Kaplan–Meier survival curve analysis suggested that AR was closely correlated with overall survival (OS) (p = 0.001) but not disease-free survival (DFS) (p = 0.051). After eliminating the potential impact caused by HR, AR also predicted longer OS (p = 0.014) and was an independent predictive factor for OS of HER2+HR− nonmetastatic breast IDC patients, as revealed by multivariate analysis (p = 0.036). For AR+ and AR− matched HER2+HR− patients, TILs (p = 0.043) and PD-L1 (p = 0.027) levels were significantly lower in AR+ patients. The strongest negative correlation was observed between AR and PD-L1 . AR+ status was markedly related to better OS in HER2+HR− nonmetastatic breast cancer patients, while a negative correlation was observed between AR and PD-L1/TILs. We provide new insights into the prognostic value of AR and its association with the immune microenvironment to optimize treatment strategies in HER2+ nonmetastatic breast IDCs.This study aimed to investigate the prognostic value of AR in HER2+ nonmetastatic breast invasive ductal carcinoma (IDC) and its relationship with the immune microenvironment. HER2+ nonmetastatic breast IDC patients diagnosed by pathology who underwent surgery at Sun Yat-sen University Cancer Center from 2016 to 2017 were included. AR+ and AR− breast IDC samples were matched 1:1 in age, T stage, and N stage for immune infiltration analysis. A total of 554 patients with HER2+ nonmetastatic breast cancer were included in this retrospective study, regardless of HR status. The cut-off value for AR was set at 10%. ER+ ( Among all invasive breast cancers, human epidermal growth factor receptor 2 (HER2)- positive breast cancer accounts for 15–20%2 and has distinct biological behaviors and clinical outcomes. HER2 activation occurs through dimerization after binding to ligands, and HER2 signaling activates proliferation, cell survival, metastasis, and adhesion through different pathways4. In HER2-positive (HER2+) breast cancer, chemotherapy together with anti-HER2 therapy has become the standard of care and is correlated with better outcomes7.Breast cancer is the most prevalent cancer that affects women worldwide9. AR plays inhibitory and stimulatory roles in different types of breast cancer11. In estrogen receptor (ER)-positive breast cancer, MDV3100 research12 has shown that AR signaling is required for both androgen- and estrogen-induced tumor cell growth in vitro and in vivo. In triple negative breast cancer (TNBC), the luminal androgen receptor (LAR) subtype, characterized by the expression of androgen receptor, is associated with better prognosis, less chemotherapy responsiveness, and lower pathologic complete response after neoadjuvant treatment10. Notwithstanding the role of AR in several pathways, its impact from a biological and clinical standpoint is still controversial in HER2+ breast cancer. In vivo and in vitro experiments show that inhibition of AR can reduce the growth of HER2+ breast cancer cells and inhibit the phosphorylation of HER2 and the activation of Akt and Erk but does not affect the expression of HER2 protein13. Epidemiological evidence suggests that among HER2+ER− patients with nonmetastatic breast cancer, AR+ patients seem to have a worse prognosis14. On the other hand, a study including 304 HER2-enriched metastatic breast cancer cases indicates that patients with AR+ tumors have a longer progression-free survival (PFS) and a higher 5-year overall survival (OS) rate than those with AR− tumors15.Androgen receptor (AR) is a steroid hormone nuclear receptor and is widely expressed in breast cancer16, the immune system still plays a key role in the growth and development of breast cancer17. The preclinical and clinical data suggest that the response to HER2-targeted therapies19 and clinical prognosis20 can be predicted by immune cell compositions. A study focusing on the interaction between AR and HER2 in breast cancer cell lines indicates that AR signaling regulates direct transcriptional induction of WNT7B and HER3, resulting in activation of the ligand-dependent Wnt and HER2 signaling pathways21. Regarding the relationship among AR level, HER2 and the immune microenvironment, van Rooijen et al. found that in patients with HER2+ metastatic breast cancer receiving trastuzumab treatment, the infiltration of tumor immune cells with low AR expression increased, while the infiltration of tumor immune cells with high AR expression decreased22.Although breast cancer is considered a cancer with poor immunogenicityBecause of the heterogeneity of HER2+ breast cancer and the complex mechanism of HER2 and AR, better understanding of the prognostic value of AR in all HER2+ and HER2+ hormone receptor-negative (HR−) nonmetastatic breast invasive ductal carcinoma (IDC) patients is urgent. In addition, interest in the tumor immune microenvironment is increasing. What is the relationship between AR expression and immune infiltration in HER2+ nonmetastatic breast cancer?Based on the evidence above, we recruit HER2+ nonmetastatic breast IDC patients diagnosed by pathology who underwent surgery and analyze the prognostic value of AR in HER2+ and HER2+HR− nonmetastatic breast IDC patients. Then, AR+ and AR− breast IDC samples are matched 1:1 according to age, T stage, and N stage to explore their correlation with the immune microenvironment to provide new insights into biological behavior and reasonable treatment strategies.28, 81.6% of patients were AR-positive and 18.4% were AR-negative. Positive expression of ER (p < 0.001) and progesterone receptor (PR) (p < 0.001) was associated with the high expression of AR using chi-square test. There was also a trend that breast IDC patients in the AR-negative group were older  (p = 0.030) (chi-square test). The clinicopathological data of the included patients are summarized in Table p = 0.001) but not DFS (p = 0.051) : 20.0–80.0). The cut-off value for AR was set at 10% according to the previous literature and clinical trialp = 0.014)   of patients were AR-positive, and 24.8% (66/266) of patients were AR-negative. The percentage of AR− patients among HER2+HR− patients (24.8%) was higher than that among all HER2+ patients (18.4%). The median AR expression was 42.5% (IQR: 8.8–80.0). There was no significant difference in clinicopathological factors or treatment strategies between the AR+ and AR− groups, as shown in Table 14) Fig. . AR was p = 0.043) and PD-L1 (p = 0.027) in tumor cells were significantly lower in HER2+HR− breast cancer patients in the AR+ group, as shown in Fig. p = 0.348). The Spearman correlation coefficient indicated that the strongest inverse relationship was found between AR and PD-L1 in tumor cells , followed by AR and TILs , and there was no obvious correlation between PD-L1 in immune cells (p = 0.204) or Ki-67 (p = 0.793) and AR in HER2+HR− breast IDC patients. In patients with low TILs , patients with high levels of AR in primary tumors were more likely to have a longer DFS (p = 0.168) and OS (p = 0.140) than those with low levels of AR using Kaplan–Meier survival curve analysis, although there was no significant difference , but 3 pairs of patients were excluded in the subsequent analysis due to the absence of pathological specimens. In 56.3% (63 of 112) of the samples, programmed cell death ligand 1 (PD-L1) was expressed by tumor cells. PD-L1 was expressed in 25 tumors in the AR+ group and 38 tumors in the AR− group. PD-L1 was positive in 61.6% (69/112) of immune cells; 33 samples were from AR+ group and 36 were from the AR− group. The median percentages of tumor-infiltrating lymphocytes (TILs) in the AR+ group and AR− group were 30% (IQR: 20–45) and 37.5% (IQR: 20–67.5), respectively. Representative images of TILs and PD-L1 staining in tumor cells in the AR+ and AR− cohorts are shown in Fig. nce Fig. . There wnce Fig. .Fig. 5ReAndrogen receptor is frequently expressed in breast cancer and might be a predictive or prognostic factor and a drug target. However, the prognostic value of AR in HER2+ breast cancer and the relationship between AR and the immune microenvironment are controversial. Our study not only confirmed the prognostic role of AR in all HER2+ nonmetastatic breast IDCs but also confirmed the favorable prognostic value of AR in HER2+HR− nonmetastatic breast cancers. AR was negatively correlated with the immune microenvironment in patients with HER2+HR− nonmetastatic breast cancer. We explored the association between AR and immune infiltration in HER2+ nonmetastatic breast cancer to deepen the current understanding of this disease, increase the stratification of prognosis and hope to facilitate individualized treatment.29. Ligand-bound AR binds to the estrogen-related element, leading to cell apoptosis in ER-positive/AR-positive cell lines, while AR binds to androgen-related element in the nucleus, leading to proliferation in ER-negative/AR-positive cell lines9. In the present study, AR expression predicted a longer OS not only in HER2+ breast cancer but also in HER2+HR− nonmetastatic breast IDC. This indicated that there was no documented association between the good prognosis of AR+ tumors and other favorable prognostic factors, such as ER and PR positivity. Consistent with our results, another cohort15, which included 304 HER2+HR− metastatic breast cancer patients, demonstrated that AR positivity was related to favorable survival and predicted the efficacy of first-line trastuzumab treatment in these patients. Moreover, we also found that the survival of AR+ patients was better than that of AR− patients, regardless of whether AR− patients received HER2-targeted treatment. It was further indicated that positive AR was a good prognostic factor of HER2+ breast cancer. Because our results and previous studies demonstrate that AR expression has prognostic value, it is recommended that AR status should be evaluated for patients with HER2-enriched breast cancer upon initial diagnosis to obtain comprehensive information. Interestingly, a meta-analysis30 revealed that the positive expression of AR was related to DFS and OS in all types of breast cancer patients, while worse clinical outcomes were conferred by AR expression in patients with HER2-enriched breast cancer. Gene analysis in this study indicated that in HER2-enriched breast cancers, OS with AR mRNA expression was significantly better. In addition, the standardized cut-off for AR prognostication has not been statistically defined. We reviewed the literature and clinical trials28 and set 10% as the cut-off value for AR, which predicted the prognosis of HER2+ breast cancer patients with statistical significance in the current study. We