatric rehabilitation ward. No revisions were suggested to the guide; however, some revisions were made to the PowerPoint that was used to present the six interventions.Four online focus group interviews were conducted in April and May 2022. All focus group interviews were moderated by one researcher (AMV); PB took notes to provide feedback to the moderator. After introducing the six interventions, divided into three types, participants were asked to reflect on the three types by initially writing down their thoughts on a digital whiteboard. This step provided each participant with an equal opportunity to contribute to the quest for which these focus groups were designed. The written information helped the moderator select topics and invite quieter participants to clarify their notes. Each focus group had five to seven participants. The interviews lasted about 120 minutes, were audio-recorded, and were transcribed verbatim.Data were analyzed using thematic content analysis , which aThis study was not subject to the Dutch Medical Research Involving Human Subjects Act; therefore, it did not undergo a review by a medical ethics committee . After bA total of 23 members of nursing staff working on geriatric rehabilitation wards participated. Table The first two interventions use scales to set goals with the patient in the admission phase At the same time, participants identified factors that hinder the geriatric patient from actively participating in the goal-setting process, the main factor being cognitive impairment and its consequences. Patients are not always able to oversee the situation, to plan, or to retain information.Setting goals is usually done by the multidisciplinary team, with each discipline focusing on their own field of expertise, and not by the nursing staff. When it comes to goal setting during the admission phase, participants describe their role as coordinating:I think as a nurse you are, especially in the multidisciplinary team, a cog in the wheel, you’re there most of the time. We do the admission and we check all kinds of things, and in the case of pressure sores, we inform the occupational therapist: please come and see the patient today, and if the patient does not need a wheelchair, she can come a day or two later. We try to coordinate, to direct…. (Participant 16)The role of nursing staff is to assess the extent to which the multidisciplinary team should take over control from the patient in the admission phase and to decide whether temporary goals need to be set that are checked with the patient at a later stage and whether, in this stage, the family should be questioned about goals. The family supplies the multidisciplinary team with essential information about the patient and their needs. Concurrently, they, like the patient, need to be informed about rehabilitation and its possibilities and limitations. Cooperating with family was seen by the participants as an important task of nursing staff.Reflecting on these interventions, participants made clear that, in the admission phase, certain nursing focus points are regularly missed, such as wound care and medication management, because they do not belong to the expertise of the other rehabilitation professionals.…within the geriatric rehabilitation there’s a lot of goal setting from the disciplines. It’s big, walking, the occupational therapist who’s busy cooking, for example. But a care team, yes, the catheters, all the nursing supplies, […]teaching someone to go home with the catheter and emptying it. Those are all goals that are often, yes, forgotten. (Participant 3)Participants considered collaboratively setting goals with a scale the responsibility of the multidisciplinary team as a whole and not as a specific task of nursing staff. They did, however, have ideas about measures to facilitate this collaborative setting of goals with the patient, for example, a multidisciplinary intake to avoid overlapping questions and thus unnecessarily burdening the patient, giving the patient time to acclimatize and unwind after traveling from the hospital, and postponing the goal setting till the second or third day after admittance. Whoever on the multidisciplinary team uses the instruments, such as the Utrecht Scale for Evaluation of the Rehabilitation, the Barthel Index, and Lorensen’s Self-Care Capability Scale, should be trained. Attention should be paid to the added value of using such an instrument.The second two interventions focus on increasing patient participation in order to personalize the rehabilitation trajectory This questionnaire has the same goal as the sessions in the Motivational Interviewing Intervention: “active listening to persons’ concern and adaptation to the rehabilitation plan” , p. 5.Participants’ practices do not include patient attendance at the multidisciplinary team meetings, as is part of the Increased Participation Intervention, or a set number of planned meetings between nursing staff and the patient, as is done in Gual et al.’s (2020) Motivational Interviewing Intervention. However, supporting the patients to participate to make the rehabilitation process as person-centered as possible is seen as a central feature of the work of nursing staff and is ingrained in their practice because of their 24/7 presence on the ward.Your contact with the rehabilitant, being first point of contact, help the rehabilitant by explaining the rehabilitation in understandable language and motivate them to rehabilitate. Looking for the intrinsic motivation… The role of nursing staff was described as “helicopter,” “connector,” and “coordinator” on several levels for example as an interpreter of