This study compared the efficacy of Motor Imagery brain-computer interface (MI-BCI) combined with physiotherapy and physiotherapy alone in ischemic stroke before and after rehabilitation training. We wanted to explore whether the rehabilitation effect of MI-BCI is affected by the severity of the patient’s condition and whether MI-BCI was effective for all patients. Forty hospitalized patients with ischemic stroke with motor deficits participated in this study. The patients were divided into MI and control groups. Functional assessments were performed before and after rehabilitation training. The Fugl-Meyer Assessment (FMA) was used as the primary outcome measure, and its shoulder and elbow scores and wrist scores served as secondary outcome measures. The motor assessment scale (MAS) was used to assess motor function recovery. We used non-contrast CT (NCCT) to investigate the influence of different types of middle cerebral artery high-density signs on the prognosis of ischemic stroke. Brain topographic maps can directly reflect the neural activity of the brain, so we used them to detect changes in brain function and brain topological power response after stroke. Compared the MI group and control group after rehabilitation training, better functional outcome was observed after MI-BCI rehabilitation, including a significantly higher probability of achieving a relevant increase in the Total FMA scores , FMA shoulder and elbow scores , FMA wrist scores , the MAS scores , the NCCT . The findings demonstrate that MI-BCI rehabilitation training could more effectively improve motor function after upper limb motor dysfunction after stroke compared with routine rehabilitation training, which verifies the feasibility of active induction of neural rehabilitation. The severity of the patient’s condition may affect the rehabilitation effect of the MI-BCI system. Ischemic stroke refers to the necrosis of brain tissue caused by stenosis or occlusion of the feeding arteries of the brain  and insufficient blood supply to the brain. Brain tissue damage leads to the rupture of the brain nerve pathways that control movement, language, and other functions, resulting in hemiplegia and even disability. According to the World Health Organization, stroke is the main cause of disability and mortality in China. In 2019, the number of stroke deaths reached 2.19 million, and there were 3.94 million new stroke cases. The number of stroke patients in China has maintained a sharp upward trend in recent years . Stroke In this study, we designed an MI-BCI rehabilitation application system using EEG and visual, auditory, and electromyographic stimulation feedback. Forty stroke patients will be randomly divided into MI and control groups. The MI group will receive routine treatment and MI-BCI treatment, whereas the control group will only receive routine treatment. The feasibility and effectiveness of the MI-BCI system in the upper limb rehabilitation of stroke patients were verified by comparing the clinical scale, NCCT, and EEG between the two groups. By comparing the rehabilitation of motor function of patients in the MI group before and after treatment, we preliminarily explored whether the severity of the disease affects the use of MI-BCI and whether MI-BCI can be used by all patients.During the rehabilitation process, patients with stroke were selected from a hospital between February 2019 and May 2020. (1) Inclusion criteria: ➀ those who met the diagnostic criteria of the Chinese guidelines for the diagnosis and treatment of acute ischemic stroke 2019  and had upper limb dysfunction and were responsible lesions; ➁ The patient had the first onset and was in the recovery period of ischemic stroke; ➂ Age 35–70 years old, without obvious cognitive dysfunction and in good mental state; ➃ Before the clinical trial, they did not receive formal motor imagery therapy; (2) Exclusion criteria: ➀ in the first aid, the patient is not out of danger and the vital signs are not stable; ➁ Having various primary malignant tumors, serious heart, liver, lung, kidney, endocrine, hematopoietic, immune system and other serious diseases ; ➂ The patient has arthritis, rheumatoid, fracture and other diseases or symptoms that affect the motor function of the upper limb; ➃ Patients who are mentally abnormal or relatively resistant to treatment; ➄ Patients or their family members cannot sign the informed consent form and cannot cooperate to insist on treatment.First, the data were collected from 47 patients. During the initial MI-BCI data collection process, three patients were excluded because the accuracy of EEG collection was lower than the standard, and four patients voluntarily withdrew for personal reasons. According to the random distribution method and personal will, the patients were divided into the MI group (20 cases) and the control group (20 cases) . Finally, a total of 20 stroke patients participated in the entire MI-BCI upper-limb rehabilitation training and voluntarily participated in the trial. They or their families signed an informed consent form and were able to adhere to treatment and examination. This study was reviewed and approved by the hospital ethics committee . The purpose of the experiment was to perform scene EEG acquisition and upper-limb rehabilitation training for stroke patients. This is a non-invasive experiment that will not cause harm to subjects and protect patients’ privacy. After initial treatment, patients regain basic mobility and then undergo rehabilitation in community hospitals; therefore, follow-up after 3–6 months is difficult to perform. The project team collected data before and after rehabilitation in a stroke hospital.All treatments in the MI and control groups were performed in accordance with “Chinese Guidelines for Stroke Prevention and Treatment (2021 edition).” The entire rehabilitation system consists of a mobile portable host, 64 channel EEG systems, myoelectric stimulation system, and motion imagination software. The repair of upper-limb motor neuron injury is completed through two categories of motor imagination. The patient imagines left- or right-hand movements, and the EEG amplifier transmits the patient’s EEG to the BCI online system. The online system analyses the EEG to obtain an output command, and the functional myoelectric stimulation equipment stimulates the limbs to provide feedback to the nervous system. Another external nerve pathway was built through the MI-BCI and myoelectric stimulation systems.Data Collection and Preprocessing: As shown in Surface EMG data were recorded using Pico EMG sensors  from 16 muscles collected in a bipolar fashion: extensor digitorum, flexor digitorum superficialis, lateral head of the triceps muscle, long head of the biceps brachii muscle, pectoralis major, lateral deltoid, anterior deltoid, and upper trapezius on both sides. The EMG sensors were placed according to the guidelines reported by MI group received MI-BCI rehabilitation training and routine rehabilitation training.(1)MI-BCI rehabilitation training: The patient sat on a comfortable chair, 70 cm away from the monitor, the visual interface was located in the center of the 22 inch LCD, the resolution was 1920 × 1080 pixels, the screen refresh rate was 60 Hz, and the EEG sampling frequency was 1000 Hz . After sitting down, the patient began rehabilitation. The patient was relaxed and looked directly at the monitor. Based on the rehabilitation process of stroke patients, we built a set of MI-BCI visual and auditory stimulation systems using E-Prime 3.0 software (which can present a combination of multiple stimuli). Play a set daily motion animation of the upper limbs on the screen . The asynchronous amplitude (SOA) at the beginning of stimulation was set to 5 s to ensure that the patient understood the visual stimulation. This 5 s includes displaying a slow-moving image for 3.5 s and then masking the image for 1.5 s. One process included 12 image appearance processes, and the patients were allowed to rest for 1 min between processes. Complete rehabilitation training was repeated the whole process 50 times. During rehabilitation, the EEG acquisition system recognizes the signals of patients. The EEG signals were then converted into motion commands. The motor command controls the myoelectric stimulation system to stimulate the limb muscles of the patient. In the entire process of rehabilitation treatment, professional rehabilitation physiotherapists assist patients in completing their movements. During the rehabilitation process, the patient tries to avoid non-subjective movements . The patient will be treated for 3 weeks, 5 days a week, for 45–60 m a day.(2)Routine rehabilitation training, balance training, standing training, standing and sitting balance training, center of gravity transfer training, bed and chair transfer training, walking training, brace and auxiliary Walker training, and daily living ability training . Physiotherapists will adjust the rehabilitation plan in a timely manner according to the patient’s condition, and evaluate the training effect.The control group only completed routine rehabilitation training. Training time, frequency, and content were the same as those in the MI group.After 21 days of rehabilitation training, the staff assessed the patients’ exercise abilities and physical status. All assessments were performed by the same trained staff who were blinded to the patient’s rehabilitation.(1)FMA motor function score: The fugl-meyer assessment (FMA) was used to assess the upper limb motor function of patients in the MI and control groups, ignoring the upper limb sensory, passive joint mobility and pain sections of the table, and the reflexes section; only the 33 items in the upper limb section were used for this assessment, with a total score of 0–2 for individual items and 0–66 for the total score, based on 34 points for shoulder and elbow, 22 points for wrist and hand, and 10 points for motor coordination, with higher overall scores indicating better upper limb motor function.(2)MAS motor function score: The motor assessment scale (MAS) was used to assess the comprehensive motor function and muscle tension of the body, which can effectively observe the curative effect and recovery of sensory movement on the affected side, ignoring the five functions of posture change and walking in the scale. This assessment used only four items: upper limb function, hand function, and general muscle tension. The individual score was 0–6 points, and the total score was 0–24 points. A higher score indicated better comprehensive motor function of the upper limb.(3)Hyperdense middle cerebral artery sign (HMCAS): On non-contrast CT (NCCT) examination, the diseased cerebral artery presents a high-density signal compared to the contralateral one. It has been suggested that cerebral artery occlusion occurs in acute cerebral infarction in the cerebral artery-supplying area. NCCT can distinguish between cerebral hemorrhage and cerebral ischemia based on density changes in the visible vascular running area. A high density may lead to acute thrombosis, resulting in slow blood flow, stagnation, and even arterial occlusion.(4)Clinical efficacy: Neurological deficit scores of Chinese patients with stroke were used as the criteria for determining efficacy. The functional impairment scores included the FMA, MAS, and HMCAS. When two of the three scores were met, patients were included at this level. Full rehabilitation: disability level 0 with 91% to 100% reduction in functional impairment score; significant rehabilitation: disability level 1–2 with 46% to 90% reduction in functional impairment score; general rehabilitation: disability level 3–4 with 18% to 45% reduction in functional impairment score; no change: no improvement in disease; deterioration (including death): increased functional impairment score compared to pre-rehabilitation. After rehabilitation training, general rehabilitation, significant rehabilitation, and full rehabilitation can be considered effective rehabilitation; no change or deterioration can be considered invalid rehabilitation.