The CT syndesmophyte score (CTSS) can evaluate spinal progression more precisely than mSASSS in ankylosing spondylitis (AS); however, it is complex and time consuming. Here, we propose a simplified CTSS (sCTSS) for measuring spinal structural changes in AS. Patients with AS were recruited from a single tertiary hospital. Baseline and 2-year follow-up whole spine CT images were used to calculate CTSS and sCTSS. The sCTSS used the anterior and posterior vertebral corners, and ranged 0–184. Intraclass correlation coefficients (ICC) were calculated, as well as the smallest detectable changes. Fifty AS patients were included. For reader 1, the mean sCTSS at baseline and 2-year follow-up were 11.7 ± 14.6 and 15.8 ± 16.1, whereas those for reader 2 were 12.0 ± 12.5 and 15.8 ± 15.7, respectively. The ICCs for CTSS at baseline and at 2-year follow-up were 0.97  and 0.98 (0.97–0.99), respectively, and that for changes over the 2 years was 0.48 (95% CI 0.23–0.67). For sCTSS, the ICCs were 0.96 (95% CI 0.92–0.97), 0.97 (95% CI 0.94–0.98), and 0.58 (95% CI 0.36–0.74), respectively. Detection rates for syndesmophyte progression were comparable between CTSS and sCTSS. The detection rate for syndesmophytes on only lateral side was 13.2 and 11.4%, and 11.4 and 15.2% at baseline and 2-year follow-up (reader 1 and 2). sCTSS and CTSS showed similar detection rates for syndesmophyte progression. sCTSS may be a reliable method for evaluating spinal structural damage in AS. The treatment goal is to reduce articular symptoms and prevent formation of syndesmophytes in the spine. Therefore, therapeutic efficacy is assessed by measuring disease activity and progression of spinal structural damage. A recent study shows that long-term treatment with tumor necrosis factor inhibitors (TNFi) attenuates spinal structural progression in patients with AS3.Ankylosing spondylitis (AS), a prototype of axial spondyloarthritis, is a type of systemic inflammatory arthritis that triggers arthralgia and stiffness in the axial joints, culminating in inflammation and ankylosis of the spine4. It is calculated from lateral view X-rays of the cervical and lumbar spine5. However, the method has several limitations. First, it can be hard to discriminate true structural damage on simple X-rays due to interference from adjacent internal organs and bowel gas. Second, the thoracic spine is not included in the mSASSS; this is important because data from spinal computed tomography (CT) images show that syndesmophytes are most common in the thoracic spine6. These critical limitations mean that a novel assessment tool is required for evaluating spinal structural progression in AS, leading to the recent development of the CT syndemophyte score (CTSS)6. The CTSS method measure syndesmophytes on cervical, thoracic, and lumbar spine (C2 lower to S1 upper) by subdividing it into four aspects ; in addition, both sagittal and coronal views of each vertebral corner are examined6. The CTSS method has definite advantages with respect to evaluation of spinal structural damage in AS, and it can detect spinal progression of AS patients more sensitively than mSASSS7. However, the CTSS is time consuming and cannot be scored easily; it is based on a range of 1–4 as follows: 0: no syndesmophytes; 1: syndesmophyte height < 50% of the intervertebral disc space [IDS]; 2: syndesmophyte height > 50% of the IDS; 3: total ankylosis6.The modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) is the tool used most widely to assess spinal progression in ASHere, we developed a simplified CTSS (sCTSS) for quantifying syndesmophytes in patients with AS. In addition, we compared the ability of the CTSS and sCTSS to detect spinal progression in AS patients.8, (2) age > 18, and (3) baseline whole spine CT taken within 12 months of a first diagnosis of AS. Patients with other autoimmune diseases, cancer, pregnancy, or current infection were excluded. The demographic and laboratory data for each patient were collected at the time that the baseline whole spine CT was taken. The whole spine CT was performed to evaluate syndesmophyte progression in AS patients. The study was conducted in accordance with the Declaration of Helsinki (1964 Declaration of Helsinki and its later amendments). Written informed consent was waived by the Institutional Review Board of Konkuk University Medical Center due to the retrospective nature of the study. The study was approved by the Institutional Review Board of Konkuk University Medical Center .Patients with AS were recruited from a single university-based tertiary hospital  from January 2015 to December 2019. The inclusion criteria were as follows: (1) fulfil 1984 modified New York criteria for AS6 and the sCTSS. The CTSS, which ranges from 0 to 552 was calculated as described previously6. The sCTSS used only sagittal plane CT images, and divided each vertebral corner into anterior and posterior aspects. The degree of syndesmophyte formation was scored as follows: 0, no syndesmophytes; 1, syndesmophytes, but not bridging; and 2, total ankylosis (bridging). The details are described in Supplementary Table Whole spine CT was performed twice per patient: once at baseline and then again 2 years later. Patients were placed in a supine position and scanned using a 64-slice CT scanner . A volume CT with 0.625 mm acquisition was acquired from the superior endplate of C1 down to the coccyx . Next, sagittal and coronal plane views including the complete vertebral column were reconstructed from 2 mm slices. Two independent readers scored the whole spine CT images using the CTSSdiff/√k × √2 6. The net number of patients with progression above 0, 0.5, or the SDC threshold values was calculated by subtracting the number of patients with a change in the score of < 0, <  − 0.5, or <  − SDC from the number of patients with a change in the score of > 0, > 0.5, or > SDC6. P values < 0.05 were deemed statistically significant. All analyses were performed using R software .Categorical variables are presented as numbers and percentages. Continuous variables are presented as the median and interquartile range, or as the mean and standard deviation. Inter-reader reliability was measured by calculating the intraclass correlation coefficient (ICC), and Bland–Altman plot. The smallest detectable change (SDC) was calculated using the following equation: SDC = 1.96 × SDWritten informed consent was waived by the Institutional Review Board of Konkuk University Medical Center due to the retrospective nature of the study. The study was approved by the Institutional Review Board of Konkuk University Medical Center .Fifty patients with AS were included in the analysis. The median age was 33.5 years, and 38 (76%) were male. Thirty-nine (78%) patients were HLA-B27-positive, and the median erythrocyte sedimentation rate and high sensitivity C-reactive protein level were 8.0 mm/h and 0.1 mg/dL, respectively. Most of the enrolled patients used non-steroidal anti-inflammatory drugs , and five (10%) were taking a tumor necrosis factor inhibitor. Other characteristics are listed in Table For reader 1, the mean CTSS at baseline and at the 2 year follow-up was 25.7 ± 43.2 and 32.9 ± 46.0, respectively, and the change in the CTSS was 7.2 ± 12.0; for reader 2, these values were 23.0 ± 34.1, 35.0 ± 47.7, and 12.0 ± 16.5, respectively. In the CTSS for reader 1, the lower vertebral corner of T3 and T4 were the most common sites for syndesmophytes at baseline and at 2-year follow-up; the results for reader 2 were similar . There was no significant difference between the CTSS and the sCTSS with respect to the ability to detect meaningful progression when using cut-off values of 0 nor 0.5. The detailed SDCs and detection rates per spinal segment are described in Table The cumulative probability plots for CTSS and sCTSS for both readers were presented in Fig. Finally, we examined vertebral corners at which syndesmophytes were found only on the lateral side of the vertebral body . Among 2300 vertebral corners , readers 1 and 2 identified 544 and 579 syndesmophytes at baseline, respectively. Among these, 72/544 (13.2%) and 66/579 (11.4%) vertebral corners had syndesmophytes only on the lateral side (right or left). Similar to the baseline CT findings, readers 1 and 2 identified 13.4% (98/734) and 15.2% (117/769) of vertebral corners as having only lateral side syndesmophytes at the 2-year follow-up. The distribution and percentage of syndesmophyte detected only in lateral side were described in Fig. The present study suggests a new method (sCTSS) for evaluating spinal structural damage associated with AS. This method was compared with the CTSS. Both methods were equally good at detecting meaningful spinal progression; however, the ICC for detecting changes in the syndesmophyte scores between baseline and 2-year follow-up was slightly better for the sCTSS.Although detailed and fine subdivisions in the scoring methods for syndesmophytes can detect small amounts of progression, it can reduce inter-reader reliability. Also, although IDSs are well-defined in the lumbar spine, those in the cervical and thoracic spine are relatively narrow, making it difficult to discriminate score 1 from between 2 on the CTSS; this is particularly true in coronal plane images of the C spine in which the joint spaces are not parallel but tilted about 45°–60°  was one-third to one-half of that taken to evaluate the CTSS (30–40 min). However, the detection rates for spinal progression were comparable. Although neglecting syndesmophytes on the lateral side may increase the risk of missing syndesmophyte progression slightly, the sCTSS can save much time, with a detection rate similar to that of the CTSS.A previous study reported that syndesmophytes were most common on the posterior lateral side of the vertebral column7; no further research based on the CTSS has been published. Many clinical trials of axSpA (including AS) still evaluate radiographic progression using the mSASSS4, even though it has critical limitations7. The biggest hurdle to using the CTSS is the time taken and the complexity of the scoring system. The proposed sCTSS overcomes the limitations of the mSASSS, and has detection rates comparable with those of CTSS, but in half the time. Fourth, the sCTSS omits syndesmophyte on coronal view of CT , it could miss syndesmophyte progression in lateral side of vertebral body. The previous study showed that posterolateral rim was the most common site of syndesmophyte involvement9. Actually the detection rate of syndesmophyte progression (change of CTSS or sCTSS over SDC) was decreased in reader 2, whereas increased in reader 1 between score based on CTSS and sCTSS. This may arise from the detection rate of syndesmphyte on lateral side, and which is the most critical limitation of sCTSS. The final limitation is that we did not compare the utility of sCTSS was with that of the mSASSS; this was because most AS patients in the present study did not have lateral view X-rays of the C and L spines at the same time when whole spine CT were taken.This study has several limitations. First, the number of enrolled patients were relatively small. Second, we compared the ICC for readers 1 and 2, even though the sCTSS has not been validated. Third, although the time taken for sCTSS was about half that taken for the CTSS, each whole spine CT still required 15 min. The CTSS was developed at 2018 and was based on a SIAS cohortIn conclusion, the sCTSS detects radiographic progression of AS as well as CTSS, but in half the time and with a better ICC, making it a viable alternative to the CTSS.Supplementary Information.