also tried to use 78% as the cut-off value for AR as recommended by a systematic analysis based on multiple studies23. Unfortunately, in the current study, this cut-off value could not predict the clinical outcomes of the included patients.Androgen receptor, as a potential biomarker, has recently received more attention. The prognostic relevance of AR may be different in different breast cancer subtypes. It has been reported that the relationship between AR and HER2 seem to be associated with ER status in all types of HER2+ breast cancer, as a significant association between AR and HER2 was observed in ER-negative tumors but not in ER-positive tumors22, which was consistent with our results in HER2+ nonmetastatic breast cancer. At the same time, it was also found that among patients with high immune infiltration, patients with high levels of AR in primary tumors had longer OS than those with low levels of AR22. Another study considering AR and the immune microenvironment was carried out on 107 patients with early and locally advanced TNBC, and it was found that AR expression was also associated with a low immune response, as revealed by cluster analysis of RNA gene expression profiling of primary tumors31. AR expression was consistent with an immune-deserted environment based on our findings and previous studies on HER2+ metastatic breast tumors and TNBCs. It was indicated that immunotherapy may have potential implications for tumors with low AR expression and rich immune cells. In addition, a low level of AR was correlated with decreased sensitivity to anti-HER2 therapies, as revealed by a preclinical study focusing on the impact of AR signaling on HER2+ER− breast cancer cells. The most likely cause was that HER2/HER3 signaling activation mediated androgen impairment and stimulating tumor cell growth21. Studies on the correlation between AR and PD-L1 have all focused on TNBC. AR+/FOXA1+ tumors exhibited less frequent PD-L1 expression in TNBC32. TNBC lacking AR expression was considered quadruple negative breast cancer, where the immune checkpoint inhibitor PD-L1 was significantly upregulated33.Since only a fraction of HER2+ breast cancer patients are responsive to the combination of anti-HER2 therapies and immune checkpoint inhibitors, a more comprehensive recognition of the composition of immune infiltration in the tumor microenvironment seems to be helpful in predicting treatment response and optimizing treatment strategy. This study demonstrated that the AR level was inversely related to TILs and PD-L1 in primary HER2+HR− nonmetastatic breast cancer. One study suggested that the level of AR was negatively associated with immune infiltration  in HER2+ metastatic breast cancerIt is apparent that androgens and AR interact with each other and affect the biology of HER2+ breast cancer, which deserves more clinical and translational research. Currently, AR is being actively investigated as a therapeutic target of HER2+ breast cancer. A single-arm phase II clinical trial (NCT02091960) exploiting anti-AR in combination with anti-HER2 for AR-positive/HER2-positive/HR-negative MBC is underway. Although this study does not explore immune infiltration, the findings may also provide additional implications for clinical trials.HER2-enriched nonmetastatic breast cancer.The limitations of our research are as follows. The optimal cut-off value for AR status remains disputed, varying from >1% to >75%. According to the systematic analysis and previous clinical studies, a threshold of 10% was usually recommended and showed independent prognostic and predictive value. We also tried to use 78% as the cut-off value of AR, but this cut-off did not effectively predict survival in patients with HER2+ breast cancer. Additional limitations of the study include its retrospective nature and the small sample size of AR-negative cases. Considering the length of follow-up and the consistency of treatment strategies, we retrospectively included the data of breast cancer patients who visited our cancer center from 2016 to 2017. Retrospective analysis may have missing or erroneous data entry. Some subgroups analyzed may have insufficient sample sizes to identify significant differences. Therefore, further large-scale prospective studies are needed to confirm our findings. In addition, unveiling the complicated interactions between AR and the HER2 signaling pathway will further help utilize AR as an attractive therapeutic target of The positive expression of AR predicted a favorable clinical outcome in HER2+ nonmetastatic breast IDC. In HER2+HR− nonmetastatic breast cancers, AR was negatively correlated with the immune microenvironment. New insights into the association between AR and immune infiltration in HER2+ nonmetastatic breast cancer can be explored to facilitate the stratification of prognosis and provide a reference for individualized treatment.34; (3) histologic grade of primary tumor; (4) pathological histotype ; (5) ER, PR, HER2, Ki67, and AR status of primary tumor; and (6) treatment strategy . DFS was defined as the interval from surgery for the primary tumor to disease recurrence or metastasis after curative surgery, and OS was defined as the interval from surgery of the primary tumor to death . All patients were followed up until death or study data cut-off (June 2021). The study was approved by the Ethical Committees of Sun Yat-sen University Cancer Center (No. B2021-266-01). Informed consent was obtained as part of usual clinical practice from subjects involved in the retrospective study, and an informed consent waiver was granted if the patients died or were lost to follow-up.Considering the length of follow-up and the uniformity of the treatment strategy, patients with breast cancer at Sun Yat-sen University Cancer Center between June 2016 and December 2017 were retrospectively reviewed. Inclusion criteria were as follows: (1) HER2+ breast IDC diagnosed by pathology, (2) total mastectomy or lumpectomy with a negative margin of surgery, (3) patients without distant metastasis (including distant lymph node metastasis) at initial diagnosis; and (4) sufficient primary tumor pathological tissues for the subsequent immune test. If the patient had a second primary malignancy, the patient was excluded from this study. The AR test was performed on all patients. The following clinicopathologic information was retrieved from medical records: (1) age at diagnosis; (2) TNM stage according to the American Joint Committee on Cancer (AJCC) Cancer Staging Manual 8th Edition35, and HER2 was assessed by immunostaining and/or in situ hybridization. ER and PR were considered positive when ≥1% of cells were stained. HER2 was expressed as the recommended 0–3+ by immunostaining evaluation. When the score was 3+, HER2 was considered positive. The tumor was considered HER2-negative and excluded with an IHC score of 0 or 1+, regardless of the in situ hybridization result. Fluorescence in situ hybridization  was carried out in cases with a score of 2+. A HER2 gene/chromosome enumeration probe 17 (CEP17) ratio ≥2.0 and an average HER2 gene copy number ≥4.0 per tumor cell or an average HER2 gene copy number per cell ≥6.0 were considered HER2-positive results. For Ki67, positive expression revealed by immunohistochemical staining was noted; high expression was defined as a percentage of stained cells ≥20% and low expression was defined as a percentage of stained cells <20%. Approximately AR ≥ 10% of the nuclear stained cells was considered positive. All biomarkers were assessed by immunohistochemistry staining in the Department of Pathology of Sun Yat-sen University Cancer Center. Immunostainings of all five biomarkers were performed using the Ventana Benchmark XT® staining system  with the Optiview® DAB Detection Kit . ER , PR , HER2 , Ki67  and AR  antibodies were utilized.The ER, PR, HER2, Ki67, and AR status of the primary tumor were assessed by immunohistochemistry staining and collected from the pathological report. Immunostaining for ER, PR, and Ki67 was evaluated according to the ASCO guidelines36, TILs were reported for the stromal compartment . The denominator used to determine the % stromal TILs was the area of stromal tissue, not the number of stromal cells. All mononuclear cells (including lymphocytes and plasma cells) were scored, excluding TILs outside of the tumor border; around ductal carcinoma in situ (DCIS) and normal lobules; and in tumor zones with crush artifacts, necrosis, and regressive hyalinization. A full assessment of average TILs in the tumor area by the pathologist was used, not including hotspots. The results are shown as a continuous parameter in as much detail as the pathologist feels comfortable with. The average percentages of PD-L1 and TILs by two observers were used as the final score for every sample. If the difference was greater than 20%, the two observers discussed until reaching an agreement.AR+ and AR− patients with HER2+HR− breast IDC were matched 1:1 in age, T stage, and N stage for subsequent analysis. The expression of markers in formalin-fixed paraffin-embedded (FFPE) tissues was quantified, and haematoxylin and eosin (H&E) and immunohistochemistry staining were carried out in one batch per marker to avoid differences in intensity. The expression of PD-L1 was assessed in both tumor cells and immune cells. The percentage of stained tumor cells  was regarded as PD-L1 expression in tumor cells, and the percentage of stained immune cells  was reported as PD-L1 expression in immune cells. PD-L1 IHC testing was performed using the E1L3N antibody  in the biomarker cohort. When ≥1% of cells were stained, PD-L1 was considered positive. According to a standardized method developed by the international TILs working groupp values < 0.05 were considered statistically significant, and all p values were two-sided. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS), version 25.0.Categorical variables are described by percentages, and continuous variables are represented by medians and ranges. The chi-square test’s phi coefficient or Spearman’s correlation coefficient was used to evaluate the relationship among the studied markers. Propensity score matching was used to select matched AR+ and AR− patients. The Wilcoxon signed-rank test was used for the statistical analysis of variation in study markers between paired tissues. The impact of clinicopathologic factors on DFS and OS was calculated by Kaplan–Meier curves. The Cox proportional hazards model was used to evaluate the simultaneous influence of all covariates on DFS and OS. Further information on research design is available in the Reporting SummarySupplementary Table 1


