The demand for physical medicine and rehabilitation services has risen significantly. Immediate rehabilitation is not always readily available which may compromise patients' functional recovery. Here, we describe a rare subtalar dislocation case and how an unsupervised home-based rehabilitation program allowed functional recovery.A 49-year-old male presented to the emergency department with an injury to the right ankle which resulted from a 3-meter height fall with his foot in plantar flexion and inversion. Clinical and imaging findings confirmed a diagnosis of a rare case of subtalar dislocation. The post-injury AOFAS Ankle-Hindfoot Scale score was 24/100 points. After six weeks of immobilization, a patient-tailored home-based rehabilitation program was prescribed. Adherence to our home-based rehabilitation program was critical to allow a range-of-motion improvement and functional recovery.Delaying rehabilitation may lead to long-term functional impairments. Thus, acknowledging the post-acute period as critical to initiate rehabilitation is mandatory. When outpatient rehabilitation settings are not readily available due to high demand, comprehensive patient education, and home-based rehabilitation programs may constitute effective alternative interventions. We demonstrate the significant improvement obtained with an early patient-tailored home-based rehabilitation program in range-of-motion and functional outcomes in a case of medial subtalar dislocation. The demand for physical medicine and rehabilitation services has been on a significant rise across a multitude of countries with varying levels of income, due in part to the rise in total disability-adjusted life years related to populations’ life expectancy increase . NationaSubtalar dislocations are extremely rare injuries that comprehend 1% of all traumatic injuries to the foot and are described as simultaneous dislocation of the talocalcaneal and talonavicular joints without any tibiotalar or talar neck-associated fractures . The medHere, we describe how an unsupervised home-based rehabilitation program was implemented for a case of medial subtalar dislocation without fracture which improved functional outcomes ahead of a supervised program in a high-demand outpatient rehabilitation setting. The reported results support our hypothesis that implementing home-based rehabilitation programs could assist in alleviating the strain on outpatient rehabilitation services.A 49-year-old physically active deaf male presented to the emergency department, accompanied by his mother, with an injury to the right ankle. The injury resulted from a 3-meter height fall from a tree with his right foot in a maintained position of plantar flexion and inversion causing pain, significant deformity, and disability. The patient had an unremarkable medical and surgical history, particularly in regard to ankle sprains or ligament laxity until this event.On arrival, the emergency orthopedic team noted a severely deformed and medially displaced foot with the prominent head of the talus projected dorsolaterally, just below the lateral malleolus Figure . AlthougAfter an unsuccessful early attempt to correct the deformity position, the patient was referred to the emergency room for close reduction with sedoanalgesia and sciatic nerve block, which was achieved at the first attempt, with optimal stability. Axial manual traction on the foot and heel in the line of the deformity was combined with countertraction with the knee in 90º flexion to relax the triceps surae complex pull over the calcaneus. An eversion force was applied on the foot with the ankle in plantar flexion followed by dorsiflexion. Dorsalis pedis and posterior tibialis pulses returned to be easily palpable. After applying a below-knee cast for tissue healing, a new radiographic image confirmed successful reduction with accurate joint alignment. Additionally, a computed tomography (CT) scan was conducted, revealing the presence of heterotopic calcifications located on the anterior talofibular ligament.Subsequently, the patient was released from the hospital with instructions to uphold a non-weight bearing status until the scheduled follow-up appointment with outpatient Orthopedics, which was set for the sixth week post-injury. During this appointment, a reassessment would take place. Thus, following a period of six weeks of immobilization, the cast was removed. At the time, on physical examination, the patient had moderate hindfoot pain with pressure, mild swelling on the ankle, and significant subtalar joint range of motion (ROM) limitation. The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale score, comprising assessments of pain, function, and alignment, yielded a total of 24 out of 100 points. Radiographic findings did not demonstrate any indications of arthritis or avascular necrosis affecting the talus. In order to obtain a more comprehensive understanding of the injury, an MRI scan was performed, revealing the presence of various ligamentous tears, encompassing the tibiofibular syndesmotic ligaments, the anterior talofibular ligament, as well as the talocalcaneal ligaments. Furthermore, the MRI also detected partial ruptures in the tendons of the tibialis posterior and peroneus brevis Figures -8.Subsequently, the patient received detailed instructions to commence partial weight bearing and was prescribed a patient-tailored home-based exercise program provided in the form of a booklet. The prescribed program encompassed various components, including ankle joint flexibility exercises involving ROM movements for foot dorsiflexion, plantar flexion, inversion, and eversion. Additionally, the program included strengthening exercises such as eccentric Achilles strengthening, heel raises, concentric ankle dorsiflexion, eversion, and inversion exercises utilizing an elastic band and towel scrunches. Furthermore, proprioception exercises comprising single leg taps and balance training using a pillow on the ground were also incorporated. The prescribed exercise regimen elucidated the recommended number of repetitions, sets, and frequency per day for each exercise. Instructions on employing static cryotherapy were provided as a means to manage pain or any indications of inflammation. Prior to initiating the exercises at home, the patient also received comprehensive guidance on the correct execution of each exercise and was encouraged to adhere to the program consistently.During the eighth week following the injury, the patient underwent a comprehensive clinical and functional evaluation at a Physical Medicine and Rehabilitation appointment. At this stage, the patient had progressed to full weight-bearing mobilization with the assistance of an ankle brace for compression and control of dorsiflexion and plantar flexion. Ankle ROM measurements using a goniometer revealed 10º of dorsiflexion, 20º of plantar flexion, 15º of inversion, and 5º of eversion. The AOFAS Ankle-Hindfoot Scale indicated a score of 72. The patient expressed adherence to the home-based exercise program, describing the proper execution of exercises and reporting significant improvements in activities of daily living (ADL) participation with minimal pain.Subsequently, a personalized physical and functional rehabilitation program was formulated by the physiatrist. The program aimed to optimize the subtalar joint range of motion and enhance muscular strength and flexibility, primarily targeting the ankle evertor muscles. Additionally, proprioceptive control training and gait normalization were included in the rehabilitation goals. Physical modalities such as cryotherapy and ultrasound were employed to manage pain and edema, while also providing support for the exercises.The increasing prevalence of chronic diseases in association with an aging population has been expected to result in over-demand for rehabilitation institutions with a plausible reach of non-sustainable levels. As rehabilitation is being progressively acknowledged as a global health priority, it is of the utmost importance that governments channel more resources to their national health services’ rehabilitation institutions. In our setting, it is not uncommon for patients to wait several weeks to months to initiate a supervised rehabilitation program directed to their functional disability. For certain clinical contexts, such as the case discussed, a long waiting time is unacceptable -4. Thus,Home-based exercise programs are usually implemented as a self-management approach for people with chronic diseases. Effectively, these programs constitute a crucial cost-effective intervention adaptable to the patient’s daily schedule by being delivered in the most accessible place for the patient and with the least medical costs ,6. MultiDespite being a known major issue in home-based rehabilitation, our group didn’t find exercise adherence to be concerning in the described case, given the patient’s past as a sportsman and the patient’s demonstration to easily integrate exercise into his daily life. Patient education about the diagnosis and prognosis of subtalar dislocation and understanding the importance inherent to early mobilization and exercise execution were key to assure patient adherence to home-based treatment. Lastly, an additional factor we consider played a part in treatment adherence relates to the acute character of the injury and its immediate functional impact on the patient’s ADL.The American Orthopaedic Foot & Ankle Society (AOFAS) score is a clinical assessment tool that measures pain, function, and alignment in foot and ankle conditions. We used this score as it provides valuable information for treatment evaluation and decision-making. The