Psychiatric rehabilitation can be considered a bidirectional technique, designed to allow patients to achieve their personal target, focusing on the individuals’ strengths and challenges related to these targets and also on the community organizations in which they will live them out. Unfortunately, psychiatric rehabilitation is too often not considered a first line treatment. Moreover, rehabilitation has been confused with a generic and rough practice, consisting of extemporary actions and aimless entertainments designed to fill “the time passing”.The aim of this study was to increase the knowledge and awareness about the state of the art of different systems of management and funding of psychosocial rehabilitation in the Italian “real-world” rehabilitative settings, using a specifically developed questionnaire.The data obtained are positive for some aspects of the rehabilitation interventions, in particular for the use of validated tools for the evaluation and revision of projects and for the trend to work on a team, even though the scarcity of evidence-based rehabilitation interventions applied in Italian psychiatric services is less encouraging.This survey presents, at least partially, the “real-world” of rehabilitation in Italy so that we can lay the foundations for the definition of an updated, validated and shared network of what is implemented in the context of psychiatric rehabilitation. In the second half of the 20th century, mental health care in all European and other high-income countries was revolutionized in its structure and conceptualization. Indeed, deinstitutionalization could take place after the introduction of antipsychotic agents in the 1950s and the consequent improvement of the treatment of schizophrenia and other psychotic disorders , 4. HoweThe aim of this study was to increase the knowledge and awareness about the state of the art of different systems of management and funding of psychosocial rehabilitation in the Italian “real-world” rehabilitative settings, using a specifically developed questionnaire.This research project was carried out by the Italian Society of Psychosocial Rehabilitation (SIRP), a scientific society, which aims to promote personal, social, and professional rehabilitation of people with SMI and their families. The Survey was planned in two phases; the first stage (performed around 2014) involved creating a “SIRP Survey Team”, a multi-professional national group composed by members of the Board of Directors of SIRP: professional educators, psychiatric rehabilitation technicians, psychologists and psychiatrists. Firstly they reviewed and adapted the questionnaire and other materials of a previous pilot project carried out in Lombardia to a national reality .The second step occurred between March and May 2015, consisting of the distribution and the collection of the questionnaire. In 2015, SIRP sections were present in 15 Italian regions that were all involved in the project. This operational phase has been characterized in building and sending the project cover letters, in paper and/or digital form, to the regional SIRP offices and then to the Departments of Mental Health of each region. Then the questionnaire was directly presented to the Directors and/or the main contacts of the rehabilitation facilities. Finally, a database was created for the collection and the analysis of data, which needed a further revision to catch incomplete or contradictory data before the definitive investigation, by directly contacting the referring facilities involved, in order to better categorize the rehabilitation activities.The former discussed questionnaire was developed with the aim to investigate rehabilitation activities in Italian MHS; it was composed mostly by closed questions and multiple-choice answers. It included a first descriptive part specifically oriented at depicting the service participating at the survey and a second part, in which single “activity forms” were used to graphically explain each rehabilitative activity. The initial section of the questionnaire was dedicated to the relevant data of the MHS: region, province, Operative Unit, Department of Mental Health, Hospital/Local Health Service catchment area, type of facility, application of the Individual Treatment Plan (PTI) and of the Rehabilitation Therapeutic Project (PTR) , as wellThe project cover letters were sent to the 15 regional SIRP offices and then to the Departments of Mental Health of each region. The final sample was composed by 4.611 institutions in 176 Departments of Mental Health: 1.221 Mental Health Center, 890 Day-time Center and Day Hospital, 2.181 Residential Facilities, 319 Psychiatric Diagnosis and Care Service facilities. The first part of the questionnaire was filled in by the structure heads, whereas the second part by the responsible operator for each activity. The services involved in the survey were then asked to fill in a single form for each structured rehabilitation activity carried out continuously for at least 12 months between 2012 and 2015. Finally, each facility provided a descriptive part of the structure and several activity cards. The method used was non-probability sampling.Summary statistics of the types of facilities and characteristics of the activities performed were expressed as mean (minimum-maximum), or counts and percentage, as appropriate.The Statistical Analysis System Software  was used for the analyses, with the support of the Biostatistics, Epidemiology and Public Health Unit of the Milan Bicocca University.Our survey has represented 10 regions, which were 66.6% of those related to the SIRP in that period. The total number of usable activity forms among the received ones was 2.255 out of 3.553, since they were completed with the description of the rehabilitative activities. Analyzing the MHS response rate we can observe that 41 Departments of Mental Health responded to the survey, equal to 23.3%, with 418 Italian facilities that wrote up the questionnaire, equal to 9.1% of the units part of the Italian Mental Health Departments linked to the SIRP in that period , published in December 2016 by the Ministry of Health. Furthermore, we looked at the percentage of activity forms received according to different types of services: residential facilities collected 49.7% of activity forms, with 1.120 cards , followed by semi-residential facilities, 36.8% with 829 activity forms . Mental Health Centers collected 3.5% of activity forms, with 80 cards, and Psychiatric Diagnosis Care Service collected 0.6% of activity forms, with 13 cards. Finally, Supportive Housing collected 4.3% of activity forms, with 98 cards, and “others facilities” collected 5.1% of activity cards, with 115 cards.The rehabilitation project in Italy is evaluated through the use of tools such as the PTI  drawn up by the Mental Health Centers sending team, and the PTR (Rehabilitation Therapeutic Project), which is a development of the patient’s PTI in rehabilitation facilities, drawn up by the team receiving the patient him/herself . In our Concerning the use of assessment scales, in the facilities performing the evaluation in the Italian regions, 35.4% investigated the psychopathological dimension, 38.9% investigated social functioning and 57.9% investigated other areas of patient functioning. In detail, psychopathological areas were more evaluated in residential facilities (42.2%), whereas social functioning was evaluated with a similar percentage both in residential facilities (46.5%) and in Mental Health Centers – MHC (41.3%). 100% of supporting housing didn’t consider this area. There were found no differences concerning “other areas” that were evaluated, with similar rates in all the facilities.Through the analysis of the questionnaires received, we looked closely at the average number of users involved per session, the place of the activity  and the duration of the activity . Hereinafter there is an analysis of the overall data divided by type of structure. Complete data are available in the Concerning the 2.255 activities examined, the national data showed that 3.5% involved an average of 1 user per session, 21.6% an average of 2 to 5, 41.1% an average of 6 to 10, 25.1% an average of 11 to 20 and 6.7% more than 20. Finally, 2% were missing data see . In partRegarding semi-residential facilities, they include in 43.7% of cases from 6 to 10 users and in 25.1% of cases from 11 to 20 users. Similar data were also observed in the Psychiatric Diagnosis Care Service, which in 61.5% of cases involved 6 to 10 users per session, while in 23.1% of cases it involved an average superior to 20. As regards Supportive Housing, the facilities differed from the other structures: 82.7% of the activities involved 2 to 5 users per meeting.With respect to the place where the activities took place, 60.4% of activities were carried out in the facilities, 32.2% in other places and 0.5% at the patient’s home. The remaining activities were conducted in multiple locations . In particular, 58.8% of the activities of the MHC were carried out outside the facilities, 36.3% indoors and 1.3% at the patient’s home. 63.7% of the activities in the residential structures occurred inside the facilities and 31.6% in other places, just as 59.6% happened in the semi-residential unit (30.4% in other places) and 69.2% of the activities of the psychiatric acute ward (23.1% elsewhere). Always concerning the Supportive Housing, 43.9% of the activities were carried out indoors and 36.7% outside the facilities. The data relating to the patient’s home and other places used can be assimilated for each structure to the overall data . However, concerning semi-residential activities, 54.6% happened continuously, whereas 23.4% occurred cyclically and 17.4% on a temporary basis. Within the Psychiatric Diagnosis Care Service, 53.8% of the activities were carried out continuously and the remainder were conducted for 23.1% on a term or cyclical basis. Furthermore, always with regard to Supportive Housing, 75.5% was carried out continuously and 12.2% at term. A Using the SISM classification , the actFrom the analysis emerged that 18.3% of the described activities were group re-socialization activities and 14.1% aimed at stimulating basic interpersonal skills (group), followed by group expressive skills 12.9 and 12.0% motorial interventions. Practical- craft interventions were 9.9%, whereas basic interpersonal skills  were 6.0%.For the leftover categories see the For each facility involved, it was examined the frequency of activities performed . UnspeciThe analysis also showed that residential facilities employed a group modality in 62.3% of the cases, an individual modality in 18.5% and a mixed modality in 19.2%. Similarly, in semi-residential facilities, where group activities represented 68.4% of the total, individual activities were 14.5% and mixed activities were 17.1%. In the Mental Health Center, group activities were 62.8%, meanwhile individual activities were 19.2% and mixed activities represented 17.9%. In the same way, in Psychiatric Diagnosis and Care Service units groups activities represented 69.2% of the total, whereas individual ones were 15.4% and mixed modality activities were 15.4%. Finally, the Supportive Housing employed in 49.5% of cases a group modality, in 23.7% of cases an individual one and in 26.8% of cases a mixed modality.Proceeding on the investigation, we conducted our analysis using the Survey SIRP workgroup’s list, instead of SISM categories. According to this list, the type of activity most frequently performed in the centers involved in the Survey was the one addressed to the leisure activities management (with 10.7%), followed by activities in support of daily life with 9.5% , physical training activities in the facility  and expressive techniques with 