(5)Brain topographic map: A plane graph of the spherical scalp represented by different colors of power values in each frequency band of the brain wave. When a certain region of the cerebral cortex is activated by various factors, the blood flow and metabolic activity in this region change with an increase in the activation intensity. As the stimulus increases, the effect of brain information modulation decreases and the amplitude of the EEG signal in the alpha and beta frequency bands decreases, which is called event-related desynchronization (ERD). That is, the event-induced spectral component was lower than the spontaneous spectral value, which was identified as negative in event-related spectral perturbation (ERSP). In contrast, the effect of information modulation in the brain is improved in the resting state, and the phenomenon of EEG signal spectrum amplitude is called event-related synchronization (ERS), which indicates that the event-induced EEG spectrum component is higher than the spontaneous EEG spectrum value, and it is identified as positive in ERSP.p-value was <0.05. The Shapiro–Wilk test was used to test the normality of quantitative data. (x ± s) was used to represent the measurement data conforming to the normal distribution. Qualitative data were explained by the number of cases and the component ratio (n [%]). The t-test was used to compare differences in continuous variables. χ2 test and comparison of differences in categorical variables.Statistical software (SPSS 26.0) was used for the data analysis. The difference was considered statistically significant when the bilateral P > 0.05).As shown in P < 0.05). All differences in the FMA scores were significantly higher in the MI group than in the control group after rehabilitation.As shown in P < 0.05).As shown in P < 0.05).As shown in As shown in The average power spectral density (PSD) of each channel was calculated according to the spatial spectral characteristics of EEG signals under tactile stimulation feedback. Finally, the PSD value was mapped to the topographic map to determine the spatial spectral characteristics of brain oscillations. The event-related spectral perturbation power of all subjects in typical frequency bands of 8–30 Hz   was extrAs shown in As shown in This study used multisensory MI-BCI and FES feedback to verify the neural plasticity of stroke patients . ExploriFor upper limb motor function rehabilitation in stroke patients, BCI combined with external devices may be more effective than conventional rehabilitation strategies, but there is a lack of comprehensive evaluation of motor function rehabilitation in patients. In this study, MI-BCI was combined with FES to perform multisensory stimulus feedback, including visual, auditory, and tactile stimuli, and an upper limb rehabilitation system based on MI-BCI was established. We used the clinical scales FMA, MAS, and NCCT to comprehensively evaluate the rehabilitation effect of MI-BCI. Clinical scale results showed that FMA, MAS, and NCCT scores significantly improved after Mi-BCI rehabilitation treatment, and the scores of patients in the MI group were significantly higher than those in the control group. These results indicate that MI-BCI rehabilitation training can effectively improve motor function in stroke patients, which is consistent with the results of previous studies. In this study, we used an EEG-based brain topographic map to comprehensively study the brain activity of stroke patients after rehabilitation therapy with MI-BCI. According to the analysis of the brain topographic map, the brain ERD of patients with full rehabilitation and significant rehabilitation in the MI group was significantly higher than that in the control group, however, there was no significant difference in ERD between patients with general rehabilitation and no change in the two groups, indicating that if patients actively participate in the rehabilitation of MI-BCI, the feedback of myoelectric stimulation induced by FES could effectively promote nerve remodeling and improve the effect of rehabilitation. The total effective rate of the MI group was 95% (19/20), which was higher than that of the control group . The results of this study prove that MI-BCI rehabilitation therapy is both effective and feasible. However, there was one patient in the MI group whose condition did not change, and three patients were excluded because the accuracy of EEG collection was lower than the standard, which was probably caused by adverse factors such as brain damage, poor motor function, speech disorders, and spasms in stroke patients.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Biomedical Ethics Committee of Hebei University of Technology. The patients/participants provided their written informed consent to participate in this study.WL and CL conceived the study. WL and JL collected the data and wrote the manuscript. JL conducted the experiments. XZ performed the EEG data processing. CL reviewed and edited the manuscript. All authors have reviewed the manuscript, agreed to its submission, read, and approved the final manuscript.


Over the last decade, augmented reality (AR) has emerged in health care as a tool for visualizing data and enhancing simulation learning. AR, which has largely been explored for communication and collaboration in nonhealth contexts, could play a role in shaping future remote medical services and training. This review summarized existing studies implementing AR in real-time telemedicine and telementoring to create a foundation for health care providers and technology developers to understand future opportunities in remote care and education.This review described devices and platforms that use AR for real-time telemedicine and telementoring, the tasks for which AR was implemented, and the ways in which these implementations were evaluated to identify gaps in research that provide opportunities for further study.We searched PubMed, Scopus, Embase, and MEDLINE to identify English-language studies published between January 1, 2012, and October 18, 2022, implementing AR technology in a real-time interaction related to telemedicine or telementoring. The search terms were “augmented reality” OR “AR” AND “remote” OR “telemedicine” OR “telehealth” OR “telementoring.” Systematic reviews, meta-analyses, and discussion-based articles were excluded from analysis.A total of 39 articles met the inclusion criteria and were categorized into themes of patient evaluation, medical intervention, and education. In total, 20 devices and platforms using AR were identified, with common features being the ability for remote users to annotate, display graphics, and display their hands or tools in the local user’s view. Common themes across the studies included consultation and procedural education, with surgery, emergency, and hospital medicine being the most represented specialties. Outcomes were most often measured using feedback surveys and interviews. The most common objective measures were time to task completion and performance. Long-term outcome and resource cost measurements were rare. Across the studies, user feedback was consistently positive for perceived efficacy, feasibility, and acceptability. Comparative trials demonstrated that AR-assisted conditions had noninferior reliability and performance and did not consistently extend procedure times compared with in-person controls.Studies implementing AR in telemedicine and telementoring demonstrated the technology’s ability to enhance access to information and facilitate guidance in multiple health care settings. However, AR’s role as an alternative to current telecommunication platforms or even in-person interactions remains to be validated, with many disciplines and provider-to-nonprovider uses still lacking robust investigation. Additional studies comparing existing methods may offer more insight into this intersection, but the early stage of technical development and the lack of standardized tools and adoption have hindered the conduct of larger longitudinal and randomized controlled trials. Overall, AR has the potential to complement and advance the capabilities of remote medical care and learning, creating unique opportunities for innovator, provider, and patient involvement. Augmented reality (AR) is an emerging technology that can enhance how the real world is experienced by the user. Compared with virtual reality (VR), in which the user is immersed in a completely synthesized world, AR combines both the virtual and real by overlaying the external world with computer-generated sensory data such as audio, video, and graphics. AR technology, often accessed through head-mounted devices (HMDs) or software on personal devices, can be used to display information and virtual objects that facilitate learning and navigation through tasks in the real world ,2.In medicine, VR and AR have been explored in educational, diagnostic, and treatment settings, with an increasing number of publications in the last decade -6. A 201A promising use of AR technology is in remote collaboration, an application seen in many industry- and engineering-related tasks over the last 2 decades ,15. As Ctelemedicine, a concept that first arose with the use of telephones to share information across hospital systems [synchronous telemedicine, defined as the use of electronic devices for real-time communication in health care services related to patient encounters, treatment, and consultation [Telementoring, a subcategory of telemedicine, is the real-time remote guidance of health care procedures or skills. Telementoring also plays a role in granting remote access to care and expertise, enabling the sharing of specialized knowledge and education [Remote medical communication is a defining feature of  systems . Since tultation ,26. Teleducation . Similarducation . By explScoping reviews entail a systematic selection of literature with the purpose of examining the extent and nature of an area of interest ,30. CompWhich devices and platforms using AR have been studied in the published literature in the context of real-time telemedicine and remote education? In which areas of medicine have these been integrated and for what purposes? How are outcomes evaluated and what variables have yet to be measured? What are the overall findings of existing studies?The literature was reviewed using PubMed, Scopus, Embase, and MEDLINE for articles or trials published from January 1, 2012, to October 18, 2022, with search queries submitted and articles accessed on October 18, 2022. The search terms were “augmented reality” OR “AR” AND “remote” OR “telemedicine” OR “telehealth” OR “telementoring.” The PubMed search was performed using article titles and abstracts. The Scopus search was performed using article titles, abstracts, and keywords, with articles and conference papers in the areas of “medicine,” “health professions,” and “nursing” included. The Embase search was performed using article titles, abstracts, and keywords, with articles and conference papers included. The MEDLINE search was also performed using article titles, abstracts, and keywords. Only articles available in English were included.Following the PRISMA  guidelines, the titles and abstracts of all articles were independently reviewed by 2 researchers (AD and AF) for relevance to AR and real-time communication between separated individuals. Articles were excluded if they were unrelated to medicine or were reviews or discussions. Any articles that were included by one reviewer but not the other were included in the full-text screening, which was also performed independently by the 2 researchers. As this review focused on the use of AR rather than the development of related equipment or software, articles were excluded if the technological design, rather than the implementation, was the focus or if the technology was not intended for remote interaction as described by the inclusion criteria. Articles that included both technological design and implementation data were included, with the review focusing on the latter. Articles that described mixed reality devices capable of both AR and VR were included if the implementation primarily used and studied AR features. Reviews, perspectives, discussion-based articles, and study proposals without results were excluded. Correspondence was sent to the authors of articles for which the full text was not available; a lack of response resulted in the exclusion of these articles. Any