jargon.We are the link between the patient and the rest. Because they all talk medically, and they all have goals, and the patient is sitting there flapping his/her ears. And you are the one who has to say: If this is it, then we are going to do it like this…. (Participant 4)Another explanation of the concept of connector is the connecting link between professional goals and patients’ lives:With the helicopter view, I mean to say: What’s in it for the rehabilitant? What’s important for them? […] we once had someone from the country, […] he had to learn to walk, but this man just wanted to sit in his chair and pull potatoes out of the ground. And not the walking. (Participant 2)The premise that “everything is rehabilitation” needs to be explained to patients. This is a third interpretation of the connecting or more precise, integrating role.They see going to the physiotherapist as rehabilitation, unlike washing and getting dressed, and we are responsible to make them understand: How will you manage in the future? (Participant 8).In addition, the role of nursing staff was defined as “motivator” or “driving force” for the patient, and virtually, all participants mentioned the importance of being able to have motivational conversations as a key skill.And as for Intervention 4 …you do this constantly. From the conversations you hear a lot and often find out why a client is struggling with something or why things don't work out. Education in motivational interviewing was emphasized by participants as a prerequisite to help members of the nursing staff make the transition from caring for patients to coaching them to work on their personal goals. Another prerequisite is that nursing staff should consciously work with plans; otherwise, they will not be able to support the patient in participating in the rehabilitation process and play a coordinating role.I think half the team is not aware of treatment plans. (Participant 10)Nursing staff have the potential to play a coordinating role, being closest to the patient and always in a position to talk about and observe their progress. Participants named several factors that stand in the way of the coordinating role, such as working with discipline-specific goals and the lack of an integrated rehabilitation plan.…it is very much discipline-oriented. In the treatment plan the occupational therapist makes a goal, the physiotherapist makes a goal, […]. And if it’s about walking […] the nurse automatically is of less importance. (Participant 3)Also, not all nurses feel in a position to play a coordinating role in the rehabilitation process, as illustrated by the last quote.The therapist focuses on the therapy, but I expect the nurses to observe: “This patient has had a couple of down days. I do not think it realistic to send him home yet.” […] But we do not always see a possibility to utter this…. (Participant 8)Finally, two interventions meant to support patients in working on short-term goals were discussed with the focus group participants In general, the initiative and management of these interventions, such as exercise goals on whiteboards or exercise sheets, were considered the responsibility of other disciplines. The role of nursing staff is to monitor progress and inform other disciplines about progress. Participants had differing opinions about whether stimulating the patient to exercise is the nurses’ task. Some see this as “extra” workload; others emphasized that if you work according to the philosophy that “everything is rehabilitation,” most exercises fit into daily activities. Involving family in the rehabilitation process was seen as an important nursing task.Exercise sheets and whiteboard with short-term exercises need to be kept up-to-date to ensure continuity.Some of the conditions for implementation mentioned by the participants apply to all interventions. First, time is needed to actually apply the different interventions, and second, care pathways and work procedures describing the role of nursing staff and the patient’s role secure the patient’s participation. It legitimizes certain activities, such as patient attendance at the multidisciplinary team meeting or having motivational interviewing sessions, and makes these activities less team dependent. Third, the need for education in geriatric rehabilitation was mentioned in all focus group interviews. Educating nursing staff promotes working with a rehabilitation mindset.Some have worked in this department for nearly a hundred years and are a fixture, but only now  they realize: I may not be attending the multidisciplinary team meeting […] or I am not the case manager of this rehabilitant, but I am on a nightshift and I notice that getting in and out of bed by himself is not going well yet. So I might ask: “how do you think you will manage at home?” So they have a much better understanding of all aspects of rehabilitation that are also needed at home, and they dare to take more control of it. (Participant 22)Participants mentioned that attending training has important outcomes such as nursing staff become more aware of the quality of their work, and it contributes to the leadership of the geriatric rehabilitation nurse. Leadership is a fourth condition for the successful implementation of interventions. The participants made an appeal to all nursing staff working in geriatric rehabilitation to be aware of and show their expertise:…what can help them take that role? I think…awareness among nurses that they are important. (Participant 4)So you take on that role by directing and participating in the whole process. And I think if you do that, your colleagues, the other