score consists of three main components: pain (40 points), function (50 points), and alignment (10 points). Each component assesses specific aspects related to patient-reported outcomes, contributing to a more comprehensive evaluation of the clinical and functional results achieved with our home-based rehabilitation program, as well as the progress made in patients' daily activities participation and quality of life. The benefits obtained with the prescribed program were determined by the notable improvement in functional outcomes, specifically the significant difference of 48 points between the two AOFAS scores and the enhancement in subtalar mobility observed within a two-week timeframe.At the time of the injury, given the controversy surrounding the period of immobilization and the very low incidence of this injury, a six-week immobilization period was established. Indeed, the optimal duration of immobilization continues to be a subject of debate. Some authors advocate for a period exceeding four weeks to facilitate adequate soft tissue healing, whereas others propose a shorter interval of two to three weeks to be more advantageous in preventing stiffness in the subtalar joint . LasaniaNonetheless, subsequent to the removal of the cast, the patient was promptly provided with a rehabilitation strategy that prioritized home-based exercises aimed at enhancing flexibility, strengthening, and proprioception. This particular approach played a vital role in the restoration of the patient's subtalar range of motion, improvement of postural control, reduction of pain, and facilitation of increased participation in daily activities, all of which were achieved within a two-week period. It is important to note that the MRI results revealed a tibialis posterior tendon rupture, which may impede further functional progress. To the best of our knowledge, this is the first case reporting such a complication resulting from a closed medial subtalar dislocation. A previous report by Boussakri et al. reported a rupture of this tendon following an open lateral subtalar dislocation .Given the high demand for our hospital's outpatient rehabilitation department, the initiation of a supervised program following a rehabilitation prescription by the physiatrist could entail a minimum waiting period of one month. Therefore, considering the home environment as the most accessible setting, the patient was advised to continue with the temporary management of a home-based exercise program following subtalar dislocation. This recommendation was based on the significant functional benefits observed within a short duration of time.While recognizing the necessity to monitor and obtain consistent feedback from patients participating in home-based rehabilitation programs, our case report identified a constellation of factors that instilled confidence in our patient's adherence to the prescribed treatment. Adherence predictors such as the patient's intention to actively engage in the program, self-motivation, self-efficacy, and previous history of adhering to physical activity regimens were discerned . We woulIn conclusion, the findings presented in this case report provide evidence supporting the effectiveness of a home-based rehabilitation program as a viable option for managing subtalar dislocation in situations where supervised outpatient rehabilitation services are limited. The documented functional outcomes demonstrate the potential benefits of this approach. In the post-acute phase following subtalar dislocation, initiating early and intensive rehabilitation is imperative to mitigate the risk of long-term complications.


The rapidly evolving COVID-19 public health emergency has disrupted and challenged traditional healthcare, rehabilitation services, and treatment delivery worldwide. This perspective paper aimed to unite experiences and perspectives from an international group of rehabilitation providers while reflecting on the lessons learned from the challenges and opportunities raised during the COVID-19 pandemic. We discuss the global appreciation for rehabilitation services and changes in access to healthcare, including virtual, home-based rehabilitation, and long-term care rehabilitation. We illustrate lessons learned by highlighting successful rehabilitation approaches from the US, Belgium, and Japan. One in every three people will need rehabilitation services at some point in their lifetime . Yet, noIn addition to barriers to healthcare and rehabilitation services –8, the iAlthough the COVID-19 pandemic resulted in an accelerated publication rate in rehabilitation, with 18% of all publications published between 2019 and 2022 including the term “rehabilitation” , only recently, there has been a first collection of publications addressing the challenges and opportunities of health systems, rehabilitation care, and COVID-19 . TherefoIn January 2023, COVID-19 was diagnosed in more than 660 million individuals in 229 countries and territories around the globe, resulting in 6.7 million deaths and over 638 million recoveries . Though Differences in how countries responded to the pandemic and adjusted their rehabilitation services demonstrate variability in healthcare systems and priorities , 32. ForThis was not a global response; in other parts of the world rehabilitation services were deemed more of a priority. A registry-based study from Norway, including 1310 hospitalized patients with traumatic brain injury (TBI), demonstrated that the direct pathway to early specialized rehabilitation was maintained during 2020–2021 . SimilarOne of the most significant transformations in the delivery of healthcare services due to the pandemic has been innovation in remote delivery of care, including the use of telehealth. What seemed improbable pre-pandemic is now becoming an option of care currently reimbursable by insurances for individuals with limited access to physical healthcare facilities in many countries . RehabilMany professional associations and some government agencies across the globe  areThe growth of telehealth and other remote services is not only seen with COVID-19 patients but also within the healthcare system for medically vulnerable individuals and persons with limited access to healthcare in isolated areas of the world, including rural areas and parts of the world impacted by disaster and war. Telehealth has been shown to support patient-provider communication when face-to-face interaction is not possible . TeleheaTelehealth, home-based rehabilitation programs, and various web-based interventions were introduced early in some medical centers in the US , 48 and In Japan, dedicated virtual consultation services were introduced early in the pandemic through the Japanese Infectious Disease Prevention Act, where public health centers became responsible for infectious disease control and prevention , 56. An Despite the many benefits to telehealth, barriers to telehealth access were also noted. In some cases, patients who were receiving care at home did not have the resources  to engage in telehealth sessions. The lack of resources in low-income countries could explain why approaches of telehealth were limited in e.g., Tanzania . Indeed,Furthermore, telehealth, was noted to not be conducive to all types of conditions and rehabilitation services. For example, in speech-language pathology, online swallowing tests were recommended only as screenings; full evaluations and interventions were discouraged. In physical therapy, requests to allow therapists to treat patients remotely were deemed impractical or even unsafe. As a result, in the U.S., Centers for Medicare & Medicaid Services motioned to deny payment for certain types of telehealth services.During this process, many allied health professionals became strong advocates, not only for their patients but also for their profession. On several occasions, professionals took action by writing letters to Ministries of Health and introducing protocols that would inform safe practice. These actions allowed allied health professionals in Europe, for example, working with the National Health System, to notify state officials and administrators as to what rehabilitation specialty consists of and what allied health care professionals do.Long-term care facilities (LTCFs) inhabiting vulnerable populations, including the elderly and persons with disability, are at significant risk for massive outbreaks of viruses, including COVID-19 . COVID-1Dominiek Savio is one of the most prominent institutes for more than 500 children and adults with physical disabilities in Belgium, a country in which on May 3rd 2020, 53% of all deaths due to COVID-19 were in care homes . Given oAt the onset of the pandemic, the board of directors selected a group of three persons that were given authority to make decisions and implement measures against the spread of the virus. The two medical doctors of the institute provided the team with the latest updates via their network. Challenges could be tackled within the organization with the support of their medical team, including 2 medical doctors, 28 nurses, and 5 healthcare providers. Because of the fast-shrinking supply of personal protective equipment (PPE), residents safely produced face masks in the workshop. Proactive actions that supported a timely response to the pandemic was the initiative taken one year before the onset of the COVID-19 pandemic, to sensitize employees on the importance of hygiene .Despite the lockdown, all patients received the treatments and rehabilitation they needed while considering the well-being of both patients and employees. Initiatives such as the Chatbus, i.e., a bus separated in two parts