disagreements regarding an article’s inclusion were resolved through discussion between the 2 reviewers.The articles were reviewed based on the context in which the AR was implemented. Articles describing mixed reality devices were analyzed for data relevant to AR use and not VR. Unique devices and platforms using AR across the articles were identified. The articles were later grouped into one of the 3 identified areas: patient evaluation, medical intervention, and education. “Patient evaluation” included articles that described the examination of patients and processes that obtained information for clinical decision-making. “Medical intervention” included articles that described procedures related to the initiation or provision of therapy. “Education” included articles that described the mentorship or training of a less experienced individual for a task or procedure. Subgroups for surgical versus nonsurgical tasks in the latter 2 groups were created. Articles that fell into more than one of the 3 identified areas were organized in the Results section of this paper based on which area was the primary focus. Finally, common objective and subjective end variables discussed in the articles were identified.For this scoping review, we first provide an overview of the devices and platforms that use AR and the types of tasks in which they appear. We then summarize the implementation and measurement of these AR-capable tools within 3 areas: patient evaluation, medical intervention, and education. Finally, we review the common methodologies and end variables observed across the studies.The PubMed, Scopus, Embase, and MEDLINE searches yielded 298, 195, 187, and 274 articles, respectively. This totaled 954 articles, 558 (58.5%) of which were identified as duplicates. The abstracts and titles of the remaining 396 articles were reviewed, with 62 (15.7%) identified as meeting the inclusion criteria. In total, 5% (3/62) of the articles, for which the full text was not available, were excluded after no response was received from the original authors. A total of 39 articles were included following full-text screening. The selection process is depicted in From the included articles, 20 unique devices and platforms with AR features were identified, with 10 (50%) being commercial HMDs in which AR features were projected before the wearer’s eyes and another 4 (20%) being “virtual presence”–type platforms in which a remote viewer can superimpose video of their hand or tools over the live stream of a local site or procedure; the hybrid video is accessed by both local and remote users via a smartphone, tablet, computer, or monitor. The remaining 30% (6/20) involved systems with no commercial HMDs or virtual presence—these included a smartphone app and systems built specifically for tele-ultrasonography, physical rehabilitation, and surgical telementoring. Overall, all the identified devices and platforms  allowed remote individuals to view the perspective or environment of the local user. Common AR features of these devices included annotation  and graphical overlay over the local user’s view, specifically 2D or 3D images  and the remote viewer’s hands or tools . The identified devices and platforms are listed in Of the 39 studies, 22 (56%) were related to surgery, 6 (15%) were related to EM, and 4 (10%) were related to hospital medicine. When looking at the setting and structure of the tasks from each study, 51% (20/39) involved an operation or technique used in the operating room, where a mentor figure used AR to remotely interact with a task performer. The remaining 19 studies involved nonoperative tasks, 11 (58%) of which also involved a mentor remotely interacting with a task performer, whereas 8 (42%) involved the mentor performing the task instead, with AR enhancing what their remote spectators saw.The articles were divided into 3 sections based on the AR-assisted task performed: patient evaluation, medical intervention, and education -3. MedicThe 26% (10/39) of articles included in this section (P=.41) [P=.04), and 90% (P=.01), whereas the duration of triage was 16.6, 37.0 (P=.001), and 35.0 (P=.01) seconds, respectively [The potential of AR to perform fast-paced triage assessments remotely was explored in 20% (2/10) of the studies. Broach et al  investigP=.41) . FollmanP=.41)  investigectively .P=.002) and admissions related to wound infection (P=.004) [Other studies focused on AR’s potential to enhance remote wound assessments. Ponce et al  demonstr(P=.004) .Borresen et al ,67 introRigamonti et al  and CarbP=.002 and P=.02) [The study by Martin et al  used an d P=.02) .The 41% 16/39) of articles included in this section  and those with low first-responder experience (P=.01) and low procedure experience (P=.03) [P=.38 and P=.85) [The efficacy of various AR-capable tools in the operative setting was tested in 25% (4/16) of the studies. Rojas-Muñoz et al  designed (P=.03) . Cofano  (P=.03)  surveyed (P=.03) . Hassan  (P=.03)  and El-A (P=.03)  describe (P=.03)  observedd P=.85) . El-Asmad P=.85)  comparedd P=.85) .Other studies  used AR in long-distance consultation and global surgery. Greenfield et al  describeP<.01) and focus shifts away from the operating field (P<.001), with time to task completion being slower but not statistically significant (P=.17) [P<.001) and higher performance scores were observed (P<.05 for both raters) in the STAR group [P<.001 and P=.01) and focus shifts (P<.001 and P<.004) but took more time (P<.001 and P<.02) [P<.05 each) [Andersen et al ,63, Roja (P=.17)  focused AR group . Rojas-MAR group  later cod P<.02) . Zhang ed P<.02)  implemen05 each) .The articles discussed in this section  of the articles described proof-of-concept studies in which a clinician wore a Microsoft HoloLens 2 to live stream footage of patient examinations during general medicine rounds to remote students. The Microsoft HoloLens 2 allowed students to not only see through the clinician’s eyes using their personal devices but also simultaneously review overlaid 2D patient data and imaging. Rafi et al  featuredP=.53), although the task completion time was longer for the AR group (P=.008) [A few studies  integrated AR tools with nonsurgical telementoring. Hanna et al  describe(P=.008) . Mather (P=.008)  implemen(P=.008) .Hess et al  describeAR-capable HMDs also allowed surgical trainees to remotely observe a procedure from the operating surgeon’s perspective. Cofano et al , discussP<.001) and more completed attempts during a posttraining suturing task (P=.02) [Vera et al  and Pate (P=.02) . Patel e (P=.02)  used ProP=.03) with 67% fewer errors (P=.04) and no significant difference between task completion times [Other articles  discussed surgical education performed through simulated procedures. Andersen et al  and Rojaon times . Stone eon times  introducon times .P<.001) and repair principles (P<.001), whereas remote sessions preferentially improved understanding of anatomy (P<.01) and increased procedural efficiency (P<.001) [Education in the form of intraoperative telementoring was featured in 21% (4/19) of the studies. A study by Armstrong et al  entailed(P<.001) .Of the 39 studies, 21 (54%) had a comparative design, with 6 (15%) being RCTs. Most studies  gathered data through user feedback surveys or interviews, 70% (16/23) of which used numerical Likert scales. The most common objective variable measured was time to task completion, with other common variables being task performance and procedure-related complications. Several studies  on the topics of telerehabilitation and telesurgery found no difference in task time compared with non–AR-assisted conditions, whereas Vera et al  found thPerformance, measured using scoring systems or frequency of errors, was seen to improve with AR use in telesurgery tasks described by Vera et al , Rojas-MP<.05) and view the virtual interaction as superior to email and SMS text messaging  than surgeons.Subjective measures included in the studies were related to device efficacy, feasibility, and acceptability. All studies that examined feedback-related efficacy, such as the perceived “usefulness” of AR assistance, reported a majority of positive ratings. However, when comparing the ratings of AR-assisted conditions with those of non-AR conditions, Wang et al  and ChinAlthough most survey- or interview-based studies measured user feedback about AR’s usefulness , far fewer studies  surveyed AR’s ability to substitute in-person methods in telemedicine. Borresen et al , who useAcross all 39 studies, there were gaps in the longitudinal measurements related to patient outcomes, such as costs, hospitalization course, and quality of life. Only the study by Davis et al  analyzedIn this scoping review, we discussed 39 studies that used AR in real-time telemedicine and telementoring. From these studies, 20 unique devices and platforms, most of which involved an HMD, were identified and found to have common features such as annotation, graphical references, and the ability to overlay a remote viewer’s hands or tools onto a local user’s screen.AR builds on the remote examinations of current audio- and videoconferencing tools by enhancing the remote acquisition and exchange of information. AR technology can supply users with visual aids, such as electronic health record data and guidelines, or facilitate communication with specialists trained to identify specific conditions or manipulate diagnostic equipment. Studies on AR-assisted remote patient evaluations took place in both outpatient and inpatient settings, including emergency triage, wound evaluation, and hospital rounding. Although the devices vary across settings, the comparative studies in this review found noninferior accuracy and reliability of AR-assisted remote conditions compared with in-person controls. Devices dedicated to remote musculoskeletal and sonographic examinations were also developed, with positive user ratings. As technology improves and becomes more accessible, the types of examinations that can be performed remotely will expand and allow for greater access to care, especially by patients and providers in low-resource areas.The research on AR in the remote delivery of medical interventions predominantly focused on surgery, with other treatment modalities such as physical therapy being less studied . TelesurMedical education emerged as a common theme underlying AR’s integration into telemedicine and telementoring. In addition to surgery, remote training using AR was studied for clinical skills that are important to inpatient wards and procedures related to pathology and EM. Both surgical and nonsurgical studies implemented AR tools in similar ways, including observational learning, real-time audiovisual feedback, and teaching by demonstration. When in-person mentorship was not possible or inconvenient, the studies showed how AR-enhanced communication allowed distant learners to not just observe but also engage with clinicians and surgeons. Distance learning of surgical and sonographic equipment could also be achieved with AR systems, with few controlled trials thus far indicating noninferior performance results compared with in-person mentoring and superior results compared with unassisted conditions, particularly for less experienced trainees. As the equipment for telecollaboration in medicine becomes readily available, AR technology is expected to advance the sharing of knowledge related to clinical skills, health care devices, and procedural techniques, which directly and indirectly improves patient care outcomes.Given the early stage of platform development, many studies included in this review  used small cohorts of ≤15 patients or participants per study group; although approximately half  of the studies included comparative data, far fewer were RCTs. This finding is expected as AR is an emerging technology in medicine, and its use in telemedicine and telementoring is still developing. Existing comparative trials that measured time consumption and performance have so far found that AR-assisted conditions mostly have noninferior results compared with other remote and in-person methods. However, as these studies are heterogeneous in methodology and equipment, dedicated RCTs with standardized designs are needed to understand whether certain AR