disciplines, well, you show them that: Hey, I know what I'm talking about. (Participant 5)The aim of this focus group study was to explore and clarify the role of nursing staff working in geriatric rehabilitation on supporting patients in goal setting and achieving. This work was done through reflecting on interventions meant to support goal setting and achieving in geriatric rehabilitation.Collaboratively setting goals in the admission phase with the help of a scale (Type 1) increases patients’ awareness of why they are in this healthcare setting and the goals they could be working on. The same is true for fostering patient involvement in the rehabilitation process (Type 2). This could be supported by the use of an instrument like a short questionnaire about progression on goals. According to the participants in this study, interventions providing support for short-term goals (Type 3) have many benefits for patients. Taking into account the characteristics of the older patient, the situation (postacute), and the short time frame in which the treatment must take place given the limited reimbursement, these interventions make rehabilitation manageable for the patient and help the family to take on a supportive role. This is confirmed in various ways by other studies. For the nursing staff, there are three aspects of importance in applying all six interventions , and these are evident from the feedback of the participants. The first aspect is the delicate process of estimating the amount of control a patient is able to take in the goal-setting process, tuning in on that level of control and establishing conditions for the patients to take as much control as possible. Research by The second aspect that emerged from the participants is involving family in the process. Participants stressed the important role of family in setting goals as well as in working on goals. Remarkably, this aspect is only marginally described in the papers about the interventions. The third aspect the focus group interviews revealed that interventions that focus on advancing patient participation during the rehabilitation process (Type 2) align well with current practice. The participants expressed that they play a linking role between the patient’s personal goals and professional treatment aimed at functional recovery. This does not come as a surprise. Two of the four functions in the theoretical framework of A strength of the study is that the subject was of interest to many nursing staff working in geriatric rehabilitation. Recruiting for the focus group interviews went very smoothly. This underscores the relevance of this issue. Another strength is the use of the digital whiteboard at the start of the focus group interviews. This gave quieter participants an extra chance to voice their ideas. The study is limited because participants expressed their ideas about the interventions mainly based on their imaginative abilities. To fully understand the contribution of the nursing interventions to a more patient-centered and efficient interprofessional process, the application of these interventions should be the subject of further research.The results from the focus groups made clear that setting goals with the aid of a scale is more the task of the entire multidisciplinary team rather than the nursing staff. In this multidisciplinary process, specific nursing focus points are currently missing and should be incorporated into the admission process. Interventions focused on advancing patient participation (Type 2) align clearly with the coordinating role of nursing staff in the rehabilitation team. Participants emphasize the benefits of working with short-term goals (Type 3) for patients. To incorporate these into their nursing practice and strengthen the coordinating role, interprofessional teamwork needs to be further developed, available interventions should be implemented, and nursing staff should be trained in rehabilitation. Lastly, the needs and role of family in geriatric rehabilitation deserves to be embedded in interventions.The role of nursing staff in geriatric rehabilitation in the Netherlands is developing. Reflecting on the three types of interventions helped to further clarify this role. Nursing staff working in geriatric rehabilitation see themselves playing a coordinating role in the multidisciplinary team, supporting the patient in goal work. Interventions aimed at advancing patient participation (Type 2) and working toward goals (Type 3) reinforce this role.Goal setting in the admission phase is a multidisciplinary responsibility. Specific nursing focus points should be incorporated into the admission goal-setting process.To optimally support patients in achieving goals, interprofessional collaboration needs to be further developed.The needs and role of family in geriatric rehabilitation deserve to be embedded in interventions.The authors declare no conflict of interest with respect to the research, authorship, or publication of this article.This research was supported by ZonMW Grant 516022517, awarded to Robbert Gobbens.