This systematic scoping review aimed to describe the content of post-operative rehabilitation programmes, and outcome measures selection following stabilisation surgery for traumatic anterior shoulder dislocation (TASD).An electronic search of Medline, EMBASE, CINAHL and AMED was conducted (2000–2021). Any cohort or clinical trial of patients receiving post-operative TASD rehabilitation were included. Study selection, data extraction and quality appraisal were undertaken by two independent reviewers.Twelve studies including fourteen treatment programmes were eligible. Period of post-operative immobilisation ranged from 1 day to 6 weeks, with exercise introduced between 1 and 7 weeks. Strengthening exercises were introduced between 1 and 12 weeks. Two studies described “accelerated” rehabilitation programmes, differing in immobilisation period and exercise milestones. No increased recurrence was reported in professional footballers. Two studies compared rehabilitation programmes, one not randomised, the other 18 years old. There was variability in selected outcomes measures, with only 4 studies using a common measure.There is minimal evidence to guide post-operative rehabilitation, variability in immobilisation periods and when exercise is introduced. There is no consensus on the definition of accelerated rehabilitation, or outcome measure selection. Clinical consensus of standardised terminology and stages of rehabilitation is required prior to efficacy studies. Although this type of injury can occur at any age, peak incidence occurs in males aged 10–40 typically involved in contact sports,8 with a second smaller peak in elderly people who sustain the injury during low-level falls.10TASD can result in structural problems such as a Bankart lesion  and a Hills-Sachs lesion ,12 both of which predispose to chronic post-traumatic instability, with recurrent dislocation rates as high as 85%–92% in the young sporting population.Traumatic anterior shoulder dislocations (TASD) account for between 80% and 90% of shoulder dislocations There has therefore been a shift to immediate surgical intervention in an attempt to lower rates of recurrent dislocation. Arthroscopic Bankart repair, is currently the most commonly performed surgery for anterior shoulder instability.17 The Laterjet is gaining increasing popularity in the presence of osseous glenoid defects, particularly in the contact athlete.19Over half of people managed conservatively will experience a recurrent dislocation.21 Accelerated rehabilitation programmes, with minimal post-operative immobilisation, have been documented as early as 2003 and have gained increasing profile following a later publication in 2016. However, it is unclear how the individual components of accelerated rehabilitation differ from more traditional rehabilitation programmes. A lack of formal comparison between rehabilitation programmes guidelines is confusing for clinicians and researchers wishing to identify “standard practice”. There is currently no synthesis of the content or outcome measures documented in research studies describing post-operative rehabilitation for TASD.Reports of surgical advancements are rarely supplemented by alterations in post-operative rehabilitation programmes. The content of rehabilitation, if described at all, is rarely in enough detail to replicate. Studies comparing different rehabilitation programmes, irrespective of publication date, are few.The objective of this systematic scoping review is to describe the rehabilitation programmes and outcome measures described in the primary literature following stabilisation surgery for TASD, the secondary aim being where possible, to compare the effectiveness of these programmes. and has been registered on the International prospective register of systematic reviews (PROSPERO) (Registration number CRD42020201438).This review was conducted according to the guidelines for the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for scoping reviewsMEDLINE, EMBASE (via Ovid) and CINAHL were searched from January 2000 to January 2020 using the NHS electronic library. The full Medline search strategy is presented in supplementary file 1 with search terms adapted for other databases. No language limits were applied. Reference lists of eligible publications were hand searched.Two independent reviewers (MC and LW) screened all retrieved titles and abstracts against pre-defined eligibility criteria. Full texts of potentially eligible papers were then sourced and reviewed (MC and LW).Any study published in a peer reviewed journal from January 2000 that met the following criteria were included in the review: Participants, irrespective of age, who had undergone any type of anterior shoulder stabilisation surgery following at least one TASD identified as such by any professional healthcare practitioner or diagnostic imaging. Interventions must have been delivered by or involve one or more physiotherapists.Studies were excluded from the review if they included participants with atraumatic shoulder instability or who had undergone surgery for degenerative superior labral anterior posterior lesions (SLAPs), posterior or multidirectional instability. The following interventions were excluded: treatment provided over the telephone, in which there had been no face to face contact with a physiotherapist or where ice/hot packs were the only form of physiotherapy.24 and refined in response to any ambiguities. Details of any immobilisation period post operatively were recorded, and each treatment and exercise intervention were categorised for ease of synthesis and presentation of results. Exercise categories were developed and defined during consensus meetings including all the review authors and included: Range of Motion (ROM), Isometrics, Strength, Movement Re-education, Stability and Proprioceptive/Neuromuscular Training. Clinical trials comparing rehabilitation programmes were appraised using the Physiotherapy Evidence Database (PEDro) scale for randomised controlled trials.Two independent reviewers (MC and LW) extracted data and entered it onto a custom designed data extraction form (Supplementary file 2). The form was piloted tested by MC and LW on three studiesThe search strategy yielded 3283 citations, of which 46 were removed due to duplication. Following title and abstract screening 31 were selected for a full text review. A further 19 were excluded as the physiotherapy management was not specified. 12 studies were finally included in the scoping review. A PRISMA summary is presented in 2527 and 7 of which were observational studies.2832 Of the 5 clinical trials in this review, two studies compared 2 groups receiving different rehabilitation programmes following surgery after TASD.21 For the remaining 3 studies;2527 the aim was to compare either different surgical interventions, in which both groups received the same physiotherapy, or surgery versus physiotherapy. Two studies describe accelerated rehabilitation programmes, one of which was a cohort study and one a clinical trial. The total number of participants included 659 males and 150 females with an age range of 15–57 years. Six papers (45% of participants) state that participants sustained a TASD due to a sport or physical activity. Full participant demographics are outlined in supplementary file 3.In total, information from 14 treatment programmes were extracted from 12 papers covering 12 studies, 5 of which were clinical trialsThe primary objective for 4 of the papers in this review was to describe the treatment programmes delivered by physiotherapists. For the remaining 8 papers, for whom this was not an objective, only a brief or general outline of treatment programmes were provided.The exercises in each treatment programme were taken verbatim from the papers, categorised and summarised for clarity and conciseness in supplementary file 4. Exercises were performed independently by the patient, unless indicated otherwise. described an immobilisation period  specified when active movements were introduced. Early exercises typically included pendulum exercises or using a rope and pulley.Range of Motion (ROM) exercises were defined as any active, active assisted or passive movements for which the aim was to regain full range of shoulder movement. They were included in all programmes as one of the first interventions. Active assisted and passive movements were initiated in 7 programmes within the first week, one study did not report when they were commencedIsometrics were defined as muscle contractions where the length of the muscle and the angle of the joint do not change. These would often be completed early in the programme, and prior to active range of movement exercises in order to activate the shoulder muscles and restore some strength. The use of isometric exercises specifically for deltoid strengthening within the immobilisation period was reported in 5 of the 14 programmes.22 Both Gibson and Kim begin strengthening in week one and week two respectively, although the intensity is higher in Gibson's than Kim's the latter being more comparable to that of Damkjaer's standard rehabilitation group or Ozturk's programme. These three papers describe similar exercises using dumbbells for the rotator cuff and scapular stabilisers from week 6. In addition to through range recruitment exercises, Gibson et al. also includes global strengthening work, incorporating closed kinetic chain exercises from week 1 and working the uninjured arm at high maximum voluntary contractions at week 3. It is not specified if these are isometric. Damkjær et al., despite not being defined as an accelerated programme, reports more advanced strengthening exercises  from week 6.Strengthening exercises were defined where there was resisted movement through range with increasing load. These were distinct from isometric exercises. Strengthening exercises began between 1 and 12 weeks. Detailed descriptions of strengthening exercises and biweekly progressions were described in 3 programmes, including both accelerated programmes.32 did not specify whether or not strengthening exercises were used in their treatment programmes. The remaining 9 programmes provided guidelines on local scapula and rotator cuff exercises in different planes of motion. The use of increasing resistance bands and dumbbells were common progressions across these programmes.Two studies26 Gibson et al. includes movement re-education in the form of proprioception and movement facilitation and “through range activation incorporating the kinetic chain” in the first week post