systems for specific tasks can effectively substitute current remote alternatives or in-person methods. Feedback surveys and interviews were the most common form of data collection observed in this review; subjective variables such as perceived efficacy and ease ratings were commonly measured with consistently positive findings despite the novelty of the technology, suggesting interest across user groups, including providers, trainees, and patients.Overall, interventions and learning that require active patient or family caregiver participation  have yet to achieve a similar level of investigation in the space of AR and telemedicine or telementoring as surgery. From the nonsurgical studies included in this review, there is an interest in AR for tele-sonography, EM, and hospital medicine, with many nonsurgical fields yet to be represented. In the realm of patient evaluation, AR’s role is still being separately investigated for electrograms , diagnosConsidering the diversity of medical fields and levels of experience across users, AR-enabled remote interactions are likely to appear in certain settings or users sooner than in others. In the interventional and educational space, studies so far have primarily implemented AR tools for remote consultation between current or future medical professionals. Few trials using untrained individuals for AR-assisted procedural, nonsurgical tasks exist; it would be reasonable to anticipate future research with AR facilitating remote provider-to-patient or provider-to-caregiver interactions in the therapeutic context . To suppAlthough more dedicated RCTs would be needed to assess the efficacy of AR-assisted communication in the treatment setting, AR’s impact on variables related to costs beyond procedure time and outcome measures beyond complication rates remains relatively unexplored. These include hospital-based measurements such as length of stay, equipment costs, and intra- and postoperative pain medication use but also patient-centered variables such as treatment cost, posttreatment functional status, and quality of life. The literature in this review focused mainly on short-term variables, which reveals a lack of longitudinal research that could provide insight into both the long-term outcomes of patients and system-wide effects on productivity and sustainability of AR use. Longitudinal studies with dedicated comparisons, which are likely to increase as devices improve in wearability, usability, and affordability, are also needed to fully understand whether AR could enhance knowledge and skill retention in the remote learning environment.This review was limited to studies from the last 10 years in 4 medical research databases. Many AR developments in telemedicine and telementoring that exist in the private sector have not been described in published articles and so cannot be systematically evaluated. Notably, a 2019 systematic review of AR in telementoring has also explored additional databases ; howeverAlthough the potential benefits of AR in telemedicine are promising, the challenges facing this technology are the early stage of research and prototype development for these application contexts and a lack of standardized devices. Outside the original and surgery-specific platforms, most of the hardware observed in this review is available to consumers but at costs that limit widespread use . FurtherThis scoping review discussed studies that combined AR with real-time telemedicine and telementoring, including patient evaluation, medical intervention, and education. Commonly explored applications for this novel intersection include consultation and procedural guidance, particularly in telesurgery. AR-assisted telecommunication was studied to complement or even improve the capability of remote visits, treatments, and training, but more RCTs are needed to validate task-specific benefits as well as understand the long-term effects for all users. As technology evolves and use at the consumer and industry levels becomes more widespread, research on AR in health care is expected to see larger cohorts, standardized equipment, and more rigorous methods of evaluation. Developing AR tools in medicine must balance user-friendly design with limited research and uptake; such challenges create an opportunity for institutional involvement and a need for perspectives from all those involved in health care, including but not limited to clinicians, caregivers, and patients.


Among the admitted patients, 16.6% required artificial pulmonary ventilation (APV), 1.8% extracorporeal membrane oxygenation (ECMO), and 11.9% high-flow oxygenation (HF). The days of rehabilitation ranged from 1–102 days. Among all rehabilitated patients, 92.0% (n = 1302) had a hospitalization duration ranging from 1–15 days and 8.0% (n = 114) longer than 15 days. Overall, rehabilitation care plays an important role in providing exercise, mobilization, and rehabilitation interventions to survivors of critical illness associated with COVID-19, enabling the early and functional return to home, and it must, therefore, be integrated into the clinical care of patients with COVID-19.In this retrospective study, we used data from the hospital information system (HIS) to evaluate the influence of the COVID-19 pandemic on rehabilitation care at the University Hospital of Ostrava (UHO). From March 2020 to December 2021, 5173 COVID-19 cases were hospitalized at UHO. Cases within individual groups and categories are shown in a flowchart. The average patient age was 64.9 ± 16.9 years. The mean BMI value was 30.6 ± 6.8 in the rehabilitated group, which was significantly higher compared to that among the non-rehabilitated cases 29.1 ± 6.9 ( The infection known as coronavirus disease 2019 (COVID-19), reported in China in 2019, spread worldwide very rapidly and was characterized by the World Health Organization (WHO) as a pandemic on 11 March 2020. Rehabilitation units have faced the challenges of supporting both physical and cognitive recovery and have played a crucial role in reducing disability to enable the reintroduction of patients into the community. Importantly, early mobilization and rehabilitation may help to prevent or mitigate sequelae related to bed rest, thereby improving physical function and outcomes and reducing the length of hospitalization by increasing ventilator-free days ,4. Between 2020 and 2022, there have been many updates to the recommendations for physiotherapy management and rehabilitation among COVID-19 patients in the acute hospital setting. In our present study, we focused on the situation in the Czech Republic. The available literature mainly presents general advice. Reports from March 2020 describe the physiotherapy needs of patients in intensive care units (ICUs) who may suffer from ICU-acquired weakness or acute respiratory distress syndrome (ARDS) and recommend increased numbers of physiotherapists ,6,7. HowIn April 2022, updated material regarding physiotherapy management was published. This update focused on maintaining the availability of health care, including outpatient treatment, for non-COVID-19 patients. This update stated that physiotherapy should not be routinely indicated for all patients with COVID-19 and that therapists should first use available options for indirect contact with the patient to minimize the risk of exposure to COVID-19. Moreover, a detailed examination and physiotherapy should be indicated in cases of severe disease with prolonged bed rest and critical disease [Early recommendations for hospital-based physiotherapy were mostly defined by safety guidelines and treatment recommendations, including staffing. Treatment approaches for different phases were also established. During hospital-based physical therapy for the management of COVID-19, one should always consider the benefits of hands-on physiotherapy treatment versus the risk of virus transmission . A rapid systematic review shows the importance of progressive exercise programs, early mobilization, and multicomponent interventions in the ICU, which can improve functional independence. The evidence regarding rehabilitation after discharge from the hospital (following an ICU admission) is inconclusive. Rehabilitation care can significantly help in shortening the length of stay at individual levels of hospitalization and substantially contributes to the improvements of patients’ functional results, such as mobility, self-sufficiency, and independence in movement and walking. There remains a need for further research to better understand the rehabilitation needs of COVID-19 patients .Inpatient rehabilitation facilities should be considered as a discharge location after severe COVID-19 infections. The average length of stay at an inpatient rehabilitation facility is reportedly about 11 days, although it is unclear what percentage of patients received inpatient rehabilitation . One stuOne study reported the inpatient bed occupancy and the predicted need for rehabilitation in two large teaching hospitals in London. It captured data from just a single day to predict the rehabilitation needs after discharge and established a model, including four pathways of discharge. The study predicted that 50% of people would be simply discharged without further need for care, ~45% would be able to return home with some kind of support from health or social care, ~4% might need rehabilitation in a bedrest setting, and the remaining 1% would not be able to be discharged from acute care. The authors collected real data and compared them with this predicted model. They focused on the last two pathways , and they found that the real percentages of patients following these two discharge pathways exceeded those expected in the assessed model by more than five times . SeveralThe clinical characteristics of post-ICU patients often include exercise-induced desaturation , muscle weakness, and a low outcome in functional tests . To idenRisk factors for hospital admission have been set, as described above, and about 6% were admitted to the ICU only and 11% were re-admitted after discharge ,24,25. OHealth workers may also suffer from post-acute COVID-19 syndrome, with some persisting symptoms, such as fatigue, shortness of breath, etc. . RespiraOur research questions were as follows: “What is the most important factor associated with the need for, and length of, rehabilitation required during acute hospitalization?” and “What are the actual caseloads in different discharge categories?”