Allosteric regulation is critical for the functioning of G protein-coupled receptors (GPCRs) and their signaling pathways. Endogenous allosteric regulators of GPCRs are simple ions, various biomolecules, and protein components of GPCR signaling (G proteins and β-arrestins). The stability and functional activity of GPCR complexes is also due to multicenter allosteric interactions between protomers. The complexity of allosteric effects caused by numerous regulators differing in structure, availability, and mechanisms of action predetermines the multiplicity and different topology of allosteric sites in GPCRs. These sites can be localized in extracellular loops; inside the transmembrane tunnel and in its upper and lower vestibules; in cytoplasmic loops; and on the outer, membrane-contacting surface of the transmembrane domain. They are involved in the regulation of basal and orthosteric agonist-stimulated receptor activity, biased agonism, GPCR-complex formation, and endocytosis. They are targets for a large number of synthetic allosteric regulators and modulators, including those constructed using molecular docking. The review is devoted to the principles and mechanisms of GPCRs allosteric regulation, the multiplicity of allosteric sites and their topology, and the endogenous and synthetic allosteric regulators, including autoantibodies and pepducins. The allosteric regulation of chemokine receptors, proteinase-activated receptors, thyroid-stimulating and luteinizing hormone receptors, and beta-adrenergic receptors are described in more detail. Saccharomyces cerevisiae has only 3 genes encoding GPCRs -pyrimidine structure with the activity of allosteric agonists of the LH receptor (LHR), including the most active LHR-agonists Org41841 and Org43553 ,328. By Tshr gene, and when combined with TSH (cultured FRTL-5 cells) or thyroliberin (rat thyroid), it partially restored it. This may be one of the mechanisms for maintaining the stimulating effects of TSH  and thyroliberin  on the production of thyroid hormones under conditions of their combined use with TPY3m -pyrimidine derivatives, TPY1 and TP48, with antagonistic activity against TSHR ,351. Wheymporter ,351. ThiIn 2019, the compound S37a with seven centers of chirality was developed, which one of the stereoisomers at micromolar concentrations suppressed the AC activity and the cAMP accumulation in HEK293 cells with expressed TSHR when they were treated with TSH and stimulatory monoclonal antibodies TSAb M22 and KSAb1, oligoclonal stimulatory antibodies TSAb characteristic of patients with Graves’ disease, as well as a small C2 agonist . S37a, wIn addition to allosteric sites localized in the ECLs and TMD, such sites are also located in the ICLs of TSHR as evidenced by our results on the stimulating effect on the TSHR activity of pepducin, which corresponds to region 612–627 of TSHR ICL3 ,354 Fig. PepduciAutoimmune thyroid diseases are found in an average of 5% of the population, the most common among which is diffuse toxic goiter (Graves’ disease), which develops as a result of an autoimmune attack to TSHR . For alms- and Gq/11-proteins, which leads to increased synthesis and secretion of thyroid hormones -pyrimidines since its replacement with alanine blocked the binding of Org41841 to mutant LHR. This is due to the formation of a salt bridge between the carboxyl group of glutamic acid and the positively charged amino group of the allosteric ligand -pyrimidine derivatives Org41841 and Org43553, which act on LHR at nanomolar concentrations . They sprrestins ,389,390. in TSHR . The negc ligand ,330. In c ligand ,392,393.Lhr gene in the testes, and their steroidogenic effect was preserved and even increased, which indicates the possibility of their long-term use to stimulate testicular steroidogenesis in the conditions of androgen deficiency -pyrimidine derivatives with the properties of allosteric agonists and (or) ago-PAMs and allosteric antagonists of LHR ,401,402.ficiency ,401. Theficiency , as wellficiency . These rAlong with thieno-pyrimidines, 1,3,5-pyrazole and terphenyl derivatives can also function as allosteric LHR ligands with full and inverse agonist activity ,410,411.N-(tert-butyl)-2-(methylsulfanyl)thienopyrimidine-6-carboxamide, a framework molecule for the synthesis of LHR allosteric regulators -pyrimidine structure, we created an allosteric TP31 antagonist, which, in the in vitro experiments, reduced hCG- and TP03-stimulated AC activity in testicular membranes, and when administered intraperitoneally to male rats, it slightly reduced the baseline testosterone and largely inhibited the stimulatory effect of hCG on testosterone production ,398 Fig. Since ps-proteins, increased the basal AC activity in testicular membranes, inhibiting hCG-induced stimulation of the enzyme [The importance of intracellular allosteric sites in the regulation of LHR activity is supported by our data on the effect of peptides derived from ICL3 of this receptor ,413,414.Since LHR is similar in structure and regulatory mechanisms to TSHR, it cannot be ruled out that it can also be allosterically regulated by autoantibodies against the LHR ectodomain. However, at present, reliable data on the possibility of such regulation, as well as on the association between the presence of autoantibodies to LHR and reproductive dysfunctions, have not been obtained. There is a clinical study in which an attempt was made to trace the relationship between the presence of stimulatory anti-LHR antibodies in the blood of women with polycystic ovary syndrome (PCOS) and the severity of their hyperandrogenemia . However2-AR but also to suggest potential candidates as regulators of these sites [As in the structure of most GPCRs, allosteric sites in β-AR are located in all main subdomains, which is confirmed by the influence of autoantibodies to ECLs, synthetic ICL-derived pepducins, as well as the endogenous and synthetic small compounds capable of interacting with sites located in different loci of the TMD and its interfaces with ICLs. The multiplicity of these sites was demonstrated using the ligand competitive saturation (SILCS) computational method, which made it possible not only to predict the possible localization and functional