by a plastic wall allowed contact between residents and visitors. Infographics were created and distributed to allow residents to make informed decisions about vaccination and PPE. Through the pandemic, the team adjusted their strategies, and in January 2022, they reduced the burden on the staff and residents by limiting the amount of PPE to Filtering Face Piece 2 masks. The call center “Coronafoon” allowed to collect and monitor the number of positive cases and provide timely information to the leadership team. The implementation of an emergency plan with a barometer which incorporates four main principles  gives guidance and trust for the future. The years of investment in solidarity and commitment amongst employees to improve the quality of life of persons with a disability proved its impact.Similar strategies were observed in Japan, which presented low mortality and morbidity rates in care homes . For exaThe COVID-19 pandemic offered insights into how different countries across the globe prioritize rehabilitation. Those countries that were not able to provide continued rehabilitation services during the pandemic are expected to suffer from detrimental consequences, including increased rates of chronic diseases, growing healthcare costs, and reduced overall quality of life. To accommodate the patient's needs and address the challenges in the COVID-19 pandemic, rehabilitation specialists have devised innovative ways to deliver rehabilitation services for patients and caregivers. Continued research of innovative interventions and remote treatment delivery methods  and government support is needed to inform clinical recommendations and rehabilitation guidelines around the globe. Common findings from the presented success stories from LTCFs demonstrate the importance and effectiveness of a comprehensive approach where health care and rehabilitation are a critical part of one another as well as preparedness and having systems that can reduce the impacts of large-scale unexpected disruption to services, such as the COVID-19 pandemic.The presented stories from high-income developed countries also align with challenges and recommendations from the low-income countries Jordan  and IndiThe unpreparedness to react effectively and promptly to the pandemic was presented as one of the significant public health challenges . Identif


Rehabilitation nutrition is expected to help treat frailty, undernutrition, and sarcopenia. It is defined as (i) holistically evaluating the presence and causes of nutritional disorders, sarcopenia, and excess or deficient nutrient intake using the International Classification of Functioning, Disability, and Health; (ii) conducting rehabilitation nutrition diagnosis and goal setting; and (iii) inducing the highest levels of body functions, activities, participation, and quality of life in patients by improving their nutritional status, sarcopenia, and frailty ,2. PreviHerein, we discuss two review articles and eight original articles on rehabilitation nutrition. Shirai et al. conducted a narrative review of the prevalence of the relationship between nutrition-related problems and falls among patients undergoing hemodialysis (HD) . Their l2 might be a predictor for sarcopenic dysphagia [2, sarcopenic dysphagia should be suspected immediately after admission. Abe et al. examined the additive effect of energy intake and rehabilitation time on ADL improvement in patients with acute stroke and sarcopenia [Furthermore, a cross-sectional study conducted by Togashi et al. revealed that although the area under the curve of body mass index (BMI) for sarcopenic dysphagia diagnosis was approximately 0.6, the BMI of <20.0 kg/mysphagia . They rercopenia  and demorcopenia . They dercopenia . They deThese articles have focused on the assessment, intervention, and prediction outcomes related to patients in rehabilitation. However, no report on the rehabilitation nutrition care process has been published to date; thus, future studies should address this issue. Further scientific evidence on rehabilitation nutrition will help overcome the problems associated with frailty, sarcopenia, and malnutrition.


The aging of the population and the progressive increase in life expectancy in developed countries is leading to a high incidence of cerebrovascular diseases. Several studies have demonstrated that robot-assisted rehabilitation therapies combined with serious games can improve rehabilitation outcomes. Social interaction in the form of multiplayer games has been highlighted as a potential element to increase patient’s motivation and exercise intensity, which professionals have described as one of the determining factors in maximizing rehabilitation outcomes. Despite this, it has not been widely studied. Physiological measures have been proven as an objective tool to evaluate patients’ experience in robot-assisted rehabilitation environments. However, they have not been used to evaluate patients’ experience in multiplayer robot-assisted rehabilitation therapies. The main objective of this study is to analyze whether the interpersonal interaction inherent in a competitive game mode affects the patients’ physiological responses in robot-assisted rehabilitation environments.A total of 14 patients participated in this study. The results of a competitive game mode were compared with a single-player game mode with different difficulty levels. Exercise intensity and performance were measured through parameters extracted from the game and the information provided by the robotic rehabilitation platforms. The physiological response of patients in each game mode was measured by the heart rate (HR) and the galvanic skin response (GSR). Patients were asked to fill out the IMI and the overall experience questionnaire.The exercise intensity results show that high-difficulty single-player game mode is similar in terms of intensity level to a competitive game mode, based on velocity values, reaction time and questionnaire results. However, the results of the physiological responses of the patients measured by GSR and HR are lower in the case of the competitive mode compared to the high-difficulty single-player game mode, obtaining results similar to those obtained in the low-difficulty single-player game mode.Patients find the competitive game mode the most fun, which is also the mode they report experiencing the most effort and stress level. However, this subjective evaluation is not in line with the results of physiological responses. This study concludes that interpersonal interaction inherent to a competitive game mode influences patients’ physiological responses. This could mean that social interaction is an important factor to consider when interpreting the results obtained from physiological measurements. According to World Population Prospects 2022 of the United Nations, the proportion of persons aged 65 or over is projected to increase globally between 2022 and 2050. At the world level in 2022, approximately 10 percent of people are aged 65 or over . A propeThe needs presented by these people make the care and rehabilitation exercises provided by robotic rehabilitation platforms even more important today and in the coming years . SeveralDifficulty adaptation algorithms are one of the most promising elements for maximizing motivation and intensity over the long term –16. TherGenerally, the game experience can be measured by physiological measures and/or questionnaires. There are numerous examples in the literature of the use of physiological measures to assess the gaming experience of patients in single-player rehabilitation therapies. The overall conclusion is that they significantly improve the evaluation of the gaming experience , 27. PhyIn the context of difficulty adaptation algorithms based on physiological measures for competitive or cooperative games, some methods have been evaluated in recent years –36. HoweWe have previously conducted a study with unimpaired participants to evaluate how the interpersonal interaction inherent in a competitive game mode affects the physiological response of participants . Ten uniThe main objective of this study is to research whether the interpersonal interaction inherent in a competitive game affects the physiological response of patients in robot-assisted neurorehabilitation therapy. For this purpose, the results of a competitive game mode were compared with a single-player game mode with different difficulty levels. The aim is to define a single-player game mode similar to the competitive mode in all aspects so that the differences observed are not due to a different level of demand but to the interpersonal interaction involved in competing against a real competitor.14 patients participated in this study, whose demographics, impairment type and clinical scales are listed in Table The study was developed in La Pedrera Hospital . The study protocol complied with the Ethical Committee of La Pedrera Hospital. Hospital therapists selected participants. They were matched according to similar conditions, based on the degree of independence in activities of daily living (ADL), the upper limb muscle condition, and the level of cognitive impairment. To assess these aspects, the hospital therapists have relied on the information provided by the clinical scales. However, their experience working with these patients in the hospital has also been considered when making the pairings. The degree of independence in ADL was evaluated through the Barthel Index as follows , 39: 100Two Rubidium devices were used in this study , 42, 43.In this study, we used a force-field-based assistance mode of the Rubidium robotic rehabilitation platform. Figure Both