.This retrospective study from the hospital information system (HIS) was approved by the Local Ethics Committee, University Hospital Ostrava nr. 971/2021. We evaluated data from the period of March 2020–December 2021. The analysis included only patients 18–99 years of age and did not include any data from the pediatric population. We also excluded data from patients with psychiatric diagnoses or patients in palliative care. The analyzed data set included repeated hospitalizations of the same person, including a new hospitalization in a different department of the hospital (transfer to another department). This inclusion is important in terms of the number of referrals for rehabilitation for the same patient. Cases within individual groups and categories are shown in a flowchart . Our results mainly focused on the topics of intensive care and BMI. We identified groups of cases admitted to intensive care units, including those receiving artificial pulmonary ventilation (APV), extracorporeal membrane oxygenation (ECMO), or high-flow oxygenation (HF). We also identified cases of patients with obesity (BMI > 30). We compared the cases that underwent some kind of rehabilitation treatment (rehab group) versus those that were not indicated for rehabilitation at all (non-rehab group). Multiple comparisons were made among these groups.Among the hospitalized patients, we identified the number of health transfers to different types of care, discharges to home, and the number of deaths. We particularly focused on the discharge of the rehabilitation group. The cases can be divided into four general categories: Category A, cases discharged to home or outpatient care; Category B, cases requiring follow-up hospitalization in an acute-care bed of the same or another medical facility; Category C, cases requiring follow-up hospitalization in a follow-up-care bed of the same or another medical facility or requiring transfer to a social care facility; and Category D, cases of death.n, %). No imputations were performed for missing data. Patients with missing body mass index (BMI) data were excluded from the statistical analysis for the relevant parameters. Differences in proportions were examined using a chi-squared test. Before the statistical testing of quantitative parameters, the normality of the data was verified using the Shapiro–Wilk test. If normality was rejected, non-parametric methods were used. Between-group comparisons were made using the independent sample t-test and F-test in the case of normally distributed data and non-parametric Mann–Whitney U test. Correlations between different types of scores were explored by the Spearman and Pearson correlation coefficient. All tests were performed at a 5% significance level. Statistical analyses were performed using the software Stata/BE 17.0.Data regarding the quantitative parameters were processed by descriptive statistics using the mean and standard deviation. Qualitative data were presented as the number of observations  and females 46% (2390/5173) of cases. There were 27.4% (1416) of cases in the rehabilitation group. The duration of active rehabilitation ranged from 1–102 days. Within the rehab group, 92.0% (1302/1416) had a rehabilitation duration ranging from 1–15 days, while the remaining 8.0% (114/1416) underwent rehabilitation for longer than 15 days .Rehabilitation was indicated in 27.4% (1416/5173) of cases, which included 31% of male patients (850/2783) and 24% of female patients (566/2390). The mean age of the rehabilitated patients was 64.6 years, not significantly different from the non-rehabilitated groups. A detailed description of the groups is shown in p < 0.001) . The mean BMI value was 30.6 ± 6.8 in the rehabilitated group, which was significantly higher compared to that among the non-rehabilitated cases of 29.1 ± 6.9 (< 0.001) .Among all analyzed hospitalizations, 16.6% involved APV, 1.8% ECMO, and 11.9% HF. Not all of the patients requiring these treatments were indicated for rehabilitation.p < 0.001), ECMO , and HF   .p = 0.002)  .p = 0.454)  was required for 337 cases (23.8% of the rehab group and 6.5% of the entire set). After excluding cases from this group that were missing BMI data, the average BMI value was 30.1 ± 6.6 among the 323 cases that required more than one therapist for rehabilitation. The distribution of BMI did not significantly differ according to the need for assistance in rehabilitation (= 0.454) .Of the total number of patients hospitalized with COVID-19, 14% died (group D), 37% were transferred to different types of care (groups B and C), and 41% were discharged home (group A) .p < 0.001). The percentages of patients discharged home were 34% in the rehab group vs. 55% in the non-rehab group. The corresponding percentages of patients requiring subsequent hospitalization (categories B + C) were 52% vs. 32%, respectively, and the corresponding percentages of patients who died were 14% in the rehab group and 13% in the non-rehab group . The aim was to outline an ideal model of the rehabilitation process and adequate rehabilitation capacity. Our findings and general recommendations for rehabilitation in the ICU have been incorporated into the care of our patients. Early and daily mobilization is applied 5–6 times/week, including at least a 30 min exercise session as part of a progressive exercise program . For patThe follow-up acute rehabilitation program was focused on patients who no longer had to be in the intensive care unit, whose condition  required further rehabilitation and who could not be discharged to home treatment due to their current state of health. Among patients who received the rehabilitation intervention in the acute and sub-acute departments, 92% of rehabilitation interventions lasted between 1–15 days. The rehabilitation intervention lasted longer than 15 days in only a small percentage of patients (8%), which corresponds to the conclusions of other authors .Although we did not establish a rehabilitation hospital , parts oAt the beginning of the COVID-19 pandemic, there was uncertainty about the indications for physiotherapy. This hesitation is why the number of indicated cases was low during the first two months. In the following months, the number of cases increased (roughly from May 2020) because it became necessary to focus on cases where rehabilitation was clearly indicated. Rehabilitation was needed for cases with a prolonged course of the disease, and effort was made to ensure that rehabilitation could be provided when required. Although we had already perceived the need for rehabilitation in the initial stages of the pandemic, this need had to be addressed with respect for the maximum safety of medical personnel. There was a certain lack of personal protective equipment (PPE) available for the field of rehabilitation, as priority was given to nursing and intensive care.The availability of further follow-up rehabilitation should also depend on the patient’s limitations in functions, activities, and participation, as defined by the International Classification of Functioning, Disability and Health (ICF). We presently monitor the severity of disability only for hospitalizations in acute rehabilitation, not in detail for patients in the ICU. The current system only uses the Barthel index assessment, which we consider insufficient. This tool was not used as a standard upon discharge from the ICU.Regarding follow-up outpatient care options, there is currently only screening in the so-called post-COVID-19 outpatient clinic for patients who have experienced COVID-19. Patients are not targeted. Post-ICU follow-up clinics are also available, which provide more systematic monitoring. In this area, we see the current system of recording severe cases of COVID-19, including a more detailed assessment of each patient’s functional abilities.A number of studies have tried to define the relationship between obesity and COVID-19 severity or death. Moreover, several other conditions have been examined in this context, including asthma, chronic kidney disease, and diabetes. Our present analysis revealed that the BMI was significantly higher in the group that underwent rehabilitation. We also found that each of the groups that received APV, ECMO, or HF had a higher need for rehabilitation. Other studies have reported an association between hospitalization and obesity ,27. The The rehabilitation process for COVID-19 patients has higher time requirements. This includes the time that must be devoted to preparation before and after rehabilitation (management of hygiene and protective work equipment), as well as a longer time for the management of the patient in isolation mode and a longer rehabilitation process itself. In patients with a severe and critical disease course, we can expect that physiotherapy will not be well-managed by just one therapist, even in cases of assistance within the framework of a multidisciplinary team. Particularly in cases where a patient has a higher risk profile , it can be assumed that the assistance of another skilled physiotherapist will be necessary, for example, to help with patient verticalization and mobilization. These factors increase the number of physiotherapists needed to provide healthcare for these patients. Physiotherapy was profiled, particularly in cases with a severe and critical course of the disease and in patients requiring a stay in the ICU. According to the currently available data, the next group of patients requiring physiotherapy will be the patients with post-COVID-19 syndrome.We identified the need to define and then evaluate the necessity of involving another therapist in the rehabilitation process, with the mean BMI as well as the receipt of APV, ECMO, or HF as factors. It turns out that a high BMI value was not statistically significant and, therefore, the only determining factor for the need for a second therapist. These parameters were not previously monitored, or it was not possible to read them from the code designations of the reported rehabilitation. That is why the so-called signal code was introduced to help another therapist. The implementation of the code within therapy helped on two fundamental levels. The first level is the forensic point of view, which enables us to clearly identify another member of the team who worked with the patient. The second level is the possibility of retrospectively determining whether the given patient had demanding needs from the perspective of rehabilitation management. This system enables better monitoring of the necessity for involvement and participation of the individual team members.Based on the current limited evidence, disease management of long-COVID-19 signs and symptoms will require a holistic longitudinal follow-up in primary care, multidisciplinary rehabilitation services, and the empowerment of affected patient groups ,29,30,31This study may have several limitations. The study covers a relatively long period of the COVID-19 pandemic in the Czech Republic. During this time period, there were mutations of the virus and gradually increasing vaccination coverage among the population. These changes could have significantly affected the course and symptomatology of the disease and thereby also affected the need for rehabilitation. Additionally, the BMI was not detected in all patients, especially in patients who were admitted in a critical condition. At the same time, it was not possible to validly verify data from other parts of the patient’s documentation. The available data were not up-to-date due to recent hospitalization.Identification of this item in the patient record also appears to be a problem. The entry in the documentation was optional and not subject to automatic error checking. We recommend this as a mandatory field with a check of the entered data.Our analysis showed that the studied university hospital and its available rehabilitation care, including acute and subsequent rehabilitation beds, provide sufficient facilities for the treatment of a severe course of COVID-19 and for the rehabilitation treatment of conditions associated with COVID-19. Ensuring rehabilitation in an acute intensive care unit required a significant modification of regular programs and the increased availability of staff to meet the needs of newly emerging units for patients with COVID-19. In ensuring an adequate regimen in terms of hygiene and protective work equipment, we noticed difficulties only in terms of the initial availability of suitable PPEs and the insufficient information about the disease at the beginning of the pandemic.Additionally, acute rehabilitation services were less accessible to patients in non-COVID-19 diagnostic groups. Further analysis will be required to examine the comparative data on accessibility for stroke patients. The COVID-19 pandemic has revealed the vulnerabilities of healthcare systems and the importance of ensuring the availability of quality care for all patients. Governments and healthcare institutions must focus on minimizing the impact of the pandemic on rehabilitation, making efforts to strengthen and protect health systems, and creating support programs to help cope with the impact of the pandemic on rehabilitation. Such efforts may include financing new technologies for online rehabilitation, increasing the capacity of rehabilitation centers, ensuring sufficient supplies of protective equipment, and training a sufficient number of personnel. The recommendation is also towards better equipment in critical care, e.g., beds with automatic measurement of the patient’s weight, automatic reading and transfer to the information system and patient documentation, etc. Greater emphasis should also be placed on staff training in working with specific personal protective equipment, as this will also improve work efficiency and speed up the care of infectious patients.Rehabilitation units do not have enough isolation rooms available. This results in a limitation and a reduction in the available capacity of beds for the needs of rehabilitation. This should be a part of planning, for example, during building renovations.