activity of allosteric sites in the βse sites . Below, se sites ,421,422,2-AR was developed [2-AR [2-AR for orthosteric agonists, and inhibition of its binding to G proteins and β-arrestins [6.36, Ser3298.47, Asp3318.49, Asn692.40, and Arg63ICL1) while the cyclohexyl and phenyl rings of Cmpd-15PA interacted with the hydrophobic package formed by the residues Val541.53 and Ile581.57 at the end of TM1, Leu64ICL1 (ICL1), Ile722.43 (TM2), Leu2756.37 (TM6), as well as Tyr3267.53 from the conserved NPxxY sequence located in TM7 and Phe3328.50 located in the H8 helix [2-AR were synthesized, and the study of their structure and molecular docking confirmed the decisive importance of their interaction with hydrophobic residues that form the allosteric site of β2-AR [In 2017, based on the DNA-encoded small-molecule library, compound 15 (Cmpd-15) with NAM activity for βeveloped . Cmpd-15ed [2-AR . The resrrestins ,421. As H8 helix . Subsequof β2-AR .2-AR was developed, which also interacted with an allosteric site located in the region of the intracellular vestibule of the transmembrane tunnel  stabilizing the active conformation of the receptor [2-AR and thereby enhanced its inhibitory effect on β2-agonist-induced stimulation of Gs-proteins and cAMP signaling and, on the other hand, enhanced the stimulatory effects of carvedilol on ERK1/2 activity, endocytosis of β2-Ars, and their trafficking into lysosomes [s-proteins [In 2018, compound 6 (Cmpd-6) with PAM activity for βreceptor ,425. Thiysosomes , which, proteins .2-AR [2-AR, Gs-proteins, and β-arrestins. The first group included pepducins, which activated Gs-proteins in a receptor-independent manner. Pepducins of the second group had a biased activity towards the β-arrestin pathways causing activation of MAPK, desensitization of β2-AR, and, as a result, reducing or blocking the cell response to β2-agonists. Pepducins of the third group receptor-dependently stimulated Gs-proteins and cAMP-signaling pathways stabilizing the active conformation of β2-AR, and these effects were not accompanied by site-specific phosphorylation by GRK-kinases, which prevented β-arrestin-mediated internalization of β2-ARs and maintained or even increased their sensitivity to β2-agonists [Allosteric sites located on the cytoplasmic side of the β-AR TMD are targets not only for low-molecular-weight compounds but also for pepducins corresponding to the ICLs and ICL/TM interfaces of β-AR. In 2014, the group of Jeffrey Benovic synthesized pepducins corresponding to different regions of ICL1, ICL2, and ICL3 of β2-AR . As a reagonists .s-dependent β1-AR and Gi/o-dependent β2-AR. As a result, apoptotic processes leading to the death of cardiomyocytes are enhanced, the expression of β1-AR is reduced, and the inotropic reserve of the myocardium is weakened. Blockers of the β-AR orthosteric site, as a rule, have low selectivity for transducer proteins, which negatively affects the activity of G protein-independent β-arrestin pathways responsible for transient β-AR desensitization and cardiomyocyte survival. Pepducins, derivatives of the ICL of β-ARs, can become a suitable alternative to such blockers. In cultured cardiomyocytes, pepducin ICL1–9, corresponding to β2-AR ICL1, stimulated β2-AR phosphorylation, induced β-arrestin recruitment and subsequent β2-AR internalization, and activated β-arrestin signaling cascades functioning as β-arrestin-biased allosteric agonist [2-AR, as well as on the presence of β-arrestins, since this effect was not detected in mutant mice lacking β2-AR and β-arrestins. A key role in the anti-apoptotic effect of ICL1–9 belongs to the signaling pathway, including RhoA, ROCK, and protein kinase D, which can be regulated both through β-arrestins and Gi-proteins, which can functionally couple with β2-AR [2-AR and have a wide range of pharmacological activity are good candidates for the development of new drugs for the treatment of cardiovascular diseases [During congestive heart failure, the level of catecholamines increases and their stimulating effect on β-AR increases, which in cardiomyocytes leads to chronic activation of G agonist . The stu agonist . Intramy agonist . The antth β2-AR ,431. Thudiseases ,430,431.1- and β2-AR are known, which are closely associated with cardiovascular diseases [1-AR ECL2, which the presence of certain types is the root cause of dilated and ischemic cardiomyopathy [1-AR induce conformational changes that stabilize both the active and inactive conformation of the receptor. In the case of stabilization of the active conformation, an increase in the affinity of β1-AR for the agonist and an increase in cAMP production are observed, which leads to cardiovascular pathology [1-AR isolated from the blood of patients with dilated cardiomyopathy, antibodies designated as “P4” predominate, which suppress the internalization of receptors, cause a β1-AR-mediated increase in intracellular cAMP levels in the absence of an agonist, and inhibit the stimulating effect of isoproterenol on AC activity [1-AR internalization caused by autoantibodies does not lead to an increase in agonist-induced AC activity can be explained by the fact that the recycling of desensitized receptors is impaired. A certain contribution may be made by the negative influence of autoantibodies on the binding characteristics and accessibility of the orthosteric site. It is important that autoantibodies to β1-AR were detected in a significant proportion of healthy subjects without any signs of cardiovascular pathology, but these autoantibodies, unlike those in patients with dilated cardiomyopathy, did not have a stimulating effect on β1-AR and in some