patients were seated in front of a robotic rehabilitation device Fig. . The patPeople in wheelchairs who cannot sit at a table may have problems using the Rubidium rehabilitation platform because the wheelchair may collide with the table, so they cannot get close enough to use the device properly. For this reason, a Rubidium device with a lifting structure was used to facilitate its use with patients sitting in wheelchairs. The other Rubidium was placed directly on a table. For this reason, both screens used have different sizes. The screen for the device placed on a table is smaller because it is closer to the patient. While the Rubidium device adapted for wheelchair use has a larger screen because it is hung on the wall farther away from the patient. Before carrying out the study, we checked that the size and distance of the screens were adequate for the patients to perform the exercises correctly.d from his/her cursor to the apple was less than or equal to the distance r  was used to estimate the exercise performance of the patients in every condition. The game score is closely related to the difficulty level of the exercise. It allows us to evaluate whether or not the patients are able to perform the exercise correctly with a certain difficulty level. For this reason, the game score has been widely used to estimate the exercise performance in virtual reality game-based neurorehabilitation therapies , 33, 48.One of the measured physiological responses was the galvanic skin response (GSR). is a standard measure in psychophysiological paradigms, and therefore it is often used in affective state detection . For thiAnother standard measurement in rehabilitation games is the heart rate (HR) . Two ZepTo analyze how the game mode affected the user’s affective state, the values reached at the end of each game mode for each physiological feature were evaluated.Which game mode did you prefer? Which game mode was more fun? .In which game mode did you feel more tension? Several assessment tools are currently available to evaluate patient motivation and satisfaction during technology-assisted rehabilitation. One of the most commonly used tools is the intrinsic motivation inventory (IMI) [The overall experience questionnaire was used to assess the preferred game mode of the patients. The version used in this study is similar to the versions used in other studies , 25, 49.ry (IMI) , 51. Thiry (IMI) . The onery (IMI) –24, 37.Figure While providing instructions to the user, an evaluation of the patients’ skills is carried out to define the different difficulty levels of the single-player game modes based on the assistance level and the maximum time to reach the targets. During the evaluation period, the hospital therapists collaborated to define an appropriate difficulty level based on these two parameters. The difficulty level set in low-difficulty mode (LDM) was challenging but low enough to reach the targets easily. This difficulty level corresponds to that usually configured by therapists in a conventional robot-assisted therapy with the Rubidium rehabilitation platform. In the case of high-difficulty mode (HDM), a more challenging difficulty level was defined, where it would be difficult to reach the targets but not so difficult as to demotivate the patient.After that, experimentation begins. The procedure is the same for all game modes Fig. . First oIn this study, all game modalities were configured with 35 objectives, in other words, 35 trials. The duration of the session is not predetermined. It depends on the speed of the patients in reaching the targets. Each of the apples appears at a random time between 0 to 2 s. The movement range of the game has been set to 20 cm (10 cm radius).Participants could not see each other during the sessions and were instructed not to interact. However, they were allowed to interact between conditions. By limiting patient interaction, we aim to reduce the variability in the results due to, for example, different interpersonal relationships. Furthermore, we want to assess whether this factor still influences the results despite reducing all external interactions, with only the interpersonal interaction inherent in a competitive game mode.A normality test was carried out using the Shapiro-Wilk test. Results show evidence that parameters are not normally distributed. Friedman test was employed to study differences between conditions. Therefore, differences between groups were studied using the Friedman test. In the post-hoc analysis, pairwise comparisons were studied by the Wilcoxon signed-rank test with the zero method proposed by Pratt . In addiThe velocity values were normalized by the minimum forward speed (forward speed of the tunnel-shaped force-field-based assistance mode) . In contrast, in the CM, although both patients could not communicate with each other outside the game, they were aware that they were competing against a person. Therefore, the difference in physiological responses must be mainly due to this interpersonal interaction caused by playing with a person. We obtained the same result in a previous study conducted with able-bodied participants . We cannThe results presented in this study prove that high difficulty single-player game mode is similar in terms of difficulty level and intensity to a competitive game mode. Despite this, it was observed that there are differences in the physiological reactions of the patients in the results obtained by the HR and the GSR. It is interesting to note that according to the questionnaire results, patients find the CM the most fun game mode, which is also the mode they report experiencing the most effort and stress level. However, this subjective evaluation is not in line with the results of physiological responses, where the results suggest that the physiological response in the CM is somehow lower than in the HDM. Based on the results obtained in this study, we can conclude that this difference in the patients’ physiological reactions is due to the interpersonal interaction inherent to the competitive game mode. This could mean that social interaction is an important factor to consider when interpreting the results obtained from physiological measurements.


Soft robotic gloves have attracted significant interest in hand rehabilitation in the past decade. However, current solutions are still heavy and lack finger-state monitoring and versatile treatment options. To address this, we present a lightweight soft robotic glove actuated by twisted string actuators (TSA) that provides whole-hand finger motion tracking. We have developed a virtual reality environment for hand rehabilitation training, allowing users to interact with various virtual objects. Fifteen small inertial measurement units are placed on the glove to predict finger joint angles and track whole-hand finger motion. We performed TSA experiments to identify design and control rules, by understanding how their response varies with input load and voltages. Grasping experiments were conducted to determine the grasping force and range of motion. Finally, we showcase an application of the rehabilitation glove in a Unity-based VR interface, which can actuate the operator’s fingers to grasp different virtual objects. Active rehabilitation training can benefit patients with hand injuries, neurological or musculoskeletal conditions, and those who have undergone hand surgery by improving muscle strength and overall physical condition. However, traditional training with a physiotherapist is expensive, and most physiotherapy mechanical devices only allow patients to perform simple movement training, which is often perceived as monotonous and boring, leading to reduced patient motivation. Moreover, these rehabilitation devices are mostly bulky and heavy, so are not suitable for home rehabilitation. Therefore, there is a need for a low-cost, portable, and entertaining rehabilitation glove.One widely used technology in rehabilitation equipment is that of exoskeletons. These can be categorized into hard exoskeletons, which use rigid joints, links, and motors to drive finger movements, and flexible exoskeletons, which are designed around a glove for improved wearability. Hard exoskeletons ,2 providTo address the limitations of hard exoskeletons, soft exoskeletons designed as gloves with peripheral actuation are a suitable solution. These exoskeletons are lightweight and comfortable to wear. Soft exoskeletons can be categorized based on actuation sources, among which pneumatic and motor-tendon-based actuation methods are the two most popular types. Current pneumatic-driven hand exoskeletons ,5,6 normData gloves with hand movement tracking are effective for assessing hand training and developing control strategies for rehabilitation. Various sensors have been investigated for use in data gloves, such as flexible bending sensors, inertial measurement units (IMUs), etc. Flexible bending sensors are highly resistive sensors that have the advantage of being lightweight, small and inexpensive. However, such sensors can be easily damaged and their costs can be high . IMUs arThe monotonous and repetitive nature of hand rehabilitation training can be demotivating for patients undergoing physical therapy. However, the introduction of hand VR rehabilitation systems has revolutionized the process by adding an element of fun to the training. Additionally, these systems allow patients to train at home, making it more convenient for them ,21. PereIn this study, we propose a VR rehabilitation training glove system. This glove can drive the users to grasp various virtual objects while the users can visualize their grasping in a virtual environment. This