This paper sought to determine impact of rehabilitation compliance on the clinical outcomes for non-surgically managed PHFs, while ascertaining reasons for non-compliance which can be addressed to improve compliance.Proximal humeral fractures (PHFs) are 3Prospective cohort study of patients undergoing non-surgical treatment for PHFs from August 2017 to April 2020 in a tertiary trauma centre was performed. Data was collected via questionnaire: patient demographic data, PHF injury details, clinical outcome measures, therapist-reported  and patient-reported  rehabilitation compliance measures. Data was analysed using multiple linear regression model to account for confounding variables.p = 0.023; 95%CI = 0.265,3.423), OSS , flexion ROM , extension ROM , abduction ROM  and achievement of functional active ROM at 3-months . Pain was the top reason impairing rehabilitation compliance from therapist (43.9% at 6-weeks and 20.6% at 3-months) and patient-perspective . Author-developed patient-reported compliance measures had good correlation with validated SIRAS score (subjective compliance: p < 0.001 frequency of exercise: p = 0.001).107 participants attended physical therapy follow-up for mean 137.8 days. 6-week SIRAS strongly predicted 3-month Constant score  no longer followed up after discharged from occupational therapy and 2) the author-developed patient-reported measures, while promising, are not fully validated for PHF outcomes as well.The online version contains supplementary material available at 10.1186/s12891-023-06894-w. Proximal humerus fractures (PHFs) account for a significant fraction of fragility fractures, comprising 5–6% of all adult fractures , with hiTreatment of PHFs can be non-surgical or surgical . The ideal treatment modality for PHFs is controversial as treatment choice is variable and based on multiple factors  . UltimatRehabilitation compliance is associated with enhanced patient outcomes for other conditions such as stroke  and anteThe primary aim of this study is to identify relationships between rehabilitation compliance and short-term (3-month)/long-term (1 year) clinical outcomes. The authors hypothesize that improved rehabilitation compliance would be associated with better short- and long-term clinical outcomes. A secondary aim is to establish reasons for rehabilitation non-compliance which can be addressed to improve compliance.This is a prospective cohort study of patients in a Singaporean 1700-bedder tertiary trauma centre which sees a large volume of PHFs undergoing non-surgical management. Ethic clearance by the institution’s research governing board was obtained prior to any research-related activities. Study design was guided by the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE)”, which was created to aid authors in ensuring high-quality presentation of the conducted observational studies  was measured with BASELINE™ 12-1012HR goniometers by occupational therapists during rehabilitation sessions and served as objective measure of shoulder function. On top of individual ROM parameters, the achievement of functional shoulder AROM (i.e. minimum shoulder ROM required for activities of daily living (ADLs) – established as 115° flexion/40° extension/120° abduction/50° internal rotation/45° external rotation ) also reAdditionally, three composite scores validated to measure functional outcomes in non-surgically managed PHFs were recorded . The QuiThere is no “perfect” measure of rehabilitation compliance for several reasons. Firstly, there are multiple aspects of compliance, each being more appropriate in different contexts . For insExisting self-reported exercise adherence questionnaires tend to be lengthy and unvalidated . To holiTwo patient-reported compliance measures were used – patient-reported subjective compliance in performing prescribed exercises  and frequency of average regime at home for exercises prescribed . These responses were converted to numerical values on a scale of 0–5 (5 being the highest compliance) to allow for statistical analysis. These measures are author-developed and unvalidated. A 5-point Likert Scale was used as it is shown to improve response rate/quality and reduce responders’ frustration levels . It alsoTherapist-reported rehabilitation compliance was based on the SIRAS, a well-validated scoring instrument for rehabilitation of musculoskeletal injuries with rater-agreement index values of up to 0.954 . The SIRLastly, the questionnaire also sought the opinion of patients/therapists regarding factors that may hinder rehabilitation compliance to prescribed rehabilitation exercises.Data was cleaned/analysed using STATA version 14.0. Demographics/clinical outcomes were presented using descriptive statistics. Distribution of numerical data was assessed using histogram and presented using mean/standard deviation as the distribution was found to be approximately normal, while categorical variables were presented using frequency/percentage.p < 0.05.Multiple linear regression was used to identify relationships between rehabilitation compliance measures and clinical outcomes. This allowed the use of multiple explanatory variables in a model to predict outcome and helped control for potential confounders. The parameters shown to affect functional outcomes of non-surgically managed PHFs , 27 – agOne hundred seven patients were selected, and all completed study follow-up to 1-year post-fracture. Demographic data is summarised in Table Figure p < 0.001, r = 0.616) and 6-week patient-reported average regime  were moderately correlated with 6-week SIRAS while the 3-month patient subjective compliance  was moderately correlated to the 3-month SIRAS. However, 3-month patient-reported average regime  was not significantly correlated to the 3-month SIRAS.Table p = 0.049,adj. OR = 1.280) and 3-month patient subjective compliance  but there was no significant predictive relationship for achieving functional shoulder ROM at 1-year.Tables p-value = 0.023,adj. coef = 1.844), 3-month OSS , 3-month flexion , 3-month extension , 3-month abduction , achieving function AROM at 3-month  on top of 1-year flexion , 1-year extension  and 1-year abduction . A direct comparison between 3-month and 1-year clinical outcomes also shows that 6-week SIRAS has stronger predictive value for short-term outcomes. 6-week SIRAS has a better predictive relationship with 3-month Constant score than 1-year Constant score . This is also seen for OSS (0.038 vs 0.872), flexion (< 0.001 vs 0.002), abduction (0.002 vs 0.006) and achieving function AROM (0.049 vs 0.093).In addition, 6-week SIRAS showed significant predictive relationships with multiple 3-month but only 3 1-year clinical outcome measures, predicting 3-month Constant Score .None of the rehabilitation compliance measures predicted short or long-term QuickDASH and NRS. These rehabilitation compliance measures also poorly predict finger grip strength – with only grip strength at 1-year being predicted by 6-week SIRAS  and OSS (p = 0.038), while 6-week patient subjective compliance significantly predicted 6-week OSS (p= 0.039). There was no such relationship between rehabilitation compliance measures and 1-year outcome measures. Furthermore, head-to-head comparison between multiple 3-month outcome measures  showed that rehabilitation compliance tends to predict 3-month outcomes better than the respective 1-year counterparts. A postulation for this is that the patient cohort – typically discharged from therapy when deemed to have achieved functional goals based on their functional expectations and requirements – tends to see a drop in exercise compliance and effort after discharge. This psychology towards rehabilitation is well documented in existing literature, as patients tend to work harder/perform longer when there is a concrete goal to provide purpose and serve as a distraction from the effort required. This may be true for short-term rehabilitation where patients seek to regain function and improve between clinic-based therapy sessions. However, the purpose of continued long-term post-discharge therapy is usually the maintenance of function – which may be comparatively poor motivation as there is no concrete end-point and patients may find it difficult to perceive any benefits [Rehabilitation compliance had stronger correlation with short-term compared to long-term clinical outcomes – with significant predictive relationships seen between 6-week rehabilitation compliance measures and 3-month Constant score, OSS and shoulder AROM. Results showed that therapist-reported compliance (SIRAS) at 6-weeks significantly predicted 3-month Constant score  . HoweverGiven the importance of rehabilitation compliance for improved short-term outcomes and functional independence, efforts should be made to facilitate PHF rehabilitation compliance via establishing a strong social support network, reducing rehabilitation-related anxiety/stress via patient education or introducing motivational strategies .In our sample, pain was the most frequently cited reason for non-compliance at 6-week and 3-month from both therapist and patient perspective within our sample. Currently, analgesia for PHF patients is largely limited to oral options as guided by the WHO pain ladder. However, there has been promising evidence for pain adjuncts in PHF rehabilitation. A large-scale systemic review by Iliaens et al. has shown that interscalene nerve blocks have had promising results for PHF patients, with decreased opioid requirements and improved functional scores  after rehabilitation . Given tIn addition, pain was notably still the most cited reason at 3-months despite the PHF likely being mostly healed and stable at this juncture. A paper by R.F. Shah et. al. discussing upper extremity fractures has re-iterated a well-known fact about pain pathophysiology – that there are not only biological but also psychosocial determinants  . While wAs such, potential arenas to expand research could be to use study designs such as randomized control trials to compare different interventions to improve PHF rehabilitation compliance. For example, nerve-block vs no nerve-block or comparing different rehabilitation motivational strategies.Lastly, this paper has highlighted the lack of consensus definition for rehabilitation compliance. In a 2016 systematic review, Hawley-Hague et al. identified 37 papers which discussed “exercise adherence”  – and shImportantly, our results have shown good correlation between the author-developed rehabilitation compliance measures (patient-reported subjective compliance and average regime in prescribed exercises) and the well-validated SIRAS. Currently, there is a lack of established