operatively, Edmond introduces scapular retractions week 4 post operatively and Kim core exercises from week 10 post operatively.Movement Re-education was defined as any movement or exercise for which the aim was to restore functional movement patterns at the shoulder. It was reported in 3 programmes. treatment programme. They were initiated early in the programme and at a higher intensity compared to the other 4 programmes. The accelerated programme had patients recruiting dynamic stabilisers from 0–4 weeks, then completing “preparatory and reactive stabilisation drills in risk positions” whilst incorporating the kinetic chain beginning from 3 weeks post operatively. Damkjaer et al. reports the commencement of stability exercises 6 weeks post operatively in which the scapular stabilisers and rotator cuff are worked at high repetitions and low resistance. Stability exercises are commenced at week 10 in Kim's programme including ‘tubing exercises in 90/90 position’ and trunk strengthening. Eren et al. reports the use of closed kinetic chain exercises such as push ups and rowing from week 13 post operatively with the aim of strengthening the scapula stabilisers.Stability exercises were defined as the application of fluctuating resistance loads incorporating the kinetic chain, while the patient stabilises the shoulder in a symptom-free position. Stability exercises were specified in 5 treatment programmes. Stabilisation exercises were a key focus in Gibson's focussed on professional footballers, commenced PNMT in the first week, initially in the form of maintaining cardiovascular fitness on a bike or incline treadmill, although this could be argued as general cardiovascular fitness than specific PNMT for the shoulder. At 3 weeks this progressed to completing non-contact drills and at 6 weeks incorporated function specific plyometrics, strength and endurance exercises, and “controlled falling drills”.Proprioceptive/Neuromuscular Training (PNMT) was defined as exercises or drills that train the nerves and muscles within the shoulder complex to react and communicate and included any sports specific or functional training, plyometrics, power, endurance, and advanced strengthening work. This was included in 6 programmes, 5 of which introduced in between 7 and 13 weeks post operatively. The remaining programme,30 and four include plyometric exercises.29Four programmes provide details about advanced strengthening, power and endurance exercises30 Three papers report recurrence rates.30Nine papers used 7 different patient reported outcome measures (PROMS) See . The AmeOf the 5 clinical trials in this review, two compared 2 groups receiving different post-operative rehabilitation programmes. See supplementary file 5 for PEDRO scores. compared “accelerated” versus “conventional” rehabilitation. Participants were blinded to which group was accelerated. Participants receiving accelerated rehabilitation only wore their sling at night. There were no significant differences in outcome between groups at long term follow up in terms of reoccurrence, ROWE, ASES or return to activity. However, participants in the accelerated programme reported significantly less pain, at 6 weeks, were faster to regain full range external rotation and return to previous activities. Most of the patients in accelerated group were satisfied with early mobilisation and most of the conventional group were dissatisfied with brace immobilisation. Eren et al. scored poorly on the PEDro scale in part due to the absence of randomisation; participants could choose their treatment group. The trial consisted of a home-based group and supervised group. There were no significant differences in DASH, Rowe or Constant scores between groups at 6 or 12 months.Kim et al.,The primary objective of this scoping review was to describe the rehabilitation programmes and outcome measures described in the primary literature following stabilisation surgery for TASD. Our findings indicate that there is significant variability in rehabilitation milestones. The period of shoulder immobilisation ranged from 1 day to 6 weeks post-operatively, during which some studies advocated absolute immobilisation, whilst others allowed various amounts of active, active assisted or passive movement. Whilst all studies included these movements as one of their first interventions, the point at which they were introduced varied between one and seven weeks. Isometric exercises, when described, were introduced early, often before active movements in order to activate the shoulder muscles and restore strength. The introduction of strengthening exercises ranged between 1 and 12 weeks. Movement re-education for shoulder function and stability, and exercises incorporating the wider kinetic chain were reported in 3 and 5 studies respectively and were introduced between 1 and 10 weeks post-operatively. Proprioceptive, neuromuscular or cardiovascular training, sports or function specific, including plyometric, power and endurance training were included in 6 studies and were introduced between weeks 1 and 13. In summary, whilst there are similarities in the overarching components of rehabilitation programmes, the period of immobilisation, type, intensity and point at which specific exercises are introduced varied considerably.29 or completing a full season without re-dislocation.31A wide variation of outcome measures was reported with no more than 4 studies reporting the same outcome. Most studies did not include PROMs specifically designed for shoulder instability. The definition of return to play varied between studies, from getting back to playing sport22 in our review suggests that early mobilisation may not be associated with increased instability. Early post-operative mobilisation has been studied extensively in the lower limb34 and has been associated with decreased pain scores, and rapid recovery of muscle function.3538 Early research following rotator cuff repair suggests integrity of repair is maintained when comparing early versus delayed post-operative mobilisation. The possibility of earlier safe mobilisation has important implications for the wide range of patients with TASD, for example, poor compliance with immobilisation periods, working populations and loss of earnings, the psychological impact of not being engaged in leisure and sport, and for older patients, the risk of stiffness due to prolonged immobilisation.The risks and benefits of early versus standard immobilisation versus are still inconclusive due to lack of research. The very limited evidence available from the two studies Small incisions and less invasive techniques, require less hospitalisation time, allowing patients to ideally return to their former activities sooner than open surgery. All studies in our review involved a Bankart in which the torn anterior labarum and anterior band of the inferior glenohumeral ligament is reattached to the glenoid rim. Other techniques such as Latarjet and Remplissage procedures, are increasingly common and involve bony and cartilaginous structures, for which physiological healing times will vary. Variation in types of stabilisation surgery needs to be considered for future rehabilitation programmes.Seventy six percent of participants in the studies included in this review had arthroscopic stabilisation, designed to minimise recovery times.4650 The fundamental components for all treatment programmes in this review included optimising ROM, strength and functional recovery. None stated consideration of the psychological or social factors that may influence, for example return to play. When an athlete sustains an injury, it has psychosocial impacts5153 and many athletes do not return to sport due to fear of re-injury. A common misconception historically is that physical and psychosocial recovery occurs at the same time.Shoulder stabilisation surgery requires many months of rehabilitation to achieve a successful outcome. Patient expectation of recovery, pain, self-efficacy and fear avoidance predict outcome following surgery and rehabilitation.56 One of these reviews highlighted that the high levels of resilience and preoperative expectations are significantly associated with low levels of post-operative pain intensity. Similarly, high levels of depressive symptoms anxiety, pain catastrophising, emotional distress and somatisation are significantly associated with high levels of pain intensity. These finding are in keeping with those of Henn et al. in that greater preoperative expectations correlated with better post-operative performance on the simple shoulder test, Disabilities of the Arm, Shoulder and Hand scale and the Visual Analogue Scale following rotator cuff repair. We therefore recommend pre-rehabilitation based on an integrated biopsychosocial model.Several systematic reviews have explored the role of preoperative self-efficacy and expectations of recovery in patients with chronic shoulder pain. Return to play is an important measure for many people and should be clearly defined.We recommend combining clinical measures and PROMs designed to capture impairment, function and participation following surgery and post-operative rehabilitation. We recommend PROMs, tested for their validity, reliability and responsiveness in capturing change specific to shoulder instability. Examples might include the Western Ontario Shoulder Index (WOSI) and Oxford Shoulder Instability. was strictly followed throughout this review. Discussions with research and clinical experts at each stage of the review contributed to the search strategy, eligibility criteria, data extraction, and defining categories to subgroup each intervention component. The main limitation of this review is that only 2 clinical studies compared rehabilitation programmes, one of which was not randomised.The PRISMA guideline extension for scoping reviewsFollowing TASD, there is considerable variability in the post-operative immobilisation period and when each type of exercise is introduced. There is a lack of research comparing the effect of different rehabilitation programmes and a lack of evidence to guide post-operative rehabilitation. There is no consensus on the definition of accelerated rehabilitation, or recommended outcome measures. Recent advancements in surgical procedures and varying populations presenting with TASD may account in part, for some of the variability. We recommend incorporating a biopsychosocial approach alongside traditional biomechanically based interventions. Clinical consensus of standardised terminology and stages of rehabilitation is required prior to developing a randomised controlled trial.


