To evaluate the efficacy of ultra-early rehabilitation on elbow function after Slongo’s external fixation for supracondylar humeral fractures in older children and adolescents.We retrospectively analyzed clinical data from 49 older children (> 8 years) and adolescents with supracondylar humerus fracture who were treated with Slongo’s external fixation in our hospital from January 2016 to August 2020. Twenty-three patients received ultra-early postoperative rehabilitation (rehabilitation group) and 26 patients were not subjected to postoperative rehabilitation (control group). Time to ROM required for functional activity of daily living(ROM-ADL) in both groups was recorded postoperatively. Patients were followed up at 3 and 6 months after surgery to compare the elbow range of motion (ROM) and carrying angle (CA). Postoperative complications were assessed in both groups. Flynn scores and modified Mayo Elbow Performance Scores were also performed.P = 0.32). Time to ROM-ADL in the rehabilitation group was significantly shorter than that of the control group (P = 0.028). The elbow function, Flynn scores, and modified Mayo scores in the rehabilitation group at 3 and 6 months after surgery were significantly better than that of the control group  = 0.012 vs 0.039; P = 0.028 vs 0.005; P = 0.032 vs 0.026; P = 0.039 vs 0.024; respectively). There were no iatrogenic injuries, secondary fracture displacements, myositis ossificans, elbow deformities, or other complications in either group. One case of nail tract infection occurred in the rehabilitation group and was cured.The elbow function at 6 months after surgery was significantly better than that at 3 months in the control group (Slongo’s external fixation is a safe and effective surgical treatment for supracondylar humeral fractures in children over 8 years old and adolescents. Ultra-early rehabilitation treatment for postoperative children can significantly speed up the recovery after surgery. Supracondylar humeral fracture is the most common elbow fracture in children. It usually occurs in children between the ages of 5 and 7 , 2. SuprTherefore, the purpose of this study was to assess the effects of Slongo’s external fixation in the treatment of supracondylar humeral fractures in older children and adolescents. Moreover, we sought to assess the clinical value of ultra-early rehabilitation after external fixation operation in older children and adolescents.We retrospectively analyzed clinical data of 49 older children (> 8 years) and adolescents with supracondylar humeral fractures who were treated with closed reduction and Slongo’s external fixation in our hospital from January 2016 to August 2020. A total of 23 patients were subjected to ultra-early postoperative rehabilitation (rehabilitation group), while 26 patients without postoperative rehabilitation were served as the control group. Children with open fractures, coexisting fractures of other parts, and injuries of other organs were excluded. Health education on disease, operation, and rehabilitation was carried out for children and their parents during the perioperative period. The informed consent of the parents was obtained prior to inclusion in the study.The operation was performed under general anesthesia. The patient was in the supine position and the fracture reduction was performed with a C-arm fluoroscopy. Distal 4.0-mm Schanz screw was used and was located above the external humeral condyle epiphyseal plate and in the rotation center of the elbow joint. The surgeon was careful to avoid screw injury to the epiphyseal and epiphyseal plate of the lateral condyle and to prevent the screw from entering the coronal fossa, olecranon fossa, and breaking through the cortex of the distal medial humerus. A proximal Schanz screw with a diameter of 4.0 mm was directly drilled into the humerus after a small incision. A sleeve was used to protect the surrounding soft tissue while drilling, and the screw was positioned at the center of the humerus. After the closed reduction was made, a connecting rod was used to fix the screws. Finally, a 1.8-mm or 2.0-mm Kirschner wire was inserted in the lateral condyle of the humerus to prevent rotation of the fracture end, with care to not limit elbow movement. Postoperative plaster casts were not used  performed a postoperative systematic rehabilitation treatment. Active and passive activity training of adjacent joints on the day after surgery were performed, with active flexion and extension exercises of the affected shoulder, wrist, metacarpophalangeal joint, and interphalangeal joint. Elbow joint loosening + progressive resistance training  was performed through passive flexion and extension of the elbow on the affected side. The elbow resistance training with an elastic band was performed starting 3 days after surgery on the premise that the patient had no significant pain. Wax therapy  was also conducted, using an appropriate wax size wax to wrap the elbow above 1 cm away from the Schanz screws. Occupational therapy (30 min ×2/day) was started 3 days after surgery and the child’s upper limbs were treated with fun occupational therapy using a RAMGUIDER upper limb rehabilitation training system, in which a suitable upper limb movement goal for the patient’s joint range of motion was set and, if painless, the overall active movement ability of the affected upper limb progressively increased through purpose-oriented training. The movement mode was adjusted according to the patient’s measured elbow joint range of motion every day. Lymphatic drainage of the affected limb (15 min/day) was performed by the physiotherapist on the affected upper limb of the patient after joint loosening and active resistance training every day. Finally, cold therapy (15 min/day) was performed after the abovementioned treatments were finished. Attention was paid to avoid secondary fracture displacements and the occurrence of myositis ossificans. The rehabilitation treatment lasted for 2 weeks, 6 days per week. After the patient and their parents had mastered the exercise methods, they were instructed to conduct exercises at home.The control group did not receive ultra-early rehabilitation treatment after surgery. Patients that met the discharge criteria were discharged from the hospital and underwent self-rehabilitation training at home.When discharged from the hospital, patients and parents in both groups were required to add a review WeChat public account to communicate with