glove has two main functions: actuation-assisted rehabilitation and real-time gesture recognition. To assist with grip training, a soft robotic glove was developed using five TSAs. Each TSA is composed of a motor and a pair of strings on the arm. The TSAs apply tension to the fingertips, yielding finger bending and helping the patient with their grip exercises. Elastic bands are attached to the back of the glove to help restore the patient’s fingers to their initial state after training. For finger gesture recognition, 15 IMUs are placed on the back of the glove. Every three IMUs are connected by one flexible printed circuit (FPC) board. The finger posture angles are solved through static threshold correction and a complementary filtering algorithm. Finally, we utilize a VR rehabilitation training system with objects in different shapes for grasping, in which the patient’s hand is mapped in real-time. The VR rehabilitation training glove is a low-cost device that costs about USD150. The proposed glove system can provide patients with more attractive, personalized, and effective rehabilitation training therapy with the help of rehabilitation training theory and VR, which can enhance patients’ initiative and motivation and improve the effectiveness of rehabilitation training.The finger posture tracking subsystem includes multiple flexible printed circuits (FPCs), IMUs, and an adapter board, while the TSA actuation subsystem comprises five actuation motors, five couplings, and five pairs of force-conducting tendon wires. These two subsystems are controlled by a microcontroller unit (MCU) that communicates with a personal computer (PC) through a serial port. The IMUs are connected to the MCU via a serial peripheral interface (SPI).When the system is activated, the IMU captures raw data that is sent to the MCU through FPC. The MCU decodes the data to obtain finger joint attitude data, which is then transmitted to a Unity VR system on the PC. The Unity VR system performs real-time simulation of the virtual hand model. Simultaneously, the TSA actuation system rotates force-conducting tendon wires and applies tension to the fingertips to aid gripping for the patient. The VR system continuously detects collisions between the virtual hand and interactive virtual objects. When a collision is detected on a particular fingertip, the Unity VR engine sends a signal to the MCU to stop the motor corresponding to that finger from working, that is, the finger stops being driven to grip.The TSA actuation system consists of five motors , five couplings, a support structure, and anchoring structures, as shown in The wearable part on the arm, including the TSA system, the cuff, etc., weighs approximately 180 g in total. This weight can be further reduced using a lighter cuff. The hand-wearable part, including the glove, IMUs, accessories, etc., only weighs 110 g. The wearable part on a single hand should weigh no more than 500 g  to minimTo evaluate the performance of the TSA, we conducted experiments to measure its traveling distance, actuation force, and traveling speed. The relationship between traveling distance and time was obtained under different loading conditions with weights  at a fixed operating voltage (12 V). The experimental results show that the curves for these loads are similar, suggesting that the actuator performs consistently within the tested range of loads, which is sufficient for actuating a single finger . The TSAIn hand rehabilitation, the force generated by the rehabilitation equipment is essential. To evaluate the gripping force supplied by our rehabilitation gloves, we made a prosthetic hand. The prosthetic hand is 3D-printed to mimic a human hand, and has 16 degrees of freedom, as shown in The measured relationship between the force exerted by the tensile testing machine and the traveling distance change of the glove is illustrated in To determine the duration of the full range of motion (ROM) for different voltages, we first adjust the fingers of the prosthetic hand with gloves to a fully grasped state , and marIn this study, the IMU system, which consists of 15 six-axis IMU  modules, is used to measure and calculate the movement angle of each knuckle of the hand. As shown in Except for the thumb, the other four fingers have three phalangeal joints—from inside to outside, the metacarpal phalangeal (MCP), the proximal interphalangeal (PIP), and the distal interphalangeal (DIP). The gyroscope in a six-axis IMU collects the real-time angular velocities Compared to using a single IMU, utilizing multiple IMUs introduces the need for sequential processing and resolving data from each IMU. Consequently, this multi-IMU system requires more time and leads to the accumulation of errors. Even in scenarios where the IMUs are at rest, the integration still occurs, resulting in significant integration errors.To address this issue, we employ the static threshold correction method proposed in our previous study . During us study .x, y, and z directions.Based on the coordinate frames established in In the study, we utilize the complementary filter to fuse the angles solved by the gyroscope and accelerometer for determining attitude. This algorithm offers several advantages, including low computational complexity, fast speed, and suitability for multi-IMU systems.f, is set to 0.96 to improve estimation accuracy. Once the estimated attitude angle of each IMU is obtained, the angle of each finger joint can be calculated from the difference between two neighboring IMU angles, as described in Given the non-negligible high-frequency motion perturbations of the accelerometer, the angle A VR rehabilitation training system was developed based on the control flow depicted in Hand gesture data collected from multiple IMUs is processed by the MCU and then sent to the VR system on the PC through a USB serial port. The VR system uses this data to simulate the movement of corresponding joints in the virtual hand, enabling real-time gesture recognition and mapping.In addition, a certain volume of the touch zone is assigned to both the interactive object and the fingertips of the virtual hand, respectively. We determine that the virtual hand and the interactive object collide when the touching zones of the two intersect. When the software is running, the VR system continuously checks for collisions between the virtual hand and the objects that can be interacted with. In the absence of any collisions, the TSA actuation system operates continuously. This system causes the strings to twist, creating tension in the user’s fingers for grasp training. When a collision between the virtual hand and an interactive object is detected, the VR system sends a signal to the MCU via a serial port. The motor controlling the finger that collided with the object stops working and the finger of the virtual hand remains on the surface of the object, resulting in a successful virtual grasp.This study proposes a VR rehabilitation training glove with both twisted string actuation (TSA) actuation and finger posture recognition using inertial measurement units (IMUs). The glove, including the entire actuation system, is lightweight (less than 300 g) and affordable (about USD150). As a cost-effective and portable VR rehabilitation device, it has great potential to enhance patients’ rehabilitation outcomes through diverse games and interactive activities.This paper provides detailed information on the principles and algorithms of TSA actuation assistance for grip training and finger posture recognition for motion tracking. A series of experiments were conducted to demonstrate the feasibility of the rehabilitation training glove. The glove achieved a full range of motion (ROM) within 35 s, exerting a total force of 17 N force on all fingers, except the thumb, with a traveling distance of 20 mm. These results show that the TSA actuation method can provide appropriate stroke, force, and speed for effective rehabilitation. Real-time VR application experiments also confirm the feasibility and effectiveness of the rehabilitation glove in the VR environment.Nonetheless, this research can still be improved in several aspects. The current study utilizes the elastic bands integrated at the back of the fingers to generate torsional stiffness to prevent the TSAs from damaging the fingers. In the future, we plan to optimize the torsional stiffness  of the g