cases even had weak antagonistic activity [Currently, a large number of autoantibodies to the ECLs of βdiseases ,433,434.myopathy ,437,438.athology ,439. Amo1-AR in patients with different forms of cardiomyopathy, it was found that immunogenic epitopes were localized in ECL2 (195–225) of β1-AR. In cardiomyopathy in patients with Chagas disease, the epitope included the region 201–205, and in postpartum cardiomyopathy, the epitope corresponded to the region 200–210. In dilated cardiomyopathy, the epitopes were located in overlapping regions 183–208, 197–202, 206–212, and 213–218, including TM4 segments adjacent to ECL2 [1-AR ECL2 was used, which made it possible to identify the key molecular determinants of this epitope, including the NDPK211–214 segment and the C209–C215 cysteine bridge. Segment 211–214 was located at the C-terminal end of the backward-oriented α-helix constituting ECL2 in β1-AR [1-AR is most likely the Asp212, the negative charge of which is neutralized upon interaction with the autoantibody. This assumption is based on the fact that substitution of Asp212 for asparagine leads to paradoxical activation of the mutant receptor by antagonists broxaterol and terbutaline [1-AR ECL2 prevented the development of chronic heart failure caused by autoantibodies to β1-AR [To identify the ECL epitopes that are most significant for β-AR activity, autoantibodies were studied by immunoprecipitation with peptides and their constructs derived from different ECL regions of β1- and β2-AR, as well as by immunization of experimental animals with peptides structurally corresponding to these regions ,440. Whe to ECL2 ,442. Morin β1-AR . In thisbutaline . In the to β1-AR ,444. A cto β1-AR .2-AR bound to β2-AR and inhibited the stimulatory effects of β2-agonists on AC activity in cultured cardiomyocytes. At the same time, bivalent antibodies stimulated β2-AR-mediated signaling pathways and caused contraction of cardiomyocytes, and these effects of bivalent antibodies were due to their two-center binding to receptor molecules promoting β2-AR dimerization [s-proteins, which indicates their bias towards β2-AR-coupled transducer proteins [2-AR depends on the number and localization of binding sites in the ECL of the receptors.Monovalent Fab-fragments of antibodies that were produced against the ECL2 region 173–180 of βrization . Subsequproteins . These d+, Zn2+, Mg2+, Mn2+, and some others), which penetrate into the inner cavity of the transmembrane tunnel of most GPCRs and, being in complex with the amino acid residues that form the allosteric site, modulate their functional activity. This determines the influence of the ionic composition and pH in the extra- and intracellular environments on the activity of GPCRs and may mediate the effect of the electrochemical properties of the membrane on GPCR signaling. Ion chelators, including peptides and proteins, affect the concentration and ratio of ions available for interaction with allosteric sites, and thus are able to regulate the GPCRs. This greatly expands the range of potential allosteric regulators.Allosteric regulation plays a decisive role in the functioning of all known representatives of GPCRs since allosteric mechanisms are involved in the regulation of their basal activity and the main stages of GPCR-mediated signal transduction, including orthosteric ligand binding, and are also responsible for receptor desensitization, endocytosis of ligand-receptor complexes , and their recycling or degradation. Since ligands of allosteric sites affect various functions of the receptor, including biased agonism, and are characterized by varying degrees of selectivity for GPCRs, this predetermines their diversity in chemical structure, pharmacological profile, and localization and configuration of the sites with which they interact. Low-specific allosteric regulators include simple ions  that interact with allosteric sites of GPCRs located on the outer membrane-contacting surface of the TMD, as well as in interfaces formed by TMs and hydrophilic loops. These interactions are involved in the regulation of receptor activity since they affect the conformational mobility and configuration of the transmembrane tunnel and are critical for the ability of receptors to form the complexes with other components of GPCR signaling. The influence of the physicochemical properties and composition of membranes on the activity of GPCRs is carried out largely through allosteric lipid–receptor interactions, and this occurs not only in the plasma membrane but also in the membranes of endosomes, the Golgi apparatus, and the nucleus, where intracellular GPCR signaling occurs. It is not entirely clear to what extent the effects of lipids are specific to a particular receptor. Some lipids, such as cholesterol, target various groups of GPCRs while other lipids, such as PIPEndogenous allosteric GPCR regulators include heterotrimeric G proteins and β-arrestins, which are part of pre-activation complexes and mediate signal transduction after receptor activation by an orthosteric or allosteric agonist. Unlike small endogenous regulators, the interaction of transducer proteins with cytoplasmic subdomains and the intracellular vestibule of the receptor’s transmembrane tunnel is usually multicentric and often involves molecular determinants that form various intracellular allosteric sites. In addition, in the functionally active state, some GPCRs are capable of forming homo- and heterodimeric complexes in which protomers interact allosterically, and this is another allosteric mechanism that is responsible for the stability and mutual transitions of active and inactive