8.3%. Furthermore, it shows that craft workshops represented 6.6% of the activities, meanwhile writing stories media represented 6.4% and cooking represented 6.3% of the total. For the remaining activities see Concerning each activities, we examined the number of the operators involved, their frequency and their carrying out modality . Analyzing the data of the 2.255 cards related to structured activities, it emerged that 13.8% of them referred to evidence-based activities (355 cards). Evidence-based activities were recognized in literature with a clear evidence of efficacy , 19, 41;The Survey outlines what has been implemented in Italy in terms of rehabilitation, albeit partial due to the spontaneous participation in the project: only 23.3% of the Italian Psychiatric Departments SIRP-related has attended. Since there’s nothing similar to this research in Italian psychiatric literature, this datum seems to be very significant. Considering the data collected from this partial presence of psychiatric services, it emerged that most of the facilities involved were residential (49.7%), whereas rehabilitation-focused facilities  were 36.8%.In order to make the project reliable, shareable and repeatable, it was necessary to use efficient tools to conduct the analysis and to continuously review it , 55, 56,Concerning individual activities, 6% of them aimed at stimulating interpersonal skills, 0.8% to social inclusion, whereof 4.7% of the projects were oriented to job placement and 3% were activities that also included family members. These small percentages are likely a consequence of the lack of staff resources, since these activities should be carried out individually , 60. TheAs regards the location in which they took place, 60.4% of the activities were carried out inside the structures, whereas 20 to 35% outside. More than half of all the activities (61.5%) were developed within the structures continuously. These data are demonstrative of what in Italian rehabilitation keeps to lack: the percentage is still too low, since a great part of rehabilitation imply that most of the activities should be carried out in external contexts and in places that are part of the patient’s daily life , 64. As These data were extrapolated by the cards received, in which all rehabilitation activities were listed by the SIRP group: the majority came from residential and semi-residential facilities (62.5%).Considering the supplied material, the survey cards of the rehabilitation activities appeared understandable in its objectives, being complete and accessible. The abundance, completeness and pertinence of the answers obtained entailed also a comment on the clarity and relevance of the elaborated questions, which had been designed to leave a certain freedom of choice and expression to the compilers, that in this specific survey were the operators conducting the activities. This has allowed us to obtain an important amount of useful information to understand what is actually being done in the national rehabilitation reality, beyond the standardized definitions, established protocols and evidence of effectiveness.Despite these strengths our study presents some limitations. The open-answer questions did not provide the categorization required for each activity, in order to allow a precise quantitative and qualitative definition of the described rehabilitation interventions. A critical point emerged in relation to the categorization of rehabilitation activities: for each of them it was necessary a free and open description, a codification by category, and a codification by SISM type. It was done to better define the detection of the activities that were carried out. Despite this, some inconsistent data appeared, which in some cases required telephone interviews with the operators who had completed the form and the revision of the database. The last matter to consider concerned the spontaneous and voluntary involvement in the project. Despite the participation was active, well received and interesting for the participating facilities, this manner of participation in the project obviously offered a lack of data, since this work is considered a survey and not a census.This survey on the rehabilitation activities in the Italian psychiatric services had the objective of outlining the state of the art of psychosocial rehabilitation in our country, taking into account that the participation of Italian facilities in this study was spontaneous and voluntary and therefore it can not represent a real and true census. Surely, it is useful to remember, that to date, there was no Italian data related to the subject of this thesis: the rehabilitation practices applied in the services are little known or shared, with the exception of some centers of excellence, which publish evidence from their own research protocols. With this survey we intended to present, at least partially, the “real-world” of rehabilitation in Italy so that we can lay the foundations for the definition of an updated, validated and shared network of what is implemented in the context of psychiatric rehabilitation. In fact, scientific research in the psychosocial field needs to be encouraged and implemented and requires the creation of a database involving the main active facilities. From the previously analyzed data, it emerges the need for greater dissemination even in non-university centers, of a rehabilitation based on evidence and proof of effectiveness, to integrate with other treatments in psychiatry, as suggested by several authors regarding personalized, effective and measurable treatment interventions . When weThe study highlights how there are still important gaps in the sharing and employment of rehabilitation evidence-based practices in the national context and it underlines the need for new and further training among mental health workers in the field of psychiatric rehabilitation. In this regard, SIRP recently published a document on good practices and recommendations to keep in mind, with the ultimate goal of spreading the most current knowledge in this complex area .The original contributions presented in this study are included in the article/CV, SB, and AV: conceptualization, methodology, and supervision. CA, DB, LF, AG, FR, and CV: data curation. CV and FR: investigation. CA, SB, DB, CV, and AV: writing, review and editing. All authors contributed to the article and approved the submitted version.


Twice daily 0.1% mometasone furoate is an effective treatment for phimosis in children. However, mometasone furoate has an important therapeutic advantage because it is effective in once-daily applications. This study was to compare the efficacy of two different topical 0.1% mometasone furoate regimens for the treatment of symptomatic severe phimosis in pediatric patients.A total of 1,689 patients with symptomatic severe phimosis classified by the Kikiros system were prospectively enrolled in the study from March 2018 to February 2021. A total of 855 patients received 0.1% mometasone furoate twice-daily (BID group) and 834 patients received 0.1% mometasone furoate once-daily (QD group) for 4 weeks.P < 0.05), while there was no difference in the success rate at 4 weeks and 3 months between the two groups  (P > 0.05). In both treatment groups, the success rate of grade 5 phimosis was lower than that of grade 4 at 2 weeks, 4 weeks, and 3 months. A total of 83 patients experienced recurrence of phimosis. Only fifteen patients had local mild adverse drug reactions.A total of 1,595 boys completed the treatment . The success rate of the BID group was higher than that of the QD group at the end of week 2 (44.8% vs. 33.3%, Topical application of 0.1% mometasone furoate once-daily or twice-daily for 4 weeks had comparable efficacy in children with symptomatic severe phimosis. A once a day regimen may be more suitable for children. Topical steroid application is more effective in children with low-grade phimosis than those with high-grade phimosis. Phimosis, the inability to retract the foreskin over the glans penis, occurs in 96% of all newborn males . Most caIn China, circumcision has been a popular treatment choice for phimosis. However, circumcision is a costly invasive procedure that is associated with complications such as infection, bleeding, urinary retention, and recurrent phimosis, among others . TherefoThe efficacy of steroids for the treatment of phimosis has been widely studied and documented, with most studies advocating the use of topical steroids twice daily , 5. A feThis was a prospective observational study. The study was approved by the institutional review board of our institution (2017109). Between March 2018 and February 2021, a total of 1,689 boys with symptomatic SP were referred to our institution, and children that received 0.1% mometasone furoate once-daily or twice-daily were included in the study. Grading of phimosis was conducted as described by Woodward and Kikiros , with atThe decision for once- or twice-daily treatment was based on the specific date of visit (once daily for odd days and twice-daily for even days). Informed consent was obtained from the parents/guardians of all patients prior to steroid treatment. A total of 855 patients were administered 0.1% mometasone furoate twice daily (BID group) and 834 patients were administered 0.1% mometasone furoate once daily (QD group) for 4 weeks . In the The outcomes of the steroid response were classed as follows: success was defined as downgrading of phimosis to grade 0–1, minor response was defined as downgrading of phimosis to grade 2–3, failure was defined as no decrease in phimosis grade, and recurrence was defined as phimosis grade 0–1  at week All patients were assessed at 2 weeks, 4 weeks, and 3 months after initial treatment. Patients with successful outcomes at 2 and 4 weeks were advised to try to gently retract the prepuce daily and reassessed 3 months after the initial treatment.t-test. Statistical significance was set at P < 0.05.Statistical analyses were performed using SPSS version 22.0. Categorical variables were evaluated using the chi-square test, whereas continuous data were analyzed using the Student's A total of 1,595 boys completed the treatment . Ninety-four patients were excluded from the final analysis; 57 patients in the BID group due to loss to follow-up (41 patients), study withdrawal (8 patients), and steroid side effects ; 37 patients in the QD group due to loss to follow-up (24 patients), study withdrawal (6 patients), and steroid side effects . The age range was 1.9–13.2 years. The median age was similar between the groups (57 months in the BID group vs. 58 months in the QD group). The number of patients with balanoposthitis, dysuria, UTI, hematuria, or foreskin bleeding in the BID group was 246, 222, 175, 21 and 134 respectively. The number of patients with balanoposthitis, dysuria, UTI, hematuria, or foreskin bleeding in the QD group was 238, 230, 181, 19 and 129 respectively. The patient outcomes are summarized in P > 0.05).At the end of week 2, there was a 44% (358 of 798) response rate (phimosis of grade 0–1) in the BID group and 33% (266 of 797) response rate in the QD group. There was no statistical difference in the success rates between the two groups at 4 weeks and 3 months  (P < 0.05). There was no significant difference in the success rates of grade 4 and 5 phimosis between the two groups at 4 weeks and 3 months. The success rate of grade 5 phimosis was significantly lower than that of grade 4 phimosis at 2 weeks, 4 weeks, and 3 months  underwent circumcision between 4 weeks and the last follow-up from the initiation of therapy. A total of 1,528 cases were reevaluated at 3 months; 83 cases (5%) had recurrence of phimosis (39 in the BID group and 44 in the QD group).Active treatment is recommended for children