The findings suggest that visual telerehabilitation and mixed rehabilitation can lead to an ergo-perimetric improvement in visually impaired children within six weeks. Further research is needed, both to corroborate the findings with a larger sample size and to attain a follow-up measurement in order to clarify whether visual telerehabilitation could represent a stand-alone method.In the last two years, orthoptists have counteracted patient drop-out through visual telerehabilitation. Efforts were made to transfer the in-person visual rehabilitation setting to the telematic environment in response to the worldwide crisis. Nowadays, statistical evidence on the effects of visual telerehabilitation is still scarce. The present research is the first, in Italy, to offer a pre-post assessment of the impact of visual telerehabilitation. Twenty-four (n = 24) children  aged 4 to 15 years  were randomly assigned to three different group types for rehabilitation: a telematic rehabilitation group (n = 7), a mixed rehabilitation group (n = 8), and an in-person rehabilitation group (n = 9). Each group underwent a six-week visual rehabilitation. Ergo-perimetric evaluation before and after the rehabilitation was administered to the three groups.  Visual rehabilitation has become an increasingly important aspect of healthcare for patients with visual impairment. According to existing scientific literature, visual rehabilitation is a fundamental approach to preventing vision loss and empowering visually impaired patients ,2. The iVisual rehabilitation protocols have been designed to address a wide range of visual impairments and enhance various aspects of visual function. For instance, visual rehabilitation can improve synaptic responses and cortical plasticity ,4, whichThe COVID-19 pandemic has posed significant challenges to the global healthcare system. One of the major challenges has been the temporary disruption of healthcare services, including rehabilitation services. Additionally, restrictive anti-contagion measures have increased the risk of rehabilitation drop-out for individuals with disabilities . In ordeNevertheless, there is still limited evidence on the effects of visual telerehabilitation. This approach was implemented in response to the COVID-19 emergency, without specific a priori research designs. Thus, the present study aims to measure the effects of visual telerehabilitation, alongside mixed rehabilitation , and traditional in-person visual rehabilitation over a six-week period. The study was conducted in Italy and is one of the first to explore the potential of telematic services for children with visual impairment.Children in rehabilitation at David Chiossone Foundation  took part in the research between January and May 2021, after the administration of informed consent for participation to their parents. Children were included in the study if: (i) their age was between 4 and 16 years, (ii) they exhibited residual vision between 1/10 and 3/10, (iii) they had monocular or binocular vision, (iv) they exhibited diagnosis determining a visual impairment. Exclusion criteria applied in order to constitute the sample were as follows: (i) age above 16 or below 4, (ii) vision inferior to 1/10 and above 3/10, (iii) they had multiple disabilities. Twenty-four (n = 24) children  aged 4 to 15 years  constituted the sample of the research. The children exhibited a wide range of pathologies determining the visual impairment . The mean residual vision of the sample was 1.3/10, in a range between 1/10 and 3/10. Children were randomly assigned to three different types of rehabilitation: (i) a telematic rehabilitation group comprising n = 7 children; (ii) a mixed-rehabilitation group comprising n = 8 children; (iii) and an in-person rehabilitation group comprising 9 children.Visual telerehabilitation consisted of six online sessions (one per week) of 30–40 min each, conducted by an orthoptist. Each session presented exercises stored in folders on Microsoft Teams, classified by program , session number, children’s age, and specific features . The exercises aimed at training different visual abilities : (a) fixBefore beginning visual telerehabilitation, the orthoptists had to provide VI children’s parents with the technical and pragmatic instructions to constitute the best setting in which to practice the telerehabilitation session. Parents were instructed to: (i) prepare a silent room, without sensory stimuli that could distract the child; (ii) position the child on a chair in front of a desk, on which the screen (computer or tablet) was positioned; (iii) not hold the child during the sessions, (iv) keep the webcam in a position where it could capture the eye movements of the child. Eventually, parents were also instructed to print materials for the exercises. On the other hand, the orthoptist conducted the online sessions in a setting that constituted of a desk station with a personal computer, accessorized with a webcam, a microphone, speakers, and an Internet connection.In the present research, the outcome utilized to evaluate the impact of the three types of rehabilitation was the response time of patients at the ergo-perimetric assessment. Ergo-perimetry is an assessment of the visual response of the patient, used to monitor the outcomes of rehabilitation . To pracThe patient has the task to gaze, identify, and verbally account for the position of the target while the orthoptist measures the patient’s response time with a chronometer. The response times of all 3 groups of participants were assessed with this procedure 1 week before and 1 week after the rehabilitation.t-test was employed for each group, which allowed for paired observations to be compared with the objective of identifying any statistically significant differences between pre- (t1) and post (t2) rehabilitation. The results of these analyses are presented in In order to determine if there were any statistically significant changes in the reaction times observed at ergo-perimetry as a result of the three types of rehabilitation, means for all three groups were analyzed and compared before and after the rehabilitation programs. To achieve this objective, a one-sample p < 0.05) was observed between the pre- and post-rehabilitation means at ergo-perimetry, indicating a reduction in response times (p < 0.01) was observed between the pre- and post-rehabilitation means at ergo-perimetry, indicating a reduction in response times .The use of technology in healthcare has revolutionized the way medical treatments are delivered to patients . Visual This study’s findings also suggest that visual telerehabilitation could be a stand-alone method in the field of visual rehabilitation . This coDespite the promising findings of this study, its small sample size constitutes a limit. Methodologically, small sample sizes can lead to less precise statistical estimations ; a futurThis study represents the first research in Italy to examine the potential of visual telerehabilitation in improving the visual function of children with visual impairment (VI). By investigating the feasibility and effectiveness of this telemedicine-based approach, this study served to catalyze the pioneering efforts of orthoptists during the COVID-19 pandemic. The findings of the study suggested that visual telerehabilitation could be a promising tool for improving the visual function of VI children, as it allows the training of compensatory eye movements, visual attention, and eccentric fixation.The results of this study also indicate that visual telerehabilitation could be a valuable means of providing access to vision rehabilitation services for VI children and their families, particularly in situations where physical distancing and lockdowns are required due to infectious disease outbreaks such as COVID-19. As a stand-alone method, visual telerehabilitation has the potential to overcome several barriers in the care of VI children, including physical distance, limited availability of specialized services, and contagion risks.Overall, the findings of this study lay the groundwork for further research and testing of the effects of telematic healthcare and rehabilitation services for VI children. By exploring the feasibility and effectiveness of visual telerehabilitation in improving visual function, this study contributes to the growing body of literature on the use of telemedicine-based approaches for visual rehabilitation in VI patients. Future studies should focus on testing the long-term effects of visual telerehabilitation, as well as exploring other measures of visual function beyond ergo-perimetry. Such efforts could help to develop more comprehensive and effective telemedicine-based approaches for the care of VI patients, from the developmental age.


Background: Allergic rhinitis (AR) is the most common chronic allergic disease in children. Several studies have shown an association between attention deficit hyperactivity disorder (ADHD) and allergies, especially AR. Patients with ADHD usually have poor therapeutic adherence, and untreated AR symptoms may worsen the quality of life of patients. Methods: The aim of our study was to analyse therapeutic adherence in patients with ADHD and AR and estimate the impact of the adherence on ADHD symptoms. Total Nasal Symptoms Score (TNSS), Paediatric or Adolescent Rhinoconjunctivitis Quality of Life Questionnaire , Swanson, Nolan, and Pelham version IV scale (SNAP-IV), and Medication Assessment Questionnaire (MGL MAQ) were recorded. Results: In the AR-ADHD group, a positive correlation between TNSS and SNAP-IV subscales was found: worse AR symptoms were related to a negative effect on ADHD scores. AR-ADHD patients with better ADHD therapeutic adherence showed higher AR symptoms and higher oppositional defiant disorder scores in the SNAP-IV questionnaire. Conclusions: Our results suggest that better adherence to AR therapy  is associated with a reduction in inattention symptoms in children with ADHD. This data could prove to be fundamental for the psychic outcome of these patients. Allergic rhinitis (AR) is the most common chronic allergic disease in school-age children ,2, with Attention deficit hyperactivity disorder (ADHD) is a common neurobehavioral disorder affecting 7.2% of children worldwide ; furtherA recent systematic review and meta-analyses  have shoAs underlined above, both AR and ADHD have