receptor conformations, the ability of the receptor to be activated by an orthosteric agonist, and also for biased agonism. The formation of homo- and heterodimeric GPCR complexes involves multiple allosteric sites located in hydrophilic loops and on the outer TMD surfaces of GPCRs. Each protomer in the complex is subject to multiple allosteric influences. As a result, in an oligomeric complex that includes protomers from different types of receptors, allosteric regulation becomes much more complicated.Highly specific allosteric regulators of GPCRs are autoantibodies developed against antigenic determinants located in receptor ECLs. They can stimulate or, conversely, inhibit GPCRs, as well as modulate their activity, including biased regulation of intracellular cascades. Considering the fact that the number of identified and studied autoantibodies to GPCRs is steadily increasing, there is no doubt that for many receptors there is a wide range of such autoantibodies with a different profile of functional activity, and these autoantibodies can be the root causes of many diseases. At the same time, autoantibodies to GPCRs are found in healthy subjects although they differ from autoantibodies in patients with autoimmune diseases. This indicates that, even under normal conditions, autoantibodies to GPCRs may be involved in the allosteric regulation of GPCR signaling.The complexity of allosteric effects caused by numerous regulatory molecules differing in structure, availability, and mechanisms of action predetermines the multiplicity and different topology of allosteric sites in GPCRs. Allosteric regulators can specifically interact with the sites located in the ECLs, ICLs, and the internal cavity of the transmembrane tunnel, as well as on the lateral, membrane-contacting surface of the TMD. Along with this, allosteric effects can be mediated by the interaction of various molecules  with signal proteins that form functionally active complexes with GPCRs . In such cases, one can speak of stepwise, both temporal and spatial, allosteric regulation of GPCR-containing signaling complexes. As a result, the search and development of artificial (synthetic) allosteric ligands should take into account the topological diversity and functional complexity of the endogenous allosteric regulation of GPCRs. It is important that artificial allosteric ligands are balanced and harmoniously included in the mechanisms of endogenous allosteric regulation supplementing and modifying it in the necessary way.In recent years, for many GPCRs, impressive progress has been made in the development of a large number of allosteric regulators with various pharmacological activities, and many of them are not only selective for a certain type of receptor but also characterized by a biased activity towards intracellular cascades, which is very valuable and in high demand in medicine. Using molecular docking and genetic approaches, new populations of allosteric sites in GPCRs have been identified, which creates prerequisites for the search for their endogenous regulators, as well as for the creation of their artificial ligands. At the same time, it should be noted that in the process of translating the results of studies on the efficacy and safety of allosteric regulators obtained in vitro and in animal models, many intractable problems appear in the clinic, and this is one of the reasons for the very limited arsenal of pharmacological drugs based on allosteric GPCR regulators. More intensive studies are needed on the allosteric mechanisms of the regulation of GPCRs in real biological systems at the organism level, where receptors are under the influence of many factors. At the same time, despite the difficulties and limitations, there is no doubt that given the high specificity of action, including biased agonism, and also taking into account moderate activity, which excludes blocking or hyperactivation of receptors as is often observed for orthosteric ligands, allosteric GPCR-regulators will occupy a significant niche in the pharmacological industry in the coming years.


Six studies of the first group (robotic rehabilitation) were compared using a forest plot for 10MWT, LEMS, WISCI-II, and SCIM-3. The other clinical trials were analyzed through a narrative review of the results. We found weak evidence for the claim that robotic devices lead to better outcomes in gait independence compared to conventional rehabilitation methods. External stimulation and intermittent hypoxia seem to improve gait parameters associated with other rehabilitation methods. Research investigating the role of innovative technologies in improving gait and balance is needed since walking ability is a fundamental issue in patients with SCI.Gait recovery is a fundamental goal in patients with spinal cord injury to attain greater autonomy and quality of life. Robotics is becoming a valid tool in improving motor, balance, and gait function in this patient population. Moreover, other innovative approaches are leading to promising results. The aim of this study was to investigate new rehabilitative methods for gait recovery in people who have suffered spinal cord injuries. A systematic review of the last 10 years of the literature was performed in three databases . We followed this PICO of the review: P: adults with non-progressive spinal cord injury; I: new rehabilitative methods; C: new methods vs. conventional methods; and O: improvement of gait parameters. When feasible, a comparison through ES forest plots was performed. A total of 18 RCTs of the 599 results obtained were included. The studies investigated robotic rehabilitation ( According to