with symptomatic phimosis . In thisThe success rate in our study was 65.8%, which was lower than the 67%–95% success rate reported in many studies . This maTopical application of 0.1% mometasone furoate once daily for 4 weeks is an effective treatment for SP in children. Although twice-daily regimens have been widely used to treat phimosis, there was no difference in the therapeutic effect between the two groups (once-daily vs. twice-daily) at 4 weeks and 3 months in our study. There are three potential reasons for the successful treatment of phimosis in the QD group. First, 0.1% mometasone furoate is a high potency corticosteroid that is used once daily to treat diseases in clinical practice . Indeed,The success rate of the QD group was significantly higher than that of the BID group from 2 weeks to 4 weeks of treatment (36.4% vs. 25.9%). This may be because many cases in the QD group were downgraded to grade 2–3 phimosis after the first two weeks of treatment, but they had not reached the success standard. Continuation of treatment to four weeks results in drug accumulation, increased elasticity of the foreskin and the skin, and improved efficiency. Changole et al.  reportedThe present study showed that the success rate of topical steroids in the treatment of phimosis was positively correlated with the application time, which was consistent with the results reported by Zavras et al. . AlthougThe success rate of grade 4 phimosis was higher than that of grade 5 phimosis in this study. This may be because grade 5 phimosis is more serious than grade 4 phimosis, and therefore requires a stronger treatment effect to achieve grade 0–1 phimosis. Similarly, Esposito et al.  found thRecurrence is a common problem in the treatment of phimosis with topical steroids. It is reported in the literature that the recurrence rate of phimosis after topical steroids treatment is 4.0%–34% –22. Ku eThis study had several advantages. First, it examined the efficacy of topical steroid therapy in a large cohort of children with SP. Second, the study design was prospective. Third, we compared different frequencies of daily topical steroid treatment for SP. Both regimens used in the present study were equally effective. Finally, the cost of 0.1% mometasone furoate cream in the treatment of phimosis was significantly lower than that of circumcision. In the Chinese mainland, the cost of one tube of 0.1% mometasone furoate cream is 8.5 RMB (about 1.258 USD); children in this study used up to two tubes of ointment, which is significantly lower than the cost of circumcision . Nevertheless, this study had some limitations worth noting, including the lack of long-term follow-up data, and the lack of comparison with a placebo group. In addition, the diagnosis of symptomatic SP and subsequent outcome assessed by the same clinician may cause bias in the results of assessment. However, the assessment of diagnosis and outcomes were strictly carried out according to the criteria of Woodward and Kikiros classification to reduce the possibility of result bias.This study showed that the clinical efficacy of 0.1% mometasone furoate in the treatment of SP is related to the duration of treatment, total dosage, and phimosis severity. The once-daily or twice-daily regimen for four consecutive weeks achieved satisfactory results. The once-daily regimen may be more advantageous for children whose guardians can only apply the steroids once daily.


PurposeThis retrospective study aims to analyze the clinical and functional results obtained over a seven-year period of performing reverse total shoulder arthroplasty (RTSA) and the subsequent postoperative rehabilitation protocol.MethodsWe analyzed data from 80 patients who were evaluated at a preoperative, as well as monthly postoperative outpatient consultation, until the discharge from the rehabilitation program, using Constant Score (CS).ResultsA comparison of preoperative and postoperative (after rehabilitation protocol) results revealed an improved functional score of absolute CS (20.8 increase), normal relative CS (29.1 increase), and individual relative CS (31.7 increase) with statistical significance (p<0.05). From the analysis of CS subscores, there was a positive evolution of the pain subscore, as well as flexion, abduction, and external rotation combined with abduction range of motion (ROM). Contrarily, there was a negative evolution of the combined internal rotation, extension, and adduction ROM, as well as deltoid muscle strength. No statistically significant correlations were found between age and postoperative CS, as well as between the time interval from surgery to the beginning of outpatient rehabilitation and CS evolution.ConclusionOur study demonstrates that RTSA is an effective therapeutic option that, if combined with a well-structured rehabilitation program, can improve pain, mobility, and upper limb functionality. Shoulder pathology is common worldwide, representing a growing concern for the elderly, workers, and athletes . ReverseFrom a biomechanical point of view, in RTSA, the center of rotation moves medially and inferiorly, increasing both the deltoid muscle lever arm and the recruitment of its anterior and posterior fibers . These cIn our hospital, RTSA is considered in the diagnoses described above when shoulder pain persists and upper limb functionality is compromised despite conservative treatment. For this purpose, clinical assessment through Constant Score (CS) proves to be very useful. CS is a validated and consensual functional shoulder assessment tool and is recommended by the European Society for Surgery of the Shoulder and the Elbow and British Elbow and Shoulder Society . RegardiGiven the increasing use of RTSA at our hospital, the Physical Medicine and Rehabilitation (PMR) and Orthopedics departments have jointly developed a rehabilitation protocol  aimed toThe aim of this study is to analyze the clinical and functional results obtained in a seven-year period of application of RTSA and the subsequent postoperative rehabilitation protocol developed in our hospital.This retrospective study included 80 patients who underwent RTSA surgery with consequent integration in the RTSA rehabilitation protocol at Centro Hospitalar de Entre o Douro e Vouga, from August 1, 2011, to November 31, 2018 [Both the rehabilitation protocol and the data collected from the functional assessment through the CS are performed as usual clinical practice at our institution. Therefore, patients are evaluated preoperatively with CS  in order to determine the previous functional state of the shoulder joint, as well as transmit and manage expectations of recovery to the patient. In the early days of the postoperative phase, still in the orthopedics hospitalization, patients are evaluated by a PMR physician for their inclusion in the rehabilitation program. This visit allows the teaching of recommended postoperative care, such as the avoidance of movements that cause prosthesis dislocation and Codman pendulum exercises. It also enables the prescription of rehabilitation treatment (according to the rehabilitation protocol ), to staStatistical analysis of the data was performed using the Statistical Package for Social Sciences (SPSS) software version 20.0 . For the comparison of preoperative and postoperative CS values, as well as for its different subscores, we used the paired sample t-test. To analyze the correlations between age and postoperative CS, as well as the time interval from surgery to the beginning of the outpatient rehabilitation program and the CS evolution, Pearson’s correlation coefficient was used. A 5% significance level was adopted in all statistical tests. Thus, statistically significant associations were considered when the p-value was less than 0.05.All authors reviewed and approved the final manuscript. This study was also reviewed by our institutional ethics committee, which waived the need for approval and informed consent due to the retrospective nature of the investigation.Between August 1, 2012, and August 1, 2019, 80 patients undergoing RTSA at our hospital were included in the study, with a mean age of 69.2 years. Of these, 55 (68.8%) were female and 25 (31.2%) were male. Forty-eight  patients underwent right shoulder RTSA and 32 (40%) underwent left shoulder surgery. No patient in this study underwent surgery on both shoulders during the follow-up period, although 23 patients (28.8%) had contralateral shoulder pathology , proximal humeral fracture in 21 (26.6%), glenohumeral arthropathy secondary to rheumatoid arthritis in 4 (5.1%) and revision of arthroplasty in two patients (2.5%) (Table The mean time from surgery until the start of the outpatient rehabilitation program at the PMR department was approximately 25 (± 11) days. The mean duration of the rehabilitation program was 139 (±56) days. Analyzing according to the preoperative diagnosis, there was a higher mean duration of the rehabilitation program in patients with a humeral fracture (186 days) as compared to the other groups (124 days), with statistical significance in the test (p <0.05).Regarding the preoperative evaluations of the CS, a mean of absolute CS of 36.9 (± 13.3), normal relative CS of 52.0% (± 19.5), and individual relative CS of 52.4% (± 19.7) were observed  of pain subscore, as well as flexion, abduction, and external rotation combined with abduction range of motion. On the other hand, a negative evolution of the deltoid muscle strength and the combined internal rotation, extension, and adduction range of motion were observed. However, these latter results were not statistically significant Table .No statistically significant differences were found regarding the correlation between age and postoperative CS. In addition, there was no statistically significant difference between the time interval from surgery to the beginning of the outpatient rehabilitation program (less than or greater than 20 days) and the CS evolution.From the analysis of the results of the application of the RTSA protocol, the favorable functional evolution of the patients after its application is highlighted. This can be inferred from the statistically significant increase, at the time of discharge from the rehabilitation program, of the postoperative CS values compared to the preoperative values. In fact, although this prosthesis was initially used in elderly patients (aged 76-89 years), a growing number of publications describe its use in considerably younger patients -15. ThisFrom the evaluation of the CS subscores, the pain subscore stands out as the one with the highest evolution, followed by the level of hand activity. In terms of mobility, we found a statistically significant improvement in flexion, abduction, and abduction combined with external rotation range of motion. These results are in agreement with the existing literature, which shows an improvement in pain, as well as a progression of flexion and abduction mobility after RTSA, due to the increase of the lever arm and consequent optimization of deltoid muscle function . HoweverAccording to the analysis of the existing literature, there is a lower magnitude evolution than the results described in this article ,24-26. TWith regard to the negative evolution of the internal rotation, extension, and adduction combined movement, this can be interpreted by restrictions inherent to the biomechanics of these prostheses and the fact that it constitutes its luxant movement ,28. ThisConcerning the strength subscore, negative evolution is not completely defined in the literature . HoweverFrom the analyzed scientific literature, we did not find references to the mean times of RTSA rehabilitation programs according to the preoperative pathology. Nevertheless, in this study, we found a longer rehabilitation time for fractures. This find may be related to the longer immobilization time to which these patients are subjected, with the consequent delay in the rehabilitation program progression.Study limitationsThis study has some limitations, namely, its retrospective nature, which affects its reliability. Additionally, the non-use of absolute values in the range of motion evaluation may have implications on the evolution of scores since the presence of wide ranges may condition lower responsiveness. Compared to the studies evaluated, in the present study no instruments of satisfaction, quality of life, or participation were used, which limits the conclusions to be drawn. According to Samitier et al., RTSA is a surgical procedure with high patient satisfaction, regardless of the type of prosthesis or surgical indication . FinallyRTSA is an increasingly common therapeutic option in cases of glenohumeral arthropathy resistant to conservative treatment, and its indications have increased over time. Given the increasing use of this surgical approach at our hospital, the Physical Medicine and Rehabilitation and Orthopedics departments aimed to standardize and improve the approach of these patients. Our study demonstrates that RTSA is an effective therapeutic option that, when combined with a well-structured rehabilitation program, can improve pain, mobility, and upper limb functionality.