rehabilitation compliance measures for musculoskeletal conditions. Having targeted, easy-to-administer and validated questionnaires on musculoskeletal rehabilitation compliance could be an area of focus to (1) help develop research in the area and (2) be used in clinical practice.To the authors’ knowledge, this paper is the largest study in this area – investigating the relationship between rehabilitation compliance and clinical outcomes of non-surgically treated PHFs, including short (3-month) and long-term (1-year) results for discussion. A key strength of this paper is a comprehensive set of rehabilitation compliance measures that sought to quantify/qualify rehabilitation compliance from the perspective of all stakeholders – including both patient-reported and therapist-reported measures with subjective and objective components. Lastly, linear regression modelling was used to control and account for other confounding variables which may affect the results.Unfortunately, given the immaturity of research in rehabilitation compliance, certain measures chosen were well-validated (e.g. SIRAS) while other aspects (e.g. patient subjective compliance) were not. Furthermore, clinical outcomes up to 1-year were discussed in this paper, the authors would have liked to include rehabilitation compliance data past the 3-month mark – unfortunately, this had multiple logistical issues as most of the patients were discharged from therapy follow-up after 3 months. Whether or not these patients continued to be compliant to home-based exercises is unknown and could very well affect long-term outcomes.Further, in terms of patient selection, while the authors tried to ensure as homogenous a study sample as possible via the inclusion/exclusion criteria, the current lack of consensus for surgical/non-surgical indications of PHFs has made doing so difficult. Without an established gold standard for this, this limitation will likely remain for all research done in this arena.This study has shown that rehabilitation compliance can predict clinical outcomes in non-surgically managed PHFs, with stronger predictive value on short-term outcomes compared to long-term outcomes. Furthermore, this study has also highlighted the need for future research in terms of rehabilitation compliance measures. Patient-reported measures used have shown some promise, with good correlation to validated and established measures such as the SIRAS. Lastly, optimising analgesia and minimizing pain can further improve rehabilitation compliance and aid outcomes – and novel techniques such as the inter-scalene block may be an area to explore to do so.Additional file 1: STROBE Statement—Checklist of items that should be included in reports of cohort studies.Additional file 2: Appendix 2. Summary of Institution’s Rehabilitation Treatment Protocol for Proximal Humerus Fractures.Additional file 3: Study on Proximal Humerus Evaluation of Effective tReatment (SPHEER).


Purpose: Enhanced recovery after surgery (ERAS) is a surgical rehabilitation protocol of increasing interest to clinicians in recent years, with the aim of faster and better recovery of patients after surgery. Our main focus in this review is to analyze the effectiveness of ERAS rehabilitation protocols in orthopedic surgery. By comparing the post-operative recovery of patients receiving the ERAS rehabilitation program with that of patients receiving the conventional rehabilitation program, we observed whether the patients who have received the ERAS rehabilitation program could recover better and faster, thereby achieving the aim of a shorter hospital stay and reducing the incidence of complications. Methods: We conducted the literature searches in PubMed, MEDLINE, Web of Science, Cochrane Reviews, EMBASE and other databases on clinical studies related to orthopedic surgery regarding the effectiveness of rehabilitation using ERAS rehabilitation protocols compared with conventional rehabilitation protocols. A systematic review was performed in accordance with the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) statement. If there was variability in the rehabilitation data of the patients between the two subgroups, it was considered that there was a difference in the rehabilitation effect of the ERAS rehabilitation protocol and the conventional rehabilitation protocol on the patients. Conclusion: The application of ERAS rehabilitation protocols can shorten patients’ hospital stay and reduce their expenses. In addition, patients with ERAS rehabilitation protocols will have fewer postoperative complications, while patients will have less postoperative pain than those with conventional rehabilitation, facilitating better postoperative recovery. Orthopedics as one of the important component departments of a general hospital, whether it is for patients with fractures, joint replacements, or spine surgery. The surgical trauma for the patient is often large and is prone to corresponding complications, which can have a definite impact on the patient’s psychological and physical function. Therefore, the rehabilitation of patients after orthopedic surgery is very important. Good rehabilitation can go a long way towards improving the patient’s prognosis and facilitating the corresponding functional recovery after surgery. It can also play an important role in maintaining the patient’s psychological well-being. If a rapid recovery plan can be developed for patients in the perioperative period from preoperative to postoperative, in order to reduce the length of hospitalization, better restore the patient’s limb function, and reduce postoperative complications, it can promote both orthopedic surgery and improve the patient’s treatment outcome and psychological recovery. It is of great clinical significance to promote the rehabilitation of patients after orthopedic surgery.Enhanced Recovery After Surgery (ERAS) is a multimodal, interdisciplinary care improvement program designed to facilitate the recovery of patients who have undergone surgery during the perioperative period; the purpose is to shorten the length of hospital stay and reduce complications ,2. The EThe enhanced recovery after surgery (ERAS) program is increasingly used in orthopedic surgery. In an ERAS rehabilitation progr for orthopedic related surgery, the medical members involved usually consist of orthopedic specialists, nurses, anesthetists and rehabilitation staff. The ERAS rehabilitation program involves a series of components that combine to minimize stress and to facilitate the return of function: these include integrated pre-operative, intra-operative and post-operative management ,4. The pIn order to comprehensively analyze the application and rehabilitation outcomes of ERAS rehabilitation programs in orthopedic surgery, we collected and compared the rehabilitation outcomes between patients with ERAS rehabilitation programs and those with conventional rehabilitation programs in all directions of orthopedic surgery in this review. The advantages of the ERAS rehabilitation programs over conventional rehabilitation programs were investigated. The aim of our study is to promote the better use of ERAS rehabilitation programs in orthopedic surgery and to improve patient outcomes and postoperative recovery.We strictly followed the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) statement in conducting the relevant literature searches ,10. The We developed the following inclusion criteria based on the needs of the study: (1) published peer-reviewed reports of human studies in English; (2) publication dates between database creation and 30 August 2022; (3) complete clinical reports; and (4) clinical subgroups of patients who were rehabilitated using ERAS and conventional rehabilitation, respectively.The following are shown as exclusion criteria: (1) reviews, hypotheses, technical articles or oral reports; (2) non-English articles; (3) patients who have previously undergone surgery; (4) cadaveric or animal studies; (5) no control group; or (6) the control group received ERAS rehabilitation therapy after surgery.We first included and excluded articles by reading the title and abstract sections of the articles, eliminating those that did not meet the requirements, and then carefully read the full text of the remaining articles. The full text was read to exclude articles that did not meet the inclusion criteria, thus identifying articles that met the inclusion criteria. After we identified the final included literature, we arranged for two researchers to conduct a quality assessment of the included articles. After completion of a risk assessment for quality and bias, the articles were subjected to data extraction, which included the first author, year of publication, study design, study period, indication for surgery, sample size, number of patients in each control group, gender, mean age, type of intervention , length of hospital stay, complication profile and visual analogue scale profile.In addition, after data extraction was completed, the quality within each study was assessed. We assessed the literature for quality by referring to the assessment manual provided by the Cochrane system ; the too2 statistics. If the I2 value was 0% it indicated no heterogeneity, while I2 < 25% indicated low heterogeneity, the I2 value of 25–50% moderate heterogeneity and I2 > 50% high heterogeneity [The statistical analysis software used in our study was Stata SE-64. The main outcome indicators were compared between patients with the postoperative ERAS rehabilitation program and patients with the postoperative conventional rehabilitation program in order to analyze the differences in the postoperative rehabilitation of patients with the two different rehabilitation programs. A 95% confidence interval was used for the outcome indicators for the dichotomous variables to maintain consistency of analysis. Mean differences (MD) were expressed as 95% confidence intervals (95% CI) associated with continuous variables. If studies reported only the median, range, and size of the trial, we used the data reported in the paper to calculate the mean and standard deviation . In addiogeneity .2 < 50% indicated little heterogeneity within the literature, a fixed effects model (FE) was chosen to analyze the data. When I2 > 50% indicated significant heterogeneity within the literature, a random effects model (RE) was chosen to analyze the data. The differences between ERAS rehabilitation and conventional rehabilitation outcome indicators were analyzed according to the resulting forest plots. Statistical significance is considered if the p-value is <0.05.After counting the data from the included articles, we