Virtual reality (VR) and augmented reality (AR) are noble adjunctive technologies currently being studied for the neuro-rehabilitation of post-stroke patients, potentially enhancing conventional therapy. We explored the literature to find if VR/AR improves neuroplasticity in stroke rehabilitation for a better quality of life. This modality can lay the foundation for telerehabilitation services in remote areas. We analyzed four databases, namely Cochrane Library, PubMed, Google Scholar, and Science Direct, by searching the following keywords: ("Stroke Rehabilitation" [Majr]) AND , Virtual Augmented Reality in Stroke Rehabilitation. All the available open articles were reviewed and outlined. The studies conclude that VR/AR can help in early rehabilitation and yield better results in post-stroke patients in adjunct to conventional therapy. However, due to the limited research on this subject, we cannot conclude that this information is absolute. Moreover, VR/AR was seldom customized according to the needs of stroke survivors, which would have given us the full extent of its application. Around the world, stroke survivors are being studied to verify the accessibility and practicality of these innovative technologies. Observations conclude that further exploration of the extent of the implementations and efficacy of VR and AR, combined with conventional rehabilitation, is fundamental. Introduction Stroke, which was first referred to as "apoplexy" by William Cole in 1689, has become a significant cause of mortality and disability, particularly among the aging population worldwide . It is dModifiable and non-modifiable risk factors predispose individuals to stroke. Modifiable factors include hypertension, diabetes, obesity, or hypercholesterolemia, while non-modifiable factors include age, gender, sex, race, and family history of stroke -10. HemoA quarter of individuals over the age of 25 are predicted to be susceptible to stroke, and the incidence is higher in men than in women over the age of 65 -13. HoweStroke sequelae lead to significant disabilities . It inclRehabilitation is a crucial aspect of managing post-stroke complications, with the goal of improving the quality of life for patients . RehabilAs opposed to traditional rehabilitation methods, AR and VR supplements offer several advantages, such as high repetition and intensity task specificity, objective feedback, greater user engagement, and improved motivation -27. RepeIn this narrative review, we will focus on the current understanding of the use of AR and VR in stroke patient rehabilitation, with a specific focus on the outcome of individualized AR/VR in rehabilitation following a stroke and their potential use in telerehabilitation for individuals residing in remote regions. Neural changes and disabilities after strokeStroke lead to an abrupt loss of neural function and damage to the central nervous system ,32. ThisPost-stroke rehabilitationRehabilitation aims to promote neural plasticity by targeting abnormal connectivity within or between brain hemispheres ,42. It cRehabilitation involves repetitive, challenging, motivating, and intensive exercises with meaningful and realistic tasks to enhance its efficacy ,47. StudVR and AR: subtypes and dynamicsVR/AR technology has emerged as a promising tool for neuro-rehabilitation. It can create an immersive virtual environment that mimics the real world and engages patients in task-oriented, repetitive, and intensive training -65. AR tVR/AR systems have been shown to yield better results when used as an adjunct to conventional rehabilitation -78. For VR/AR also plays a role in aphasia therapy . BTS-NirVR/AR techniques are showing promise as a way to improve outcomes in stroke rehabilitation. Conventional rehabilitation can become tedious, leading to decreased motivation and treatment adherence over time . VR/AR oSeveral studies have shown that VR/AR techniques can refine the motor control of stroke patients, filling the gap between the real and ideal world, and aiding in the early stages of recovery . Motor-cThere are several examples of VR/AR systems that target specific aspects of stroke rehabilitation. For example, Gait-triggered mixed reality (GTMR) is a cognitive-motor dual-task with multisensory feedback targeted at lower-limb post-stroke rehabilitation. This platform has the inherent capability of adapting to the difficulty of a task to challenge the user continually but only making the task achievable . AnotherDespite the promise of VR/AR techniques, the lack of standardization in stroke rehabilitation leads to varied results in different systems. Additionally, some individuals using VR/AR reported limitations in mobility, and the head-mounted display caused some patients to experience nausea and headaches. Furthermore, VR/AR technology requires more experts to maintain and utilize the systems effectively. However, the advantages of VR/AR, such as better functional gains, incorporation of activities of daily living (ADLs) into VR/AR devices, individualized training, enhanced motivation, and enjoyment, make it an exciting area for further exploration in stroke rehabilitation ,66,80. It is important to acknowledge the limitations of our study. Firstly, our inclusion criteria only allowed for articles published in English, which may have introduced language bias. Secondly, we did not include unpublished or grey literature, which could have provided additional valuable insights to our review. Finally, the heterogeneity of the studies included in our review precluded a meta-analysis. Despite these limitations, our comprehensive review provides a useful overview of the potential of VR/AR in stroke rehabilitation, highlighting the need for further research in this area. Our review highlights the promising role of VR/AR in enhancing neuroplasticity and improving the quality of life of stroke patients when used in conjunction with conventional therapy. Despite the limitations posed by targeted exercises and technical difficulties reported in some studies, the benefits of VR/AR, including its ability to engage patients in task-oriented, repetitive, and intensive training, are noteworthy. Our review also underscores the need for further research to explore the affordability and accessibility of VR technology in remote regions and clinics, as well as encourage neurologists to incorporate VR/AR as a tool for assessing stroke recovery.


To investigate the efficacy of technology-assisted rehabilitation compared to that of usual care programs after total hip arthroplasty (THA) through randomized controlled trials (RCTs).The Medline (PubMed), Cochrane Library, Embase and Web of Science databases were searched for RCTs regarding the efficacy of technology-assisted rehabilitation following THA. Data were analyzed using Stata 12.0 software.Eleven RCTs involving 1327 patients were included in the meta-analysis. The pooled effect size showed that compared to usual care, telerehabilitation significantly improved the Harris score  and functional independence measure (FIM) score . In addition, video-based therapy could significantly improve walk test results .The findings suggest that technology-assisted rehabilitation, especially telerehabilitation, have been shown to improve the physical function of patients following THA compared to conventional rehabilitation. More robust studies are needed to validate the long-term efficacy and safety of innovative technology-assisted training strategies. Rehabilitation is a multidisciplinary approach that improves joint function and activities of daily living, as well as reducing pain for the individual after surgery. Several studies have demonstrated the effectiveness of rehabilitation after hip replacement surgery.–7 Rehabilitation therapy, for example, can promote functional recovery and reduce adverse complications such as dislocations of prosthetics and deep vein thrombosis.,9Total hip arthroplasty (THA) is a common reconstructive hip surgery that is performed on patients who do not respond to long-term medication and conservative treatment to alleviate their pain and joint stiffness. eHealth interventions include internet-based interventions, telephone support, virtual reality, exercise games, and mobile applications. In recent years, eHealth has been utilized to facilitate the management of chronic diseases, cardiac rehabilitation, musculoskeletal disorders, cancer, and neonatal care improve the health outcomes of patients.–14 eHealth can also improve access to treatment, reduce waiting times, and be more cost-effective than face-to-face interventions.Technology and science have been advancing rapidly in recent years, and which led to frequent changes in the methods and measures of rehabilitation. Therefore, new technology-assisted training strategies can be applied to guide the rehabilitation of patients after arthroplasty, aimed at improving their motor function and activities of daily living. One definition of eHealth is “the use of digital information and communication to support or improve health and health care services.”Despite systematic reviews of technology-assisted rehabilitation, there is insufficient evidence to support the effectiveness of this method in the rehabilitation of THA patients. Additionally, there is no consensus regarding the impact of technology-assisted rehabilitation on the management of hip replacement due to conflicting findings and high heterogeneity between studies. Therefore, the objective of this meta-analysis was to determine the effectiveness of technology-assisted rehabilitation in THA rehabilitation versus conventional rehabilitation care.This study was performed according to the standard methodology outlined in the Cochrane Handbook and PRISMA  checklist. Ethical approval was unnecessary in this study because the analyses were based on previously published studies.http://links.lww.com/MD/K623. In addition, the reference lists of the included studies, present meta-analyses, and systematic reviews were searched manually for any missed studies.The Medline (PubMed), Cochrane Library, Embase and Web of Science databases were searched by 2 reviewers. The MeSH terms and keywords were used to generate a strategy for the following terms: telecare, remote rehabilitation, virtual rehabilitation, telerehabilitation, virtual reality, exergames, games, video, eHealth, mobile health, internet-based intervention, hip replacement, hip arthroplasty, random, random allocation, and randomized controlled trials. The databases were searched from their inception to March 1, 2023. The detailed retrieval strategies were provided in Supplemental Table 1, Eligible studies were considered if they met the following criteria: PICOS . Eligible studies were identified by following the PICOS  principle. Participants: patients undergoing rehabilitation after THA. Intervention: the experiment group received any eHealth interventions. Comparison: the control group received usual care or no