a negative impact on social habits, school performance, and the sleep quality of affected children, especially in untreated patients.The purpose of our study was to analyse the therapeutic adherence in a small group of children with ADHD and AR, while also evaluating if satisfactory medication adherence may improve symptoms control and the quality of life of patients suffering from AR and ADHD.Pilot, prospective, monocentre case–control study.Children of both genders, aged 6–18 years old, with a confirmed diagnosis of AR  and ADHDExclusion criteria included: children younger than 6 years old and older than 18 years old without a diagnosis of ADHD and AR.Age-matched children with AR and requiring medications for AR, without ADHD, who had a regular follow-up in the Paediatric Unit, University of Messina, Italy, were enrolled as the control group. These children fulfilled criteria for AR diagnosis according with the ARIA guidelines .Exclusion criteria included: children younger than 6 years old and older than 18 years old without a diagnosis of AR and without an intermittent or chronic therapy for AR .Parents of all enrolled children completed validated questionnaires about the AR symptoms  , the quaThe Total Nasal Symptom Score (TNSS)  was usedThe impact of AR symptoms on the quality of life was analysed in the two groups through two different questionnaires: the Paediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ), approved for children 6–12 years of age; and the Adolescent Rhinoconjunctivitis Quality of Life Questionnaire (ARQLQ) approved for adolescents 13–17 years of age ,19.The PRQLQ consists of 23 questions about five items: nose symptoms, eyes symptoms, practical problems, other symptoms, and activity limitations. The score of each question ranges from 0 (no impairment) to 6 (maximum impairment); herein, higher scores are related to a worse quality of life.The ARQLQ is a 25-item questionnaire that adds a sixth item (emotions) to the other five. The score ranges are the same the PRQLQ.The Swanson, Nolan, and Pelham version IV scale (SNAP-IV)  is a 26-The Morisky Green Levine Medication Assessment Questionnaire (MGL MAQ)  defined p < 0.05.Data were collected and statistically analysed using Excel version 2013. Descriptive statistics (median and range) were used to describe demographic characteristics and clinical variables. The independent t-test was used to compare differences in age, TNSS, RQLQ, SNAPIV, and MGL MAQ scores between the AR-ADHD group and the controls. Fisher’s exact test was used to compare differences in preterm birth, exposure to parental tobacco smoke, neurological and allergic co-morbidities, sensitizing allergens, and different type of AR therapy  between the two groups. The relationship between possible explanatory parameters  and the subscales of SNAP-IV were evaluated via Pearson correlation in the AR group and the AR-ADHD group. The statistical significance was set at the level of The study was conducted in accordance with the Declaration of Helsinki, and all the participants’ parents gave written informed consent. This prospective observational study was carried out after the approval of the local Ethics Committee.A total of six AR-ADHD children and six AR control subjects were included in the study . All of With regard to allergic co-morbidities, 4/6 children (66.6%) in the AR-ADHD group showed comorbidities: 2/4 patients reported the diagnosis of asthma, and 3/4 patients were affected by allergic conjunctivitis. Among the AR group, 5/6 children (83.3%) had allergic diseases: four patients showed allergic asthma, two patients suffered from atopic dermatitis, and three patients reported a food allergy.p = 0.58 and p = 0.26, respectively) were detected. However, children in the AR-ADHD group achieved slightly higher scores in TNSS than the controls . Conversely, the AR group achieved higher scores in AR medication adherence (MGL MAQ) compared to the AR-ADHD group .Patients of both groups were divided into three different AR medication categories: the first one included children on oral antihistamines therapy; the second comprised patients on INCS; the third included children on both therapies . Overall, 50% of patients in the AR-ADHD group were under oral antihistamines therapy; in the AR group, 100% of children were under a combination therapy , principally due to the severity of the AR symptoms at the onset and the presence of atopic comorbidities. Regarding the questionnaires, no significant differences in AR symptom scores (TNSS) and AR medication adherence (MGL MAQ) between the two groups (p = 0.008) [The six children of the AR-ADHD group demonstrated significantly higher scores in SNAP-IV compared to the controls  .p = 0.06), TNSS and ODD subscale , and MAQ ADHD therapy and ODD subscale . Although these data were not statistically significant, a negative correlation was found between age and hyperactivity/impulsivity subscale and between MAQ AR therapy and inattention subscale .We compared possible explanatory parameters  with each subscale of the SNAP-IV in the AR-ADHD group . We idenp = 0.00018, p = 0.00002, and p = 0.00007 for the inattention, hyperactivity/impulsivity, and ODD subscales, respectively).We compared possible explanatory parameters  with each subscale of the SNAP-IV in the AR group . We did p = 0.21, p = 0.55, and p = 0.29 for the TNSS, SNAP-IV, and MAQ AR therapy questionnaires, respectively); however, the patients on combination therapy  totalized the higher mean scores in all the questionnaires compared to the other subgroups. This result may show that patients who need AR combination therapy are the ones with worse AR and ADHD symptoms.In the AR-ADHD group, we divided patients in three AR therapy subgroups  and analysed the different impact on TNSS, SNAP-IV, and MAQ AR therapy scores . No signp = 0.01 in AR-ADHD group vs. p = 0.00051 in the AR group) [Furthermore, a significant correlation was found between TNSS and number of sensitizing allergens in both groups of patients (R group) .ADHD is a common neurodevelopmental disorder which is accompanied by several psychiatric comorbid conditions. The high rate of comorbidities could make it complicated and difficult to manage . Severaln = 40) compared to non-ADHD controls (n = 40); in this study, they identified a higher number of maternal smoking in ADHD patients (3/40) but without a statistical significance (p = 0.241) and without specifying if the patients were allergic or not. Second-hand smoke exposure at home was defined as a potential risk factor for developing ADHD and allergic diseases  in the study of Wong et al. [In a Taiwan population-based study , a higheg et al. .In our study, we aimed to perform the following: (1) analyse the impact of demographic and social background  in AR-ADHD versus AR children; (2) evaluate the influence of neurological and/or allergic co-morbidities, AR symptoms (TNSS), ADHD symptoms (SNAP-IV), quality of life (PRQLQ and ARQLQ), AR and/or ADHD medication adherence (MGL MAQ) in both groups of patients; (3) investigate the relationship between possible explanatory parameters (particularly AR and/or ADHD medication adherence via 4-item MGL MAQ) and the subscales of SNAP-IV.Our study found no difference in age, pre-term birth, exposure to parental smoking, and neurological and/or allergic co-morbidities between both groups.p = 0.58). Based on the Pearson correlation results, it was observed that in the AR-ADHD group, there was a positive correlation between TNSS and SNAP-IV subscales, particularly the hyperactivity/impulsivity subscale  and the ODD subscale . These data showed how higher scores on TNSS were related to a negative effect on ADHD scores in the AR-ADHD group. Instead, no association was found between SNAP-IV subgroups and TNSS scores in the controls. The quality of life scores (PRQLQ and ARQLQ) did not show a statistical correlation in both groups , probably as a consequence of the small number of the sample. These results were in accordance with other studies. In particular, Feng et al. [In our analysis, patients in the AR-ADHD group achieved slightly higher scores in AR symptoms (TNSS) compared to the controls, but without a significant difference  after starting treatment for AR. Another recent 3-month prospective study [p = 0.005), with a significant decrease only in the AR group after treatment (p < 0.001).Previously, few studies have investigated the relationship between therapeutic adherence and AR symptoms in children with ADHD or with hyperactive/inattention symptoms. In 2014, Kim et al.  evaluateve study  enrolledp = 0.95), while the other subscales showed a non-significant positive correlation. Conversely, when evaluating the ADHD therapeutic adherence in the AR-ADHD group, we detected a significant positive correlation  in the ODD subscale. In other words, contrary to expectations, patients with better ADHD therapeutic adherence showed higher AR symptoms (worse TNSS scores) and higher ODD scores in the SNAP-IV questionnaire. However, only 33.3% of AR-ADHD patients were under AR combination therapy, in contrast to the control group (100% in combination therapy). Data analysis showed that AR-ADHD patients with higher TNSS scores are those on dual therapy  and with a more significant therapeutic adherence to ADHD and AR medications [Our study evaluated the relationship between therapeutic adherence (MGL MAQ) and the SNAP-IV subscales through the Pearson correlation in the AR-ADHD and AR patients. By analysing the AR therapeutic adherence in the AR-ADHD group, we found a slightly negative correlation only in the inattention subscale  of AR and/or ADHD.In our study, the patients in AR-ADHD group with worse symptoms seem to have a good AR therapeutic adherence, without a significant impact on their quality of life and on their symptoms. However, our results suggest that better adherence to AR therapy is associated with a reduction in inattention symptoms in children with ADHD. The data, if confirmed by further studies, could prove to be fundamental for the psychic outcome of these patients. The principal limitation of our study is the small sample size. However, this research was designed like a pilot study with the purpose of increasing the number of participants. In this perspective, a multicentre study maybe proposed with the possibility of increasing the number of possible explanatory variables .