The increase in the number of elderly patients with degenerative diseases has brought additional medical and financial pressures, which are adding to the burden on society. The development of sports rehabilitation robotics (SRR) is becoming increasingly sophisticated at the technical level of its application; however, few studies have analyzed how it works and how effective it is in aiding rehabilitation, and fewer individualized exercise rehabilitation programs have been developed for elderly patients. The purpose of this study was to analyze the working methods and the effects of different types of SRR and then to suggest the feasibility of applying SRR to enhance the physical abilities of elderly patients with degenerative diseases. The researcher’s team searched 633 English-language journal articles, which had been published over the past five years, and they selected 38 of them for a narrative literature review. Our summary found the following: (1) The current types of SRR are generally classified as end-effector robots, smart walkers, intelligent robotic rollators, and exoskeleton robots—exoskeleton robots were found to be the most widely used. (2) The current working methods include assistant tools as the main intermediaries—i.e., robots assist patients to participate; patients as the main intermediaries—i.e., patients dominate the assistant tools to participate; and sensors as the intermediaries—i.e., myoelectric-driven robots promote patient participation. (3) Better recovery was perceived for elderly patients when using SRR than is generally achieved through the traditional single-movement recovery methods, especially in strength, balance, endurance, and coordination. However, there was no significant improvement in their speed or agility after using SRR. Currently, the global population is aging. In many countries, life expectancy has increased to 70 years or more. For the first time in history, in 2020, the number of people aged 60 or older exceeded the number of children under five years old, globally. Furthermore, over the coming decades, the greatest increase in aging will occur in developing countries . As one The excessive aging of the population will lead to various social problems, such as a lack of economic growth, overburdened public finances, and a sharp increase in the cost of medical care, with medical care becoming the main social burden. As elderly people age further, their physiological functions deteriorate and their physical abilities decline, to some degree . PhysicaMost of the previous review papers have been organized and analyzed for the types of rehabilitation robots or their working principles. The novelty of this review is to analyze and compare how different rehabilitation robots work and how effective they are in restoring the physical abilities of elderly patients with degenerative diseases, focusing on the ways in which locomotion-based rehabilitation robots help patients to restore their physical abilities and their effectiveness.This paper compiles and analyzes the studies related to the high level of motor rehabilitation robots that are being used to promote physical activity in the elderly; compares the advantages and shortcomings of different types of motor rehabilitation robots, in terms of their working methods and their effects; and then proposes feasible suggestions for the application of motor rehabilitation robots in enhancing the physical abilities of elderly patients with degenerative diseases.The scope and review of the literature search followed the EQUATOR guidelines, which improve the quality and transparency of research. We ensured that articles related to rehabilitation robots were searched for rather than articles related to rehabilitation and robots, separately. Five databases were searched using the PRSIMA for Protocols guidelines: (1) Web of Science; (2) Engineering Village; (3) Science Direct; (4) the online library, Wiley; and (5) Scopus.The search was conducted using a Boolean logic combination search for keywords, including the following: ‘rehabilitation robotics’, ‘physical activity, ‘human–robot interaction’, ‘rehabilitation training’, ‘robotic therapy’, ‘assistive technology’, and ‘older people’.First, a total of 633 articles were obtained from the literature search across the five databases, published over the last five years (2018–2022). In total, 23 duplicate articles were deleted; 134 articles with non-relevant articles were excluded; and 6 articles that could not be downloaded through various sources were deleted. A total of 470 articles were obtained after this screening.Second, 70 of these articles were read in full. They were chosen out of the 469 articles by screening the titles and abstracts. The last five researchers further screened the remaining 70 articles by reading the full text of the articles separately, and the articles that included conference reports, literature reviews, the introduction of a technology principal, and those that did not contain an experimental design, were excluded. The screening flow chart is shown in When disagreements arose, a sixth author participated in the discussion, until a consensus was reached among them. At the end of this process, 38 qualitatively published articles  were eveIn the context of global aging, the risk of diseases in the elderly increases as their age advances; therefore, there is a growing demand for robot-assisted motor rehabilitation technology in society. Robot-assisted rehabilitation has, thus, become a prominent research topic, with broad application prospects . CurrentMost of the communication between devices and users is currently achieved through human–computer interaction systems; however, current human–computer interaction methods usually only have one of these functions, and only the elderly communicated instructions to the robot, meaning that there is no way to obtain feedback from the environment and to adapt to the behavior of the elderly user, accordingly . The desSince the operating object of the sports rehabilitation robot is a human, its performance must meet the requirements of adaptability to individual differences and environmental changes, fluency of human-machine interaction, safety in the face of abnormal situations, and adaptability to human physiology and psychology, thus putting higher requirements on the accuracy, reliability, and intelligence level of the control system.Therefore, the current system of sports rehabilitation robots integrates research fields—such as artificial intelligence, human–computer interactions, and machine learning technology—to achieve intelligent, humanized, and accurate rehabilitation assistance . ElderlyCompared with the traditional manual, assisted rehabilitation training, robot-assisted motor rehabilitation and neurological rehabilitation training has unique advantages. Firstly, sports rehabilitation robots can provide high-intensity and repeatable rehabilitation training. Once popularized, they will be able to greatly relieve the pressure on the level of staff input in rehabilitation institutions and will be able to reduce the workload of clinical rehabilitation physicians. However, a more prominent advantage is that robots can provide flexible and precise rehabilitation training, which can enhance the effectiveness of patients’ rehabilitation. The main example of this is that the rehabilitation robot can combine modern multimedia and interactive technology in patients’ training to stimulate their interest and enthusiasm in participating in the rehabilitation training, and to mobilize their awareness and ability to actively participate in the training, which, thus, promotes the recovery and compensation of patients’ neurological functions .At the same time, the sports rehabilitation robot can also combine sensor technology with multiple modalities to accurately detect changes in a patient’s physical condition in real-time and then use these data to adjust rehabilitation training strategies . ResearcDegenerative diseases can have an impact on the physical abilities of strength, agility, balance, endurance, coordination, and speed for elderly patients. In particular, they can lead to limb dysfunction and to the inability to perform basic physical activities. Different types of sports rehabilitation robots have emerged in the market to assist with the dysfunction of different parts of the human body. These robots meet the different rehabilitation needs of patients through their range of different working methods to help restore limb functions and to return the patient to normal life.According to the results of our literature analysis and according to previous classification methods , we founAmong the robots used for upper limb function recovery is the QM-FOrMS, a portable and cost-effective upper limb rehabilitation system. The system is able to give some exercise instruction to help patients perform active upper extremity activities; however, it only provides a small amount of assisted strength, which is a limitation for patients with low levels of physical ability .This system, first proposed by Lin (2016), advocates the acquisition of EMG signals from the patient’s upper limb muscle groups to identify their motor intent and drive them to active training in order to complete the training task, through a combination of electrical stimulation and robot-assisted technology . It is eThe end-effector robot uses assistive devices to assist in the movement of more than 20 free flexible joints in the hand, which helps patients to record the recovery process of their small muscles and nerves, and helps them, to a certain extent, to achieve dexterity and coordination in their hand functions. For example, REO-GO includes a telescopic arm and a screen, and offers different movement therapy modalities, according to the patient’s motor ability and motivation. This robot has two types of handles, spherical and platform, and places EMG electrodes on the patient’s upper limbs to record their muscle activity . In a liUnlike the two types of robots discussed above (the upper limb rehabilitation system and the end-effector robot), the smart walker is a lightweight robotic assistive device. It is intended as a lower limb function recovery robot. It can provide support and assistance to patients and can improve their autonomy and the effectiveness of their rehabilitation work. In addition, it also has a certain degree of safety and does not