treatment. Outcomes: available data about Harris score, functional independence measure (FIM), timed up-and-go test (TUG), Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR), walk test, activities of daily living (ADL), mental, and physical health were reported. The Harris score, TUG, HOOS JR, and walk test were used to assess physical function. The FIM, ADL, mental health, and physical health were used to assess independence level and quality of life (QOL). Study design: Randomized controlled trials. The exclusion criteria were as follows: unavailable data, case reports, animal studies, reviews, and duplicated publications. Any disagreements between the 2 reviewers were resolved by a third reviewer.Two authors independently collected available data from the eligible articles using a standard data extraction form. The extracted data included the first author name, publication year, age, gender, sample size, intervention method, outcomes, and follow-up. Any disagreements between the 2 reviewers were resolved by a third reviewer. The methodological quality of the randomized controlled trials (RCTs) was accessed using the Cochrane risk-of-bias tool. The tool contains 6 items, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data and selective reporting, and other biases.I2 test and Cochrane χ2 statistic were used to quantify heterogeneity among the studies. A chi-squared P ≤ .05 and an I2 > 50% indicated substantial heterogeneity among the studies and a random-effects model was used. A chi-squared P > .05 and an I2 ≤ 50% indicated that there was no obvious heterogeneity among the studies, and a fixed-effects model was used. For continuous data, the standardized mean difference (SMD) and 95% confidence interval (CI) were calculated. Potential publication bias was assessed by Begg and Egger tests. Subgroup analysis was used to explore the origins of heterogeneity if applicable.We conducted the meta-analysis using STATA 12.0 . The –26 were included in this study. Among these studies, a total of 1327 patients were included; there were 634 cases in the intervention group and 693 patients in the control group. The median age of the included patients ranged from 53.3 to 77 years. The sample size varied from 15 to 200. Technology-assisted interventions have been applied in different studies. Eight studies,19–25 had intervention groups that received telerehabilitation. Three studies,18,26 investigated video-assisted rehabilitation. The characteristics of the included studies are described in Table The PRISMA 2020 flowchart was used to represent the selection process Fig. . A total–25 reported random sequence generation. Seven RCTs,21,23,25 reported allocation concealments. Four RCT–18,23 outcome assessors were blinded. In addition, details of the blinding of participants and personnel were not described in all studies and 4 studies–18,21 had a high risk of bias. All studies had a low risk of incomplete outcome data and selective reporting, and other biases.Based on the Cochrane Collaboration recommendation, the quality assessment of the included studies is summarized in Figure P = .001, I2 = 0%)  Fig. .I2 = 60.9%, P = .078), so we used a random-effects model. The pooled meta-analysis showed that technology-assisted rehabilitation were not significantly superior to usual care . Subgroup analysis showed that telerehabilitation significantly improved the FIM score      Fig. .I2 = 0%). The meta-analysis showed no obvious difference in TUG performance telerehabilitation and control groups .Two studies reported data on TUG. A fixed-effect model of analysis was used due to low heterogeneity among the studies (I2 = 0%). The pooled meta-analysis showed that technology-assisted rehabilitation significantly improved the walk test results . Subgroup analysis showed that telerehabilitation was not significantly superior to the usual car. In contrast, video-based therapy could significantly improve the walk test results . The meta-analysis showed no obvious difference in HOOS JR between the 2 groups .The HOOS JR function was evaluated in 2 studies. A fixed-effect model of analysis was used due to low heterogeneity among the studies ( As the demand for rehabilitation of discharged THA patients has increased, the workload of medical personnel has been significantly increased. In recent years, the availability of low-cost internet and communication technology has encouraged the use of technology-assisted rehabilitation in clinical settings.An early rehabilitation program is essential for functional recovery following THA.,31 The effectiveness of telerehabilitation techniques in THA patients has been compared with traditional face-to-face rehabilitation techniques in several randomized trials. Several studies reported positive results; however, the generalizability of the findings was limited by small samples and a variety of outcomes. The purpose of this study was to synthesize the current evidence regarding the effect of technology-assisted rehabilitation on patients with THA. Based on our findings, technology-assisted rehabilitation improved the Harris score and the walk test results more effectively than conventional rehabilitation care.While community-based medical care is currently being established, it is difficult for patients in rural or remote areas to obtain rehabilitation treatment through outpatient physiotherapy or family follow-up due to geographical isolation or inadequate community services. Alternative rehabilitation approaches are necessary. In previous studies, telerehabilitation has been found to be beneficial in a variety of postoperative orthopedic conditions; however, much of the research has examined the effects of telerehabilitation on patients with total knee replacements. It is feasible for patients to study rehabilitation courses under the remote guidance of rehabilitation teachers from home, benefit from more intensive and autonomous rehabilitation, and participate in therapeutic exercises with greater ease and safety. In comparison to conventional rehabilitation therapy, telerehabilitation showed improvements in physical activity and functional status in TKA patients. The results of our meta-analysis indicated that telerehabilitation was associated with a greater Harris score and higher FIM in THA patients than conventional rehabilitation.A new option for early rehabilitation is a systematic program of rehabilitation in a hospital and a home rehabilitation program supervised remotely. Several studies have reported that VR is beneficial to rehabilitation following TKR. Recent meta-analyses have shown that compared to traditional rehabilitation, VR-based rehabilitation improved functional outcomes 6 months postoperatively. There is, however, very limited evidence in support of the use of THA. The study by Zavala-González et al found that patients receiving the VR program had better performance on WOMAC, Berg, and 6-minute walk tests. In contrast, Fascio et al showed that compared to the traditional rehabilitation program, VR-based home rehabilitation resulted in similar improvements in functional outcomes. Our study showed that a video-based therapy programs after THA might be able to improve the walk test results compared to a traditional rehabilitation program. Although some interventions are provided at the patient home, the cost and availability of therapists remain a barrier to access. Since videoconferencing capabilities have become more widely available on mobile phones and laptops, it is anticipated that most interventions will be remote delivery soon. Therefore, VR-based rehabilitation can remove these barriers since patients can access and perform therapy at home without a therapist being present.Virtual reality has gained popularity in rehabilitation over the years, showing promising results in reducing falls and improving balance and functionality.This meta-analysis has some limitations, which should be considered when interpreting the results. Firstly, the impact of publication bias could not assess owing to too few studies. Second, it may not be appropriate to generalize the results as the studies were conducted in different healthcare settings with patients of varying socioeconomic status. Third, the sample sizes were relatively small in the included studies, which might lead to bias in the pooling of effects. Fourth, due to a lack of long-term follow-up data, this study cannot determine the long-term effectiveness of technology-assisted rehabilitation. Fifth, there was heterogeneity among some outcome measures in this study. This may be related to differences in technology-assisted rehabilitation, including intervention duration, intensity, frequency, content, and so on. Lastly, since the outcome measures varied and statistical heterogeneity exists among the studies, it is not possible to make a strict recommendation for methods that promote functional improvements.The results of this meta-analysis revealed that technology-assisted rehabilitation, especially telerehabilitation, improved the physical function of patients following THR when compared to conventional rehabilitation. The study is limited by the availability of high-quality evidence, however, more robust studies are needed to validate the long-term efficacy and safety of innovative technology-assisted training strategies.Conceptualization: Qiuhua Sun.Data curation: Lingyun Wu.Formal analysis: Lingyun Wu, Xiaoyan Li, Lijiangshan Hua.Investigation: Lingyun Wu, Xiaoyan Li.Software: Lingyun Wu, Xiaoyan Li.Supervision: Qiuhua Sun.Validation: Qiuhua Sun.Writing – original draft: Lingyun Wu, Xiaoyan Li, Lijiangshan Hua.Writing – review & editing: Lingyun Wu, Xiaoyan Li, Lijiangshan Hua.