The field of equine sports medicine and rehabilitation provides a career opportunity for students interested in remaining in the horse industry but not focused on a career as a veterinarian. However, throughout the United States, there are limited educational opportunities for undergraduate students to prepare for this career. The objective of this work was to determine what skills and theoretical knowledge professionals in the equine rehabilitation industry deemed most useful for employment in the equine rehabilitation industry, and, using that information, develop a curriculum to meet these industry needs. To meet this objective, a Qualtrics survey was distributed through email and social media to veterinarians, veterinary professionals, rehabilitation service providers, and horse owners. In addition to demographics, the survey asked respondents to list practical skills and theoretical knowledge that are essential for professionals in the equine rehabilitation industry. The majority of the 117 respondents (84%) were located in the United States, with the remainder from Canada (5%), the United Kingdom (5%), and several other countries. Eighteen percent of respondents were veterinarians, 26% owned or managed rehabilitation facilities, 8.5% were veterinary technicians, and the remainder were horse owners, rehabilitation service providers, and others. Horse handling skills (19%) and communication skills (18%) were the most commonly listed practical skills deemed essential for rehabilitation professionals. Of the theoretical skills, evaluation of lameness (29.5%), anatomy (31%), and fundamentals of equine reconditioning programs (32%) were deemed equally important for rehabilitation professionals. These data were used to design a minor in Equine Sports Rehabilitation that incorporated fundamental knowledge in lameness evaluation and rehabilitation methods as well as significant hands-on opportunities with rehabilitating horses and communicating about rehabilitation methods and progress with clients. Experiential learning opportunities in undergraduate curriculums are recognized as a primary driver of success in postgraduation career placement . Animal The horse industry itself is responsible for US$55 billion dollars of direct input to the United States GDP . DirectlThe procedures used in this study were approved by the University of Connecticut Internal Review Board, protocol X21-0095. The survey was designed in consultation with equine rehabilitation experts and veterinarians. The eight-item questionnaire included demographic questions and topical questions related to practical skills and theoretical knowledge required for lay professionals in the equine rehabilitation industry. The questionnaire was entered into Qualtrics for distribution . The surN = 98 responses) were located within the United States. Canada  and the United Kingdom  were also represented within the respondents. Remaining respondents were from Australia, France, Ireland, Lithuania, New Zealand, Spain, and Switzerland (N = 1 respondent each). Of the respondents from the United States, the majority  were located within the Northeast , 25.3% were located in Southern states , 18.9% were located in Western states  and 9.5% were located in Midwestern states . Of respondents, most were rehabilitation farm owners or managers , or other practitioners (N = 17).A total of 117 responses were returned from the survey . Of thos N = 27; , veterinN = 93 responses, N = 87 responses), wrapping (N = 83 responses), and hot and cold therapies (N = 79 responses). “Other” responses accounted for 37 total responses. When evaluated, these responses were further categorized (N = 11), identifying lameness (N = 7), administering medication (N = 6), nutrition (N = 5), and first aid/emergency care (N = 5), with nine other responses that did not fit in to other categories. Basic handling (32%) and communication (24%) were the most frequent skills listed as “most important” by respondents.In response to the question “What practical skills do you believe are essential for professionals in the equine rehabilitation industry?”, basic handling was the most selected response (egorized  into knoN = 86 responses), anatomy (N = 84 responses), and evaluation of lameness/biomechanics (N = 79 responses) as top choices (N = 19) included knowledge of first aid and emergency care (N = 9), physiology and behavior (N = 4), specific modalities (N = 3), and critical evaluation of medical data/use of modalities (N = 2). Fundamentals of exercise reconditioning programs (35%) and anatomy (31%) were identified as the two “most important” areas of knowledge by respondents.In response to the question “What medical knowledge do you believe are essential for professionals in the equine rehabilitation industry?”, respondents identified fundamentals of exercise reconditioning programs . Within Qualtrics, responses were tagged with key words, and which were then sorted in to three parent topics: Transferable skills (36% of responses), practical skills (34% of responses), and knowledge , and the “return to work” phase, which is a longer phase where the animal slowly gains fitness, while minimizing the risk of reinjury. Both phases of rehabilitation require specific practical skills and training. Given that the majority of time (likely more than 50%) in an equine rehabilitation position will be spent working with individual horses, it is not surprising that basic equine handling was identified as the most selected skill required and thus is incorporated into learning objective 4. In fact, “controlled hand walking” was the most frequently used modality of rehabilitation in a global study of rehabilitations specialists . To meetFurther, due to the frequent interactions with other caregivers , it was unsurprising that communication was also high on the list of required skills. The importance of the relationship  between different care providers has been previously identified . LearninIt is not surprising that fundamentals of exercise reconditioning programs, anatomy, and evaluation of lameness/biomechanics were identified as top responses to “What medical knowledge do you believe are essential for professionals in the equine rehabilitation industry?” These responses are incorporated into learning objectives 1, 2, and 3. To meet the learning objectives, students are required to take an upper (3000 or 4000) level exercise physiology course in Animal Science or Kinesiology, Equine Sports Rehabilitation Seminar, Equine Sports Rehabilitation Practicum, and can opt to take additional kinesiology courses. The exercise physiology courses both have prerequisite anatomy and physiology courses, ensuring students have fundamentals of anatomy and physiology. Fundamentals of exercise programs are covered in both exercise physiology courses, and both require evaluation of scientific evidence. The Equine Sports Rehabilitation Practicum incorporates lameness evaluations as students assess the progress of their horse. Other responses to this question included knowledge of first aid and emergency care, behavior, specific modalities, and critical evaluation of medical data/use of modalities. These are addressed in the Equine Sports Rehabilitation Practicum and Seminar courses. In particular, the seminar covers specific modalities through discussions and demonstrations, including the mechanisms and when each should or should not be used. The practicum includes recognition of stress and pain behaviors, how to handle horses with challenging behaviors, and first aid. Further, these courses/experiences will provide opportunities to learn and practice bandaging and wrapping, administering medications (under supervision of the instructor), record keeping and reporting (through required assignments in the Practicum), and situational awareness as students continually evaluate the horses they are working with. It is expected that the professional internship will also address these learning objectives by providing additional situations to apply the learned knowledge.In response to the question “Are there specific skills or qualities you look for in employees that will be rehabilitating horses? If so, what are they?”, potential employers focused on three general areas—transferrable skills, practical skills, and knowledge. Transferable skills are defined as those that can be used in multiple situations or careers , includiSurvey respondents identified several practical skills as desirable in potential employees. Many of these skills are related to basic horsemanship and handling, with few listing riding as a desired skill. In a study of rehabilitation providers, it was identified that lay people (nonveterinarians), trainers, and owners were frequent providers of hand walking, massage, treadmill, hot and cold therapies, and bandaging , similarBehavior, identifying lameness, and basic horse knowledge and management were among the “knowledge” characteristics identified as desired in potential employees. These skills and knowledge are incorporated into equine training 1—groundwork, equine sports rehabilitation practicum, and the professional internship. Employers also valued knowledge of anatomy and nutrition, which is included in the exercise physiology courses, as well as potential electives . Further, scientific literacy was also identified as a desired characteristic. Scientific literacy includes content knowledge, scientific practices, identifying and judging scientific expertise, and application of science to real-world scenarios . These sLearning objectives for Animal Science curricula generally cover nontechnical skills such as critical thinking, scientific communication, and scientific literacy in addition to discipline specific competencies such as knowledge of domestic animal husbandry and management, physiological processes underlying the development and production of food and other domestic animals, and the structure and function of the animal food and fiber industry . Many anLimitations to this study include a lack of available data on industry demand for positions in equine sports rehabilitation. In the United States, there is no national governing body that tracks individuals in equine sports medicine outside of the veterinary field, and requirements for rehabilitation practitioners vary from state to state. Thus, our understanding of the job market and demographics of practitioners is limited. Of note, several respondents noted that in their areas, there was a shortage of facilities and individuals willing to do rehabilitation work. However, additional research is needed to confirm this demand.Current options in equine rehabilitation training programs for undergraduate degree students are limited. For example, the University of Tennessee offers the only university-based, American Association of Veterinary State Boards Registry of Approved Continuing Education approved credentialed program in equine rehabilitation, but this is only available to veterinarians, veterinary technicians, physical therapists, or active students in these professions. Midway University offers an equine rehabilitation concentration within their Equine Studies Bachelor of Science program. This area of concentration includes similar courses to those described above, such as exercise physiology and equine rehabilitation courses focusing on understanding different therapeutic modalities and participating in hands-on experiences rehabilitating horses. Other programs offered by nonuniversity organizations often include considerable cost to the participant, as well as a need to travel to the location for the hands-on part of the training. The added cost and travel make this inaccessible for many students. Thus, creating a minor that integrates into the animal science curriculum allows students to gain additional knowledge and hands-on skills, better preparing them for careers in the horse industry.txad042_suppl_Supplementary_DataClick here for additional data file.