restrict the range of motion in the patient’s joints or their amplitude, which allows the patients maximum freedom . For eldThe intelligent robotic rollator, e.g., i-Walk, is an integrated set of sensing, navigation, and user–robot interaction modules, which are designed in such a way as to enable the real-time operation to support the envisioned user-assisted functions . They arThe researchers believe that the greatest advantage of this type of robot is its high intelligence—it not only has a verbal human–computer interaction system, but also recognizes the patient’s commands and feeds the language back into the system to recognize and respond to the patient’s intentions. It breaks through the limitations of the support provided by assistive devices and takes the patient as the main intermediary by incorporating the patient’s intentions into a functional rehabilitation training program in order to achieve a holistic improvement in the patient’s physical and cognitive abilities.The research on this topic generally agrees that robotic exoskeletons are one of the most-used motor rehabilitation robots in the rehabilitation field today . ThroughThe research in and the development of the technology for exoskeleton rehabilitation robots are currently more mature than they are in other areas. Consequently, there are not only local joint rehabilitation assistance robots, but also full-body, wearable exoskeleton robots. This connects to the individual patient in a wearable way and has multiple points, and, because its joint axis matches human joints, it can control the movement of all the patient’s joints and can therefore train muscles in specific areas during the rehabilitation training. Furthermore, it can also provide corresponding training for patients with limb dysfunction to help restore the working ability of their limbs . At presCompared with the first four types of robot-assisted technology discussed in this paper, the current challenges in robotic exoskeleton research and development are as follows: (1) its rigid structure and multi-link design affects the freedom of movement in a patient’s joints—a patient can only execute the angle and speed that has been fixed for their training method; (2) spending a long time repeating single action exercises could easily trigger other parts of a sports injury and, thus, the function of other parts of the body could be weakened; and (3) it is a non-intelligent functional system, which is unable to follow up a patient’s rehabilitation progress in a timely manner or adjust the movement strategy.The working methods of motor rehabilitation robots can be divided into three categories: assistant tools as the main intermediaries, the patient as the main intermediary, and the sensors as the intermediaries.The robots in which the assistant tools are the main intermediaries focus on stimulating the patient’s motivation for rehabilitation and on guiding the patient to carry out their rehabilitation training. The robots in which the patient is the main intermediary are mainly controlled by the patient’s will and they help the patient to complete their rehabilitation training movements. In the robots in which the sensors are the main intermediaries, myoelectric sensors automatically identify the patient’s rehabilitation needs and make the rehabilitation process more intelligent. Patients can choose the right exercise rehabilitation robot, according to their needs and to the different stages of their rehabilitation to improve its efficiency.Assistant tools, as the main type of rehabilitation robot, consist of software and hardware tools and generally include not only the robot, but also a rehabilitation system, which work in conjunction with each other. Because there are different types of assistive rehabilitation, the robots’ components have different characteristics, and their working methods vary accordingly. Usually, each component is directed towards the device’s function to guide the patient through their motor rehabilitation.As described above , the uppUsing this information, the rehabilitation robot actively constructs an inverse dynamic model to precisely calculate and control the starting friction, motion friction, and motion compensation force of the patient’s affected limb, laying the foundation for the subsequent development of the treatment plan . MoreoveThis type of approach can restore the medical staff’s motor rehabilitation purpose to a greater extent and does not negatively affect the final rehabilitation of the patient if the they choose to make a change in the rehabilitation’s movement trajectory, or if they decide to abandon the program due to the patient’s pre-control or insufficient motivation. The FELXO-Arm1 rehabilitation system and the ULRR upper limb assisted robot can personalize the activity parameters according to patients’ different needs and abilities, for example, by including the patients’ background complexity, the running speed, the training time, the background music. These factors can effectively cultivate patients’ motivation for active rehabilitation and can therefore enhance the rehabilitation results.The patient-oriented motor rehabilitation robot is mainly patient-controlled, and the rehabilitation robot is manipulated to perform rehabilitation activities according to the patient’s wishes, and with the help of the robot’s functions. For example, the REO-GO upper limb rehabilitation robot first uses a platform to stabilize the patient’s upper limb, and then relies on the patient to actively apply grip force to the handle, after which the robot assists the patient in achieving the free movement of their upper limb . SimilarThe whole-body exoskeleton robot, FB-AXO, connects the upper and lower systems through the lumbar and spine modules. Patients with muscle weakness can remain standing with the external assistance provided by the whole-body exoskeleton robot and they can therefore actively operate the robot to complete the physical activities set in the rehabilitation training program. Ultimately, this enables them to achieve the purpose of their rehabilitation .The motion rehabilitation robot mainly targets elderly patients and can help them with their personalized physical activity exercises, under the active operation of the patient. These robots can supplement the patient’s subjective rehabilitation and the corresponding parts of their rehabilitation treatment. They can also allow the patient to perceive the recovery of their corresponding body parts through the feedback that they provide. The patients’ choice of an appropriate physical activity program (a choice offered by these robots) is also important for their subsequent rehabilitation. Therefore, this patient-led rehabilitation robot only provides external assistance, which maximizes the patient’s initiative in the rehabilitation process, unlike the robot-led rehabilitation approach, which requires patients to passively receive their rehabilitation treatment .Robots in which the sensors are the intermediaries have a significant impact on the way that the motor rehabilitation robot acts . In addiWith the sensors as the intermediaries, the data obtained by using EMG to observe the actual recovery of the patients will be more quantitative and objective than the data obtained through the observation of medical personnel and through personal perception. The use of a myoelectric drive to control the rehabilitation robot enables the patient to execute the rehabilitation movements precisely and enables the maximum possible fit with the patient’s rehabilitation wishes. Moreover, it also perfectly demonstrates the effectiveness of the medical rehabilitation program. Of course, how best to use myoelectric-driven rehabilitation robots to assist elderly patients with precise limb rehabilitation activities will become a major research focus in the future.Traditional exercise rehabilitation programs are designed to focus on the characteristics of the patient’s disease and do not pay enough attention to the physical and mental characteristics and to the individual differences of the elderly patients . For fraMoreover, the study showed that the exercise rehabilitation robot assisted elderly patients with degenerative diseases. It was found that they exhibited a better recovery of their strength and endurance and a significant improvement in their balance and coordination. However, no significant improvement in their agility or speed was observed. The main areas of the body targeted by the different types of rehabilitation robots and their effects are shown in Strength is the basis of all physical activities, and the elderly generally show a gradual weakening of muscle strength as they age. Resistance training is the main way to help the elderly restore muscle strength . HoweverBalance and gait disturbances are common manifestations of dysfunction in older adults as they age. Professionals need to accompany elderly patients during the exercises necessary for their balance and coordination training, in order to reduce or avoid falls and sports injuries. This requires a significant amount of human and material resources . In contAgility is a unique physical ability that has not received much attention from rehabilitators, and, thus, there are very few agility training methods for improving the agility of older patients . To someCurrently, sports rehabilitation robots use clinical measurement scales to assess whether patients’ functional improvement is significant after receiving the intervention. However, due to the different nature of the ordinal scales used for taking the measurements and their lack of sensitivity in detecting subtle changes in the patient’s exercise performance during the assessments, future studies will need to use specific instruments—such as electromyography and kinematic analysis—to accurately assess the effects of the interventions on the exercise performance and on the motor unit recruitment . BecauseStudies have confirmed that patients with physical dysfunction can recover considerably with the aid of a sports rehabilitation robot . This stExisting sports rehabilitation robots can provide high-intensity, repeatable rehabilitation training for patients, which can greatly relieve the pressure on staff input in rehabilitation facilities, and can reduce the workload of clinical rehabilitation practitioners. However, compared to professional rehabilitation physicians, sports rehabilitation robots are not able to accurately determine a patient’s recovery or their motivation to recover, based on the patient’s response and physical state, nor are they able to adjust the rehabilitation arrangements in a targeted manner. It is suggested that future sports rehabilitation robots should combine modern multimedia interactive technology to stimulate patients’ interest and enthusiasm in participating in rehabilitation training; to mobilize their awareness and ability to actively participate in training; and to combine multiple modal sensor technologies to achieve intelligent recognition of patients’ physical status and intentions, while having the ability to adjust the rehabilitation plans in a targeted manner.The service object of a sports rehabilitation robot is a human being, and its user experience determines its value. Because the design of the sports rehabilitation robots mainly uses a mechanical multi-link structure, manufacturing is based mainly on alloys, carbon fiber, and other rigid materials. This results in a poor wearing experience for the user, as the prolonged use of a fixed mechanical structure to carry out activities affects the flexibility of the other joints, making it easier for them to sustain sports injuries. It is hoped that the future development of sports rehabilitation robots will include flexible materials to