analyzed the data. The statistical analysis methods included fixed effect model and random effect model. When IAccording to the description in the respective articles, the patients who had used ERAS rehabilitation in the perioperative period were included in an ERAS rehabilitation group and those who did not receive ERAS rehabilitation were grouped into a conventional rehabilitation group. Among the included studies, we summarized and aggregated the various data provided in the article, in which the more frequently reported outcome indicators were length of hospitalization, postoperative complications, and patient-related postoperative pain scores (VAS). Therefore, the primary outcome indicators in our current analysis are length of stay and complications, and the secondary outcome indicator is pain score. In the included articles, all reported postoperative complications were included in the outcome index of complications, such as postoperative gastrointestinal bleeding, infection of the surgical opening, urinary tract infection, respiratory tract infection, thrombosis and other postoperative complications. The length of stay in hospital and the presence of complications were used to analyze the recovery of patients after undergoing orthopedic surgery together with the length of recovery time. The VAS pain score allowed us to analyze the pain of orthopedic patients after surgery.After excluding the articles that did not meet the inclusion criteria, a total of 40 articles were included. Of these articles, 11 are for fracture-related procedures ,22,23,24Of the 40 clinical studies included, 2 randomized controlled trials (RCT), 31 retrospective case-control studies, and 7 prospective cohort studies were included. A total of 29,856 patients were included in all articles, of which a total of 10,991 patients underwent surgery related to fracture, 3607 patients underwent surgery relating to the spine, and 15,258 patients underwent joint replacement surgery. p < 0.001, I2 = 99.6%), p = 0.141 > 0.05, I2 = 99.7%), and p < 0.001, I2 = 91.9%). As for the analysis of the length of hospitalization, the length of hospital stay in patients with fracture or spinal surgery undergoing ERAS rehabilitation is found to be shorter than that of patients undergoing conventional rehabilitation, p < 0.05. There is no difference in the length of hospital stay for patients undergoing joint replacement regardless of the rehabilitation program.For the outcome indicator of length of stay, 9 articles were reported for fracture surgery, 11 articles for joint replacement surgery, and 14 articles for spine-oriented surgery. p < 0.001, I2 = 39.6%), p < 0.001, I2 = 53.0%), and p = 0.017 < 0.05, I2 = 46.9%). Regardless of the type of surgery , the postoperative complications were significantly less in patients receiving ERAS rehabilitation than in patients receiving conventional rehabilitation, p < 0.05. The use of ERAS rehabilitation can significantly reduce the occurrence of postoperative complications.The clinical outcome of complications occurring after surgery was reported in 9 articles for fracture surgery, 13 articles for joint replacement surgery, and 12 articles for spine-oriented surgery. p < 0.001, I2 = 97.7%) and p < 0.001, I2 = 67.2%). After joint replacement or spine-related surgery, the patients with ERAS rehabilitation have significantly lower pain scores than those in the conventional rehabilitation group.There are relatively few data on this indicator of VAS pain score, and only data related to joint replacement and spine surgery are summarized. A total of 6 of these articles were reported for joint replacement surgery and a total of 6 articles were reported for spine-oriented surgery. p > 0.05). The LOS was approximately the same in both rehabilitation groups. However, there was a significant difference in postoperative complications between the two rehabilitation groups of patients in joint replacement surgery (p < 0.001). There was also significant variability in postoperative pain among arthroplasty patients who had received different rehabilitation protocols (p < 0.05). These results suggest that the patients who had received the ERAS rehabilitation program experienced less postoperative pain and complications than those who had received conventional rehabilitation. The use of the ERAS rehabilitation program can help patients to reduce the incidence of post-operative complications and reduce their pain and discomfort. This can go a long way in promoting better post-operative recovery for patients. There was no significant variability in the length of hospital stay for patients in the joint replacement group, which may be related to the patient’s age, underlying disease, psychological status, and intraoperative blood loss, which can lead to a longer postoperative hospital stay [According to the forest plots we obtained and the results of the analysis, there was no difference in the length of stay in patients who underwent joint replacement, either with the ERAS rehabilitation protocol or with the conventional rehabilitation protocol . The analysis results for patients who had undergone fracture surgery and spinal surgery show that the two different rehabilitation protocols had different effects on the patients’ post-operative recovery. The use of the ERAS rehabilitation program can help patients to recover better after surgery. These advantages are fully reflected in terms of length of stay, postoperative complications and VAS scores. The results of our analysis were consistent with those of some current studies. The ERAS rehabilitation program provides comprehensive rehabilitation management of patients before, during, and after surgery, and can improve postoperative outcomes, reduce complications, shorten hospital stays, and reduce the impact of postoperative pain in patients [Overall, there were significant differences in outcome indicators, except for the length of hospital stay in joint replacement. In patients who had undergone fracture surgery and spine surgery, there was a significant difference in all outcome indicators between the ERAS rehabilitation group and patients in the conventional rehabilitation group (patients ,57.For the patients who had undergone joint replacement surgery, the length of stay in hospital was somewhat shorter for those with the ERAS rehabilitation program than for those in the conventional rehabilitation group. These results suggested that the ERAS rehabilitation can improve the patient’s post-operative condition and achieve the clinical requirements for discharge from hospital more quickly. These could show that the ERAS rehabilitation program can help patients recover better and faster, and thus return to normal life and work more quickly. For the patients in the ERAS rehabilitation group and the conventional rehabilitation group, there was a significant difference in post-operative complications and pain between the two. It could be that the two methods of rehabilitation have different factors affecting postoperative complications and pain,, or it may be that there were differences in the specific implementation process in the clinical setting which has an impact on the outcome. For example, the differences in the clinician’s surgical experience and technique, or differences in the specific pain relief protocols and pain medication used, may also have an impact on post-operative complications and pain. The impact of an ERAS rehabilitation program on complications, pain and even function after arthroplasty is a question that clinicians will need to consider and explore in the future, and deserves further evidence from more clinical trials.In addition, as a multimodal management, the ERAS rehabilitation program can reduce the length of hospitalization of patients while also reducing the cost of patients’ expenses and reducing medical stress . The resOf course, there are still some concerns and controversies about some of the measures in the current ERAS rehabilitation program. For example, the ERAS Society often advocates a reduction in the use of anti-inflammatory analgesics along with early parenteral nutrition, which may increase the risk of postoperative inflammation. In terms of preventing post-operative thrombosis, the ERAS Society recommended that adequate thromboprophylaxis should be provided during the patient’s post-operative recovery period. Thromboprophylaxis can be gradually reduced and discontinued after the patient has fully resumed activity . HoweverBased on our comprehensive analysis of postoperative patients in all directions of orthopedics, comprehensive rehabilitation management of patients by using ERAS in the perioperative period can provide clear benefits for patients. Compared to conventional rehabilitation, ERAS rehabilitation programs can significantly improve the overall postoperative condition of patients. Of course, in addition to improving length of stay, post-operative complications and pain, ERAS rehabilitation may also can improve other post-operative indicators for patients, such as the patient’s functional recovery and functional scores after surgery, the need for postoperative blood transfusions and the readmission rate after discharge. Improvements in all these indicators can make an important contribution to the patient’s postoperative recovery. More consideration can be given to the exploration of these indicators in future clinical studies on ERAS, together with a more comprehensive analysis of the benefits and drawbacks of ERAS rehabilitation programs for patients, thus promoting better clinical application of ERAS rehabilitation programs.Of course, there are some limitations to the current review. First, the vast majority of the included clinical research articles were retrospective, with fewer randomized controlled studies, which may have confounded the results. Second, the specific measures of ERAS rehabilitation protocols used by individual departments or hospitals vary to some extent and cannot be completely standardized, which may also cause bias in the final outcome.In the perioperative period in all directions of orthopedics, the application of ERAS rehabilitation protocols can shorten the length of stay and reduce the cost of patients’ expenses compared to conventional rehabilitation protocols. In addition, patients benefiting from the ERAS rehabilitation program will have fewer postoperative complications, and patients will have less postoperative pain than those with conventional rehabilitation, which is more conducive to better postoperative recovery. Therefore, ERAS rehabilitation protocols deserve more consideration in the perioperative period for orthopedic patients.