Platelet concentrate (PC) transfusion seeks to provide haemostasis in patients presenting severe central thrombocytopenia or severe bleeding. PCs may induce adverse reactions (AR) that can occasionally be severe (SAR). PCs contain active biomolecules such as cytokines and lipid mediators. The processing and storage of PCs creates so-called structural and biochemical storage lesions that accumulate when blood products reach their shelf life. We sought to investigate lipid mediators as bioactive molecules of interest during storage and review associations with adverse reactions post-transfusion. To facilitate understanding, we focused on single donor apheresis (SDA) PCs with approximately 31.8% of PCs being delivered in our setting. Indeed, pooled PCs are the most widely transfused products, but the study of a single donor lipid mediator is easier to interpret. We are investigating key lipid mediators involved in AR. Adverse reactions were closely monitored in accordance with current national and regional haemovigilance protocols. Residual PCs were analysed post-transfusion in a series of observations, both with and without severe reactions in recipients. A decrease in the lysophosphatidylcholine species to produce the lysophosphatidic acid species has been observed during storage and in the case of AR. Lysophosphatidic acid increased with primarily platelet-inhibitor lipids. Anti-inflammatory platelet-induced inhibition lipids were weakly expressed in cases of severe adverse reactions. We therefore propose that a decrease in lysophosphatidylcholine and an increase in lysophosphatidic acid can prospectively predict serious adverse transfusion reactions. LPA & mostly platelet-inhibitor lipids increased during SDA-PC storageLPC & LPA balance could be markers of AR in SDA-PC transfusionBlood transfusion is used to save lives and promote health through medical and surgical procedures. Platelet concentrate transfusions are used in life-threatening conditions in which patients are exposed to severe thrombocytopenia, especially of central origin, and severe bleeding of varying aetiology . Differeresolving Mediators (SPM). Platelets generate these various categories alone or in combination with red and white blood cells  products and eicosanoids were significantly involved in AR occurrences post-SDA-PC transfusion. We selected SDA-PC  over Buffy coat (BC-PC), which is pooled from five PC donors. SDA-PCs induce adverse reactions with a higher frequency compared to BC-PC. The SDA-PC lipidomic data provide a clear-cut analysis, showing the donor effects.Single Donor Apheresis - Platelet Concentrates (SDA-PC) were obtained from “Etablissement Français du Sang (EFS) Auvergne-Rhone-Alpes” with 9,206 volunteers enrolled between March 2013 and February 2016 giving their informed consent. The study was approved by EFS’s institutional review board for ethics (DC-2019-3803 & AC-2020-3959)  to remove platelets, aliquoted and frozen at −80˚C until further use for mass spectrometry and ELISA analysis.Liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis was performed by the MetaToul-Lipidomic MetaboHUB Core Facility, France. More information is available in the SDA-PCs with/without AR were analysed with human ENPP-2/Autotaxin Duo set ELISA , as per the company protocol.Soluble CD62P was quantified with the Milliplex Map Human cardiovascular disease magnetic beab panel 2 (Merck-Millipore), according to the manufacturer’s protocol.SIMCA 17 software  was used to analyse the mean centre and unit variance scaling of lipid mediators detected, SDA-PC with or without AR as described above .Data from the lipidomic analysis (multiple samples for AR and AR storage times) were subjected to principal component analysis (PCA). Each point represents the mean of AR or AR lipid, taking storage times into account. The score plot shows the clustering among observations. The closest lipid, presents greater similarity in the matrix.A web-based tool was used to assess lipid pathways in order to ensure the non-biased analysis of lipidomic data (BioPAN) .Multiple comparisons were performed by analysis of variance . Statistical analysis and Pearson correlation was carried out using GraphPad version 6 .To validate our hypothesis on lipid mediator involvement in adverse reaction following a PC transfusion, single donor apheresis platelet concentrates (SDA-PC) were collected from different female and male donors with different ages  detected in transfused PC from different time of storage ([1-2] or [3-4] days) significantly decreased during storage and in the presence of AR  (The presence of lysophosphatidylcholine (LPC) in PCs has been highlighted in several studies and is generated through PLAp= 0.0152) (p<0.0001) (Autotaxin (ATX) is a phospholipase D, able to catalyse the hydrolysis of LPC in lysophosphatidic acid (LPA) and to catalyse sphingosylphosphorylcholine (SPC) in Sphingosine-1-phosphate (S1P) , we measWe then considered a possible correlation between ATX products and LPC species. We initially compared the species without taking in account the storage time. We noted a correlation between some S1P, LPA and LPC species in SDA-PCs without AR   are by far more prevalent compared to LPA species (104.44 ng/ml ± 12.56 for [1-2] and 205.30 ng/ml ± 67.06 for [3-4]) and S1P (44.96 ng/ml ± 13.39 for [1-2] and 21.82 ng/ml ± 6.45 for [3-4]) in no AR SDA-PC, 2-way ANOVA with Tukey’s multiple comparisons test for no AR =0,7529) B. HowevLysophospholipids are not the only bioactive lipids in circulation . The var2 is distant compared to others  and 15-LO enzymes to generate 5-HETE and 15-HETE. Reticulocytes express 15-LO. However, platelets do not express 5-LO and 15-LO but LTC2 (2 and 8-HETE). Their expressions are increased during storage but strongly decrease in AR-related SDA-PCs  present in human platelets  to gener2 . These lLinoleic acid (LA) is an essential omega 6 fatty acid present in copious quantities in food and especially in vegetable oils, meats and nuts. It can be metabolised into different bioactive lipids  such as protectins, resolvins and maresins . It is produced by α-linoleic acid. DHA can also be released from the plasma membrane by PLAEPA is an omega-3 fatty acid mostly found in marine organisms. EPA products in SDA-PC were clustered according to the AR group  is a bioinformatic tool to investigate lipidomic pathway with our set of data. The pathways are built from literature. The analysis highlighted the change at the lipid subclasses or lipid molecule levels.2α and TXB2; in FA 20:4: 12-HETE, 15-HETE, 5-HETE, 8,9-EET, 8-HETE, LTB4, LXA4, PGA1, PGD2 and PGE2; in FA 20:5: 18-HEPE, 8isoPGA2, LTB5. Interestingly, a positive z score in active status was obtained between FA 20:3 and FA 20:4 and a negative z score between FA 20:4 and FA 20:5 . FA 20:3 to FA 20:4 is also classified as active pathways Figure 62, 5-HETE, 8-HETE, 15-HETE, RvD1, RvD2, 17-HDoHE and 8,9-EET compared to LPC expressions, which decrease during storage  is still open to debate . LPC couPLD1 and/or PLD2 in the process of PC to PA and LPC to LPA  play a role in triggering adverse reactions , 25. It In conclusion, this study assessed lipid mediators in single donor apharesis platelet concentrates during storage and in the onset of adverse reactions post-transfusion. We demonstrated modulation of bioactive lipids during storage, mainly in the form of the platelet function activator. However, all lipids, except LPA species, are low in PC with AR occurrence compared to PC without AR occurrence. Based on these data and with bioinformatic analysis, we suggest that the imbalance between LPA and LPC expressions could be a marker for AR occurrence and could be targeted in the future to enhance PC transfusion Figure 7The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.FC, OG and HH-C designed the study, supervised the research, secured funding and obtained approval from the ethics committee. A-CD analysed data. A-CD wrote the manuscript. A-CD and FC reviewed the manuscript. SF-D, CS, TE, MH, C-AA, M-AE, AP, EA, JB-M, BP, EB conducted research. All authors contributed to the article and approved the submitted version.