improve the user’s comfort when wearing the devices, based on considerations of safety and support.Robot-assisted technology is of great significance for the rehabilitation of the elderly. Sports rehabilitation robots can assist in the enhancement of the physical ability of elderly patients with degenerative diseases, thus, their development and application will have a significant practical value.The current types of SRR are generally classified as end-effector robots, smart walkers, intelligent robot rollators, and exoskeleton robots—exoskeleton robots are the most widely used. The working methods of these SRR include the following: (1) assistant tools as the main intermediaries—e.g., the robots assist the patients in participating with their rehabilitation; (2) patients as the main intermediaries—e.g., patients dominate the assistant tools to proactively participate in their rehabilitation; and (3) sensors as the main intermediaries—e.g., myoelectric-driven robots promote patient participation. The robot-assisted rehabilitation method is better than the traditional single-motion recovery method, and the elderly patients’ strength and endurance can be better restored through this. In addition, their balance and coordination can also be significantly improved. However, there was no significant improvement in the elderly patients’ agility or speed when they were assisted by these robots.With the continuous innovation of human-computer interactions, the Internet of Things, artificial intelligence, new materials, robot simulation, and other technologies, the sports rehabilitation robot needs to be further improved through the development of assistive technology, intelligent recognition, user perception, and other technologies, to bring new developments into the field of medical rehabilitation . Crucial


The COVID-19 pandemic created the need for telerehabilitation development, while Industry 4.0 brought the key technology. As motor therapy often requires the physical support of a patient’s motion, combining robot-aided workouts with remote control is a promising solution. This may be realised with the use of the device’s digital twin, so as to give it an immersive operation. This paper presents an extensive overview of this technology’s applications within the fields of industry and health. It is followed by the in-depth analysis of needs in rehabilitation based on questionnaire research and bibliography review. As a result of these sections, the original concept of controlling a rehabilitation exoskeleton via its digital twin in the virtual reality is presented. The idea is assessed in terms of benefits and significant challenges regarding its application in real life. The presented aspects prove that it may be potentially used for manual remote kinesiotherapy, combined with the safety systems predicting potentially harmful situations. The concept is universally applicable to rehabilitation robots. Often, ideas about the future include the ability to control objects over long distances, visiting shops without leaving home, interactive, engaging games or meetings with loved ones anywhere and anytime thanks to a remote connection . Within The paper aims to present the current uses of the digital twin technology and assess its applicability for home remote motor therapy. The chosen cases are based on the best practices, and not necessarily limited to medicine. They were selected in the process of an in-depth literature overview. Only the most popular and technologically advanced of each type were elaborated on to reduce the number of the presented solutions.In the process of the literature overview, 64 relevant original papers were analysed. These were selected based on the search within ResearchGate, Google Scholar, PubMed, and IEEE Xplore engines. The results for scientific publications were limited to 2017 and newer. For the search, the following keywords phrases were used: digital twin, digital twin medicine, digital twin surgery, digital twin rehabilitation, digital twin treatment, digital twin industry, digital twin manufacturing, digital twin education, digital twin robotics, digital twin robotics VR, digital twins physiotherapy.Additionally, an overview of the needs of contemporary rehabilitation is presented. This is intended to form a design intent for the developed technologies for remote home physiotherapy of the future.The overview of these is based on in-depth interviews with physiotherapists followed by the questionnaire research on a group of 138 professionals and the literature analysis. The investigation method is described in the corresponding section.In the process of the literature overview, 15 relevant papers were analysed. These were selected based on the search within ResearchGate, Google Scholar, PubMed, and IEEE Xplore engines. The results for scientific publications were limited to 2017 and newer. For the search, the following keywords phrases were used: future rehabilitation, rehabilitation needs, telerehabilitation.The paper also contains the original concept of remote robot-aided treatment based on the digital twin technology. The presented solution addresses the contemporary problems of unintuitive or ineffective remote treatment. The technology is strongly dependent on the initial state of the art presentation to correspond to actual needs and possible technological advancement. All the discussed ideas can be developed and fulfil the requirements towards home remote kinesiotherapy.Medicine is a field that will undoubtedly benefit from the development of digital twins. This is an effect of the rising popularity of smart mobile devices for organised patient data storage, limited human learning capabilities, the need for personalised and targeted treatment, and the need to reduce treatment costs. Introducing the ability to work on models and simulations allows faster, more cost-effective elimination of risk for patients . As descOne of the most significant factors affecting the general population’s health is physical activity. Coaches are now being trained to motivate people who are not interested in sports. However, not everyone can afford a private trainer. Digital Twins can allow highly customised workouts for people who do not collaborate with professionals . AnotherAdditionally, cardiac resynchronisation therapy for patients with unclear electrocardiography (ECG) was developed within mechanistic modelling. Based on simulations of the human circulatory system, it was found that the response to cardiac resynchronisation therapy can be predicted from the presence of non-electrical substrates. Mechanistic modelling helped to solve the problem of ablation of ventricular tachycardia. The synergy of models is a unique solution for interpreting structure–function relationships and improving risk assessment in inherited diseases such as hypertrophic cardiomyopathy . In addiMoreover, works on the digital twins for multiple sclerosis are promising. They may accelerate advances in diagnosis, treatment, individualised clinical decisions, and more efficient management within this field . The useDespite the rising interest in digital twins for healthcare, they are mainly used in industry. Their application is one of the fourth industrial revolution’s (Industry 4.0) central pillars. Such technology is primarily involved in Product Life Management (PLM) or Smart Manufacturing; however, these are not the only possible applications. Digital twins allow online visualisation of manufacturing devices or robotised workstations. This, in turn, allows engineers to supervise industrial processes from any place on the Earth, which is especially important during an ongoing COVID-19 pandemic ,22. In aHowever, industrial digital twins are not only used to monitor processes. Thanks to augmented reality (AR) technology, such systems allow the collaboration of humans with manufacturing devices, robots or production lines, among others. In the case of production lines, the AR sets display instructions needed to perform a given process and allow the monitoring of its course in an intuitive environment. The presented content is strictly related to the data gathered from the real-life machine and implemented by its digital twin estimating the current operation states ,25. On tIn addition to AR, industrial digital twins are built within virtual reality (VR). They enable the control and programming of robots in the immersive digital environment. This is superior for complex industrial processes with complicated, precise robot movements, difficult to reach manually with the operator’s panel. The solutions to such challenges are systems reconfiguring robots while manipulating their virtual models . AdditioIndustrial digital twins are also involved in simulations of production lines’ operations. Such systems are often used as proof of concept at the initial design phase. Their application helps to improve construction and test the solution at various stages—before purchasing components or final launch, among others. Thanks to these, it is possible to create the solution corresponding to the needs without the risk of budget outspending, damaging the devices or injuring humans . The revTaking on the topic of telerehabilitation was preceded with three in-depth interviews and the questionnaire research on the group of 138 Polish physiotherapists—mainly specialists in orthopaedics , neurology (32.6%), ambulatory rehabilitation (29.7%), sports rehabilitation (28.3%), paediatrics (13.8%), cardiology (8%), and geriatrics (5.8%). The demographic characteristic of respondents are presented in What are your major problems while performing the therapy? What are your wishes related to physiotherapy, even unrealistic? (up to three answers grouped into the categories)For the purpose of defining needs in contemporary rehabilitation, the questions related to home rehabilitation were analysed. As 38.4% of physiotherapists declared they perform treatment at the patient’s place of residence, the results were considered relevant. Remote treatment can reduce costs for healthcare providers while lowering costs for patients ,31, espeThe results of the mentioned questions are illustrated in This analysis was followed by validating the theses for the Polish population regarding global requirements based on the available literature sources. In search of rehabilitation necessities, Kamenov found a great need for an investigation, especially in low- and middle-income regions. The paper elaborates on studies conducted in Mozambique, Malawi, Zimbabwe, Zambia and Lesotho. These show that up to two thirds of people with disabilities living in the mentioned regions who require rehabilitation do not have access to it. Furthermore, there is a growing demand for rehabilitation worldwide due to an ageing population and a more frequent incidence of non-communicable diseases, especially in developed countries. The analysis also identifies numerous barriers to accessing rehabilitation services .Studies indicate that, even in developed countries, access to rehabilitation in rural areas is limited. It is difficult for low-income individuals to receive physiotherapy due to a lack of transportation, poor equipment in the closest facilities, physically inaccessible locations of centres, or high treatment costs. Because of such barriers, distant rehabilitation is attracting increasing interest. Moreover, the cultural aspect is essential while working with patients, which may cause limitations in the work of some specialists  . Volkov These days, motor rehabilitation is often focused on function-oriented treatment. Physiotherapists concentrate not only on examining values such as muscle strength or range of motion but also on the overall functional state of the patient. Such therapy aims to help the patient fully