Purpose: The goal of this research is to translate and analyze the psychometric properties of the Arabic version of the Waterloo Footedness Questionnaire-Revised (WFQ-R).Materials and methods: Two native Arabic speakers created separate forward translations, which were then merged. Two different multilingual translators were used to translate it back into English from the synthetic version. Experts were gathered for a discussion on how to improve the localization and adaptation processes. A group of specialists was convened to analyze the localization and modification procedures. We now have the Arabic version of the WFQ-R which is "WFQ-R-Ar". Two hundred and ninety Arabic-speaking adults over the age of 18 were surveyed to evaluate the WHQ-R-Ar's characteristics .Results: The WFQ-R-Ar had no collisions with the ground or the sky. The factor analysis showed that the construct validity of the WFQ-R-Ar was dependent on a single factor. The WFQ-R-Ar also has excellent internal consistency, with a Cronbach's alpha of 0.93. The reliability of the examinations was examined, and it was found to have an intraclass correlation value of 0.94.Conclusion: The WFQ-R-Ar may be relied on to provide accurate results when used to evaluate footedness in Arabic-speaking society. One of the behavioral predictors often used to determine cerebral lateralization is foot preference, also known as footedness . FootednResearch has looked into footedness and how it relates to postural control, gait, or motor abilities . AccordiEvidence suggests that leg preference may influence postural control -14. For The WFQ-R, however, has not been cross-culturally modified and translated for the Arabic population. Given the significance of doing so in clinical and behavioral contexts , 21, fooTranslation and cross-cultural adaptationThe original WHQ questionnaire's developer, Dr. Lorin Elias, permitted the Arabic translation. The WFQ-R-Ar was translated and cross-culturally adapted in the following five steps according to recommendations made by Beaton and colleagues .Forward translationIn step one, two bilingual, native Arabic speakers with a strong command of English, carried out the forward translation from English into Arabic separately. A written report for each translated version was presented to an expert committee together with the translators' observations and the justifications for decisions made regarding difficult problems. After settling disagreements between translators, the two forward-translated texts were combined into one Arabic version in step two. The expert committee also received a written report for the integrated version.Back-translation and expert committeeIn step three, two native English speakers independently completed the back-translation of the synthesized Arabic version into English and each submitted a report to the expert committee. In step four, a group of specialists in research methodology, language translation, and rehabilitation was assembled to assess all the translated versions and examine all the written reports provided. A prefinal version of WFQ-R-Ar was created after the committee resolved all differences following evaluation and review.Pilot testing of the pre-final versionA total of 30 participants, all 18 years old and able to read, speak, and understand Arabic, took the pre-final WFQ-R-Ar version test in step five. Independent completion of the pre-final WFQ-R-Ar version was required from the participants. During the in-person interview, patients were invited to speak openly and honestly about the items' clarity, relevance, and any challenges they had in answering the questionnaire. The pre-final draft was modified slightly after the committee had read the notes and recommendations from the patients.Participants and data collectionParticipant recruitment was done in the community via advertisement posters and word of mouth, using a convenient sampling approach. Men and women aged 18 and up were eligible to participate from all throughout Saudi Arabia, and those who could read, write, and interpret Arabic were given priority. The study cohort included in the analysis consisted of the 290 remaining individuals after 30 of the 320 recruited participants withdrew from the study. The study's investigator contacted potential participants to participate. The study's objectives and methods were explained to patients who accepted the invitation, and they were also requested to read and sign a written consent form.All study participants (n = 290) needed a demographic form to determine which foot was dominant. The footedness was evaluated using the following question, with the choices "right" and "left". It's like asking, "With which foot do you prefer to kick this ball in front of you?". The WFQ-R-Ar questionnaire was then administered to individuals twice at baseline and once within one week following the first test-retest reliability assessment. The patient's demographic data, which included age, gender, education, occupation, and dominant foot, were provided.QuestionnaireThe WFQ-R-Ar measures how often each foot is used via 13 questions answered on a 5-point Likert scale. A number between -2 and 2 is given to each response, with scores closer to 0 showing ambipedalism , scores closer to -2 suggesting left-footedness, and scores of two indicating right-footedness. Respondents are classified as ambipedal, left-footed, or right-footed based on their total score, which ranges from -6 to +6, -7 or below, and +7 or more, correspondingly .Data analysisParticipants' characteristics were analyzed using descriptive statistics. The foot dominancy was measured by the footedness question and WFQ-R-Ar. The participant's responses to the interview questions regarding the applicability and suitability of the scale to assess foot dominance were used to determine face validity. If the experts on the committee agreed that the scale was pertinent and suitable for assessing Arabic speakers' footing, then the content's legitimacy was established. More than or equal to 15% of respondents needed to provide the lowest or highest possible score for the scale to have a floor or ceiling effect .Factor analysis using the direct oblimin rotation approach was used to determine whether or not the WFQ-R-Ar has construct validity by identifying and extracting components with eigenvalues larger than one, as defined by Kaiser . The relThe construct was validated using hypothesis testing. Construct validity is the degree to which an instrument's score reflects what it is intended to reflect . The expThis article was previously posted to the medRxiv preprint server on April 27, 2020.Two hundred and ninety Arabic-speaking participants took part in this investigation. Table The WFQ-R-Ar's translation and cultural adaptation were smooth and error-free operations. The question "Which foot would you use to help push a shovel into the ground?" (#9) was the only one that needed further explanation to be understood. Furthermore, by replacing acronyms (La/Ru) with genuine words , the subsequent cultural adaptation improved the respondent's understanding of the answer grid. In addition, people questioned after the pilot study said the questionnaire was clear, relevant, and appropriate for determining foot dominance. The testimony of these people attests to the WFQ-R-Ar's apparent validity. Also, the expert group has agreed on the usefulness and suitability of the WFQ-R-Ar for Arabic speakers to identify foot dominance. The analysis's satisfactory item completion rate and the absence of floor and ceiling effects further support the WFQ-R-Ar's content validity.In terms of construct validity, The Kaiser-Meyer-Olkin test of sample size (p = 0.93), the sphericity test (p 0.001), and the determinant score r = 0.112) all indicate that the distribution is not multicollinear. These three outcomes indicated that factor analysis was a viable option for the data. There's only one thing that accounted for 60.05% of the variance and had an eigenvalue greater than Kaisar's threshold of one (6.01), which was identified through factor analysis  of 0.93. Excellent test-retest reliability was found for WFQ-R-Ar stability, with an intra-class correlation coefficient (ICC) value of 0.94  = 0.93-0.95) .This study details the psychometric features of the WHQ-R-Ar, an Arabic version of the original WHQ that has been modified to fit local customs. Results show that the WFQ-R-Ar translation and cultural adaptation were effective. The WHQ-R-Ar's validity, internal consistency, test-retest reliability, and measurement error were all sufficiently high to recommend it for use in predicting footedness among Arabic-speaking adults.The results of cross-cultural adaptation support WFQ-R-Ar's face validity. The WFQ-R-Ar was deemed relevant and acceptable for measuring footedness by a committee of experts who worked on the translation. Face validity was further reinforced by participant testimonials, which unanimously agreed that the WFQ-R-Ar was understandable, applicable, and well-suited to the purpose of measuring footedness. According to the assessments, the WFQ-R-Ar has sufficient content validity since it shows no floor or ceiling impact . The WFQFactor analysis was used to look into the WFQ-R-Ar's construct validity, and it was hypothesized that the WFQ-R-Ar would only consist of a single factor. The results of the factor analysis demonstrated that the WFQ-R items' Ar's are derived from a single common component. Every item extensively loaded this factor in the WFQ-R-Ar. The WFQ-R-Ar was responsible for a significant proportion (55.79%) of the variance. The WFQ-R-Ar's construct validity is confirmed by the factor analysis's overall findings, which also support the idea that this measure evaluates one underlying construct: footedness. The construct validity results from the present investigation are consistent with those previously reported .Excellent internal consistency for the WFQ-R-Ar indicates that the scale's items are correlated, homogenous, and not redundant . By remoThe new research has better dependability than the Turkish study , BraziliClinicians and researchers in Arabic-speaking countries now have a validated instrument to evaluate footedness, thanks to the efforts of this study to cross-culturally adapt and examine the measuring features of the WFQ-R-Ar. As was said, assessing footedness is a common first step for therapists when designing treatment plans. The evaluation of footedness by clinicians too often relies on a single inquiry. However, multi-item surveys are preferable for assessing lateral preference to binary ones.For this analysis, we employed a translation of the WFQ-R into contemporary standard Arabic; dialects were not included. This translation was done in this way to encourage the usage of the current standard Arabic language in all Arabic-speaking countries, as it is understood across these regions. All the same, the participants in this research were all Saudis. So, before using the WFQ-R-Ar in other Arabic-speaking countries, a formal assessment of its measuring properties in the local context should occur. The WFQ-R-Ar has also been piloted on typically developing adults. The measuring properties of the WFQ-R-Ar need further study in different populations.Some study limitations are that the study's sample consisted of participants who were at least 18 years old and could speak Arabic. This criterion may unintentionally exclude certain members of the community, which might introduce bias into the sampling process and reduce the results' applicability to a wider age range or individuals with less skill in Arabic. Participants' perceptions were used as data in the research. This raises the possibility of a biased reaction, as participants might provide answers that align with social desirability or misrepresent their true experiences. The study did not address the criterion validity of the WFQ-R-Ar by comparing its results to a gold standard measure or an established footedness assessment tool.The current study was conducted to explore the measuring characteristics of the WFQ-R-Ar's questionnaire by culturally adapting the original WHQ. The adaptation process went without a hitch, with minor changes to the original WHQ. The WFQ-R-Ar is a reliable and valid tool for measuring footedness in an Arabic-speaking population aged 18 years old. These WFQ-R-Ar measurement characteristics confirm the measure's relevance to all practical and academic purposes.