the WHO , spinal cord injury (SCI) is defined as any “damage to the spinal cord resulting from trauma or disease or degeneration” , represeOne of the main goals of patients with SCI is to restore ambulation  since reTo date, gait rehabilitation protocols for SCI treatment include physical therapy  with nonThe aim of this systematic review is to investigate the emerging technologies and strategies for gait recovery in adults with SCI, with particular interest in robot-assisted rehabilitation. This review follows the PRISMA ,23 and PTo meet PICO criteria, a search was conducted on some of the major scientific databases , identifying randomized trials (RCTs), published in the last 12 years in English, and investigating innovative rehabilitation programs for walking recovery in people with SCI. Previous systematic reviews were excluded since we wanted to analyze the row data of the included study by ourselves. Only the first parts of crossover trials were included to avoid risk of overlapping results between the two methods. Association of more than one therapeutic device was accepted, if it drew comparisons with conventional rehabilitation. https://pubmed.ncbi.nlm.nih.gov/) with the following search string: “ AND ((recovery) OR (outcome) OR (prognosis)) AND ((ambulation) OR  OR  OR (gait))”. Data from 2010 to 2022 from studies containing RCTs and clinical trials were considered, totaling 151 results. Another literature search was performed on August 8 2022, using the PEDro database (https://pedro.org.au/) with the terms “spinal cord injury” gait. Data from 2010 from papers containing trials only were considered, totaling 23 results. A third literature search was performed on the 10 August 2022 using the Cochrane website (https://www.cochranelibrary.com/) with the search string “ AND ((recovery) OR (outcome) OR (prognosis)) AND ((ambulation) OR  OR  OR (gait))):ti,ab,kw (Word variations have been searched)”. Publications dated between January 2010 and December 2022 that contained trials (word variations were searched)as well as included ICTRP 65 and CINAHL 39. totaled 117 results from Pubmed, 128 from Embase, and 103 from CT.gov. A literature search was performed on 29 July 2022 using Pubmed . Discrepancies between the three reviewers were resolved through discussion and consensus. The results of every stage of selection were reviewed by the senior investigators (R.S.C. and M.G.O.).Risk of bias was evaluated by one of the authors (M.A.) through the RoB 2  method, N stands for the statistic sample. Studies showing results as median and interquartile range were converted to mean ± standard deviation (SD) according to the method of Wan et al. [Where necessary, data expressed as Standard Error (SE) were converted to Standard Deviation (SD), which was more manageable, through the formula n et al. . 2 = 0) and wide confidence intervals (CI 95%). Forest plots were generated, where possible, for more clearness regarding effect size, using the statistic software ProMeta 3 by . Effect sizes were acquired by comparing arithmetic means and SD pre and post intervention of the outcomes through the “Hedge’s G” method. The statistical model adopted was the “Random effect model”. The statistical analysis was performed by the first author (G.L.).Effect size was analyzed, not strictly, because of the low heterogeneity of the outcomes evaluated : one comparing it with conventional physical therapy [Two studies evaluated the use of an exoskeleton  and transcranial Direct Current Stimulation (tDCS). The TMS functioning mechanism seems to be activated by two different pathways, such as recruitment of neural networks ,61,62, rIn contrast, robotic rehabilitation using Lokomat coupled with tDCS was applied in the study by Raithatha et al. , whereinIntermittent hypoxia (IH) appears to increase physical performance of people with incomplete SCI, as shown by Trumbower in al. . This me2 9%, 15 times a day for 5 days in a row, followed by IH 3 times a week for the following 3 weeks. Gait training sessions were executed 3 times a week for 3 weeks. Beginning on the fifth day of IH therapy, an increase in speed measured through the 10MWT was observed; moreover, this gain was maintained for the next 3 weeks, and endurance increased as well. Navarrete-Opazo et al.  associatAnother study by Hayes et al. , appliedFinally, it has been shown that IH elicits clinically meaningful improvements in walking speed and distance that persist for weeks after treatment . HoweverA cohort of new rehabilitation methods have been studied in the last 12 years to improve gait recovery in SCI patients. These can be associated with conventional rehabilitation to enhance neuroplasticity and consequently motor function and mobility. We observed, with low evidence, that robot-assisted gait rehabilitation, alone or associated with other methods , leads to improvement in gait function and independence, in comparison to conventional therapy alone. Moreover, we may say that this kind of rehabilitation relieves the care to acquire the same therapeutic dosage we can deliver with traditional methods using fewer human resources. External stimulation appears to be a promising technique when TMS is associated with robotic rehabilitation. Finally, the usage of Intermittent Hypoxia associated with physical exercise seems to be the fastest method to improve gait outcome measures. Nonetheless, there is still a lack of large sample trials with good homogeneity of data and long-term follow-up. Future research should take into account different combinations of treatment to further increase motor outcomes, and therefore quality of life, in patients with SCI.