recover or get close to the functional state before the disease. It is essential for patients who need to perform certain professional or daily-life motor activities . The funThe demand for physical support of older physiotherapists and preparing methodology of remote motor treatment led to the need for the overtaking of tiring activities by machines. Hence, an operator-less robotic solution must be implemented for home-based kinesiotherapy. However, current commercial devices are typically either too simple or too complex for self-in-house workouts. The first type of these machines is the one that mechanically supports a small number of DOFs or triggers the motion by the end effector attached to the body in series only ,36. WithThe complex rehabilitation robots are typically too large, heavy, and expensive to be purchased and applied by single users . MoreoveAccording to the aspects presented beforehand, the device for remote home motor therapy should be relatively simple in terms of mechanics, while remaining technologically advanced. Its structure has to enable easy putting on and training within the limited space. Moreover, it must enable control over the dynamic parameters of rehabilitated body parts—either by monitoring corresponding parameters in all the DOFs of machines or by involving an additional bio-signals tracking system. For these reasons, the exoskeleton lightweight structures are considered. They allow direct mobilisation of particular DOFs. Therefore, kinematics of corresponding joints may be calculated based on the data from encoders and impedance-based torque estimations .At present, multiple various designs of exoskeletons for all the body parts have been developed ,43,44. AWith the development of Information and Communication Technologies (ICT), new potential was unlocked for motor treatment. So-called telerehabilitation is a process of clinical therapy provided remotely using ICT . HoweverAs derived from Telerehabilitation can be synchronous , asynchronous  or a combination of both . The conDuring the session, the robot should either support or resist the intended motion . Some coHowever, sometimes the treatment requires unpredictable means. Continuous non-anatomical motion patterns resulting in unequal loads distribution within the musculoskeletal system and extensive efforts , or the The concept of the presented solution includes the industrial-like application of the digital twin to robot-aided motor therapy. The rehabilitation robots currently used for kinesiotherapy support or resist the motion of a patient. They may be either attached to the body segments in series (by end-effectors) or parallel (as exoskeletons) ,57. TheyWhile performing the physiotherapy in a clinic, it may be realised by combining manual therapy sessions and training with rehabilitation robots . The reaThe presented idea considers using the exoskeleton in the home of a patient connected with the remote control module. The treatment is initially based on the automatically generated routines based on the registered performance. However, all the adjustments may be modified online by the physiotherapist. Moreover, they have an opportunity to constantly monitor patients’ activity based on the impedance of the mechatronic device or additional sensors .The rehabilitation system is complemented with its digital twin. Additionally, the model contains schematic geometry of the rehabilitated body segment. The digital twin may be displayed in the VR goggles of the physiotherapist, as this provides the best immersion. AR or MR technologies are not considered because the patient is treated remotely, and the real-life environment of the physiotherapist is not connected with the rehabilitation process. Thanks to this, the professional can monitor the actual activity of the patient not only via registered signals but also based on the observed multibody model. As for the manual remote therapy, the physiotherapist should be able to drag the body segments to the desired configurations. This is realised by control over the virtual multibody model. Thanks to the kinematics formulas, the motion of the body segment may be recalculated into the desired motion of the motors. With the presented approach, manual therapy may be performed remotely in an intuitive and immersive way.The concept of such an application is visualised in Using technology such as digital twins in rehabilitation will contribute to its cost reduction, as one therapist will be able to provide treatment to multiple patients simultaneously. It will bring precise and individualised physiotherapy to less affluent patients. Moreover, the time spent on related frequent journeys of convalescents or professionals will also be shortened. With a patient-tailored therapy, its time may be decreased as well, cutting costs even further. Collecting data from a broad selection of sensors will allow collecting and transferring patient information between specialists. With such capabilities of a system, the interdisciplinary teams could provide holistic care for patients even with rare diseases. Thanks to the distant treatment, barriers such as different locations will be mitigated. This can be crucial for individuals whose access to professional health care is restricted by long distances from specialist centres. Reducing journey times to the minimum while providing common access to knowledge about the patient’s conditions results in the possibility of continuous rehabilitation regardless of external factors. It also reduces the occupancy rate in hospitals, as patients do not have to visit these. Moreover, telerehabilitation may also positively affect the lives of the seriously ill patients’ relatives, who often accompany their kin .The digital twins are an opportunity for those living in underdeveloped areas. They allow health checks by specialists not accessible within close reach. Additionally, their application enables the faster detection of disorders and their further observation. In some cases, this is the only way to monitor people’s health in less developed regions . NeverthOne of the most significant benefits of using digital twins in rehabilitation is the accurate assessment and monitoring of patients’ progress during workouts. Physiotherapists often do not have the tools to evaluate the performance reliably. They use sight observations, goniometers, scales and other instruments that are too inaccurate for deep biomechanical analysis. In addition, physiotherapists are trained mainly for functional diagnoses. On the contrary, the digital twins give insight into dynamic parameters of rehabilitated body segments and time spans of motion trajectories. Hence, this may impact the development of computer-aided physiotherapy and its effectiveness .The databases collected by such systems could become a breakthrough in individual rehabilitation. These may be used to investigate the ongoing efficacy of physiotherapy, assess the patient’s conditions, and automatise the treatment planning. In addition, gathered information may contribute to creating artificial intelligence algorithms for predictive control algorithms or adaptive training .The implementation of digital twin technology within robot-aided treatment can also affect the consistency of procedures in medicine. This includes combining therapy at different stages, from initial intervention, through diagnosis to treatment and rehabilitation. The continuity of the entire treatment process shall benefit from faster recovery and reduced complications .The technology of digital twins is developing rapidly and finding new applications in synergy with other fields . This trUndoubtedly, such an innovative approach requires facing and finding answers to significant challenges. As digital twins are informatics constructs, they are exposed to hacking attacks. This is associated with the risk of unauthorised entities taking control over a device collaborating with humans . MoreoveThe solution presented in the paper is intended for people with limited mobility or difficult access to medical centres. Such conditions often go hand in hand with poor access to the Internet. It is not necessarily just a matter of the individual financial situation, but also a specific location, especially for third-world countries . There iCurrently used mainly in industry, the technology itself should be adapted to medicine, which requires a more precise approach . The accApart from positional inaccuracies, the control system should also be robust, particularly to the time shifts. Tracking latency introduces a delay of around 20-40ms into the mechatronic system . AdditioPhysiotherapists may also encounter problems with the implementation of the presented technology. Even though the solution guarantees high immersion, it has particular limitations regarding control over the device. The physiotherapist would have to undergo thorough training in using the software and learn how to perform remote manual treatment naturally. The required hand motions may differ from the ones typical for conventional therapy. Such a significant shift in working routine may not be easy to implement, especially for physiotherapists with long work experience . To skilIn addition, the patients’ safety is a crucial aspect during treatment. Therefore, a system of controlling the device should react to the user’s discomfort to prevent the hazard of injuries. This is particularly important for patients with comorbidities, especially spasticity . As hypeThe difficulties are also related to the sensory perception during teleoperations. Conventional manual therapy performed onsite involves the physiotherapist’s physical engagement. Thus, the specialist has haptic feedback, used to detect irregular organism behaviour. Such feedback is based on kinaesthetic and tactile information . The firThe presented State of the Art proves that the technological advancement in the field of digital twins corresponds to the current needs for rehabilitation and enables remote robot-aided therapy. Combining VR-based control with mechatronic kinesiotherapy devices gives an opportunity to drag patients’ body segments during conventional treatment. Thus, this allows treatment individualization and on-spot modifications during unexpected problems with motion patterns. Thanks to such an approach and the automation of the process, faster improvements in the users’ physical conditions are expected.Such an approach enables the overcoming of the main problems of physiotherapists and patients. These are, as investigated, mainly correlated with a measurable assessment of performance and decreasing time spent on commuting between specialist centres and private houses. Implementing digital twins for robot-aided kinesiotherapy additionally allows international therapy, where the most experienced specialists can work with difficult cases. Application of this may bring particular benefits to people living in rural areas, severely immobile patients and the elderly, in general. This remains in line with the Sustainable Development Goal 3 of the United Nations. Hence, it has a large-scale worldwide impact.Major challenges towards the presented concept include providing stable Internet connection in less-developed regions, resulting in lags of the system, cybersecurity, precision of the device operated with VR sets, and user safety. The last aspect creates the need to design a system that continuously monitors users’ performance and predicts hazardous configurations of the exoskeleton. With this, the described solution should be capable of remote use.As for the continuation of the research, a digital twin of the ExoReha rehabilitation exoskeleton developed in the Industrial Research Institute for Automation and Measurements PIAP, based on the presented methodology, will be developed.