surgeons and rehabilitation doctors about their rehabilitation and exercises at any time through the form of WeChat video, so that they could receive timely guidance. Educational booklets for exercise in postoperative rehabilitation were given to the patients in both groups. Regular outpatient follow-up was conducted and suggestions on postoperative rehabilitation were given. The external fixation was removed after fracture healing.Follow-up clinical examination and X-rays were taken at 3 and 6 months after the surgery. Range of motion (ROM), time to ROM required for functional activity of daily living (ROM-ADL), and carrying angle (CA) of the elbow were recorded. ROM-ADL was defined as 30°of extension, 130°of flexion . Postopex2 ± S. Paired t-tests were used for comparisons of normally distributed data, while independent sample t-test was used for comparison between groups. Non-parametric chi-square was used to compare data that did not conform to a normal distribution. P < 0.05 was considered statistically significant.The SPSS22.0 software was used to process the data. Measurement data were expressed as P > 0.05), as shown in Table P < 0.05, Table P < 0.05, Table P < 0.05, Tables There was no significant difference in basic information such as age, sex, height, and weight between the two groups  and adolescents that have a larger body weight, there is an increased risk of secondary fracture displacement and elbow stiffness due to the limited fixed strength of the Kirschner wire and the need for supplementary plaster cast.External fixation is a surgical alternative for supracondylar humeral fractures and was first proposed by Taller et al. . CurrentRehabilitation medicine greatly advanced in the rehabilitation of adult orthopedic surgery, but it is still limited in the field of children orthopedics. It is still debatable whether postoperative rehabilitation is necessary for children with supracondylar humeral fractures . The supA key limitation of this study is that this is a retrospective analysis. The incidence of supracondylar humeral fractures is relatively low in older children and adolescents. Therefore, we plan to further expand the number of patients and apply more appropriate rehabilitation techniques to the treatment of supracondylar humeral fractures in older children and adolescents. Future studies will focus on how to make the elbow function of children recover better and faster, which is in line with the concept of Enhanced Recovery After Surgery (ERAS) .Slongo’s external fixation is a safe and effective surgical treatment for supracondylar humeral fractures in older children and adolescents. It allows early postoperative elbow movement, avoids elbow stiffness, and ensures good fracture healing. The ultra-early rehabilitation treatment for older children and adolescents after Slongo’s external fixation can significantly speed up the recovery of the elbow joint, improve the quality of life of patients, and quickly enable them to return to normal life.


Androgen receptor splice variants (AR-Vs) play an important role in prostate cancer progression, especially as a putative resistance mechanism against AR-targeted therapies. Recent technological advances have enabled detection of AR-Vs in many types of human specimens including circulating tumor cells. Here, we discuss the biology of AR-Vs, the clinical utility of AR-Vs as prognostic and predictive biomarkers, and AR-Vs as potential therapeutic targets with a special focus on AR-V7.Over the past decade, advances in prostate cancer research have led to discovery and development of novel biomarkers and effective treatments. As treatment options diversify, it is critical to further develop and use optimal biomarkers for the purpose of maximizing treatment benefit and minimizing unwanted adverse effects. Because most treatments for prostate cancer target androgen receptor (AR) signaling, aberrations affecting this drug target are likely to emerge following the development of castration-resistant prostate cancer (CRPC), and it is conceivable that such aberrations may play a role in drug resistance. Among the many AR aberrations, we and others have been studying androgen receptor splice variants (AR-Vs), especially AR-V7, and have conducted preclinical and clinical studies to develop and validate the clinical utility of AR-V7 as a prognostic and potential predictive biomarker. In this review, we first describe mechanisms of AR-V generation, regulation and their functions from a molecular perspective. We then discuss AR-Vs from a clinical perspective, focusing on the significance of AR-Vs detected in different types of human specimens and AR-Vs as potential therapeutic targets. The androgen receptor (AR) is a member of nuclear receptors activated by androgenic ligands such as testosterone and dihydrotestosterone. Because the development and progression of prostate cancer (PCa) depends on AR signaling, inhibition of AR signaling by androgen deprivation therapy (ADT)  is the mainstay of treatment for advanced castration-sensitive PCa (CSPC). However, CSPC eventually develops resistance to ADT and progresses to castration-resistant PCa (CRPC), often by gaining an ability to activate AR signaling under low-ligand environments. Even after CRPC develops, ADT is continued indefinitely and combined with secondary hormone therapy agents that further block AR signaling either by suppression of androgen synthesis  or by direct inhibition of AR . Because all these drugs target the AR ligand-binding domain (LBD), truncated AR splice variants (AR-Vs) lacking the LBD, i.e., the drug target, have been evaluated as a biologically plausible mechanism of drug resistance to AR-targeting agents. Some AR-Vs have been validated as having constitutively active AR activity in the absence of androgenic ligands ,2. AmongAR gene comprises eight canonical exons, and the full-length AR (AR-FL) protein contains four functional domains: the NH2-terminal domain , the DNA-binding domain , the hinge region (encoded by exons 3 and 4), and the ligand-binding domain . The nuclear localization signal (NLS) is located at the junction between the DBD and the hinge region, spanning both exon 3 and 4 [AR gene rearrangements [The human  3 and 4 . AR-Vs c 3 and 4 ,7, and tAR gene [AR gene amplification [Two major mechanisms driving the expression of AR-Vs have been reported in the literature—aberrant RNA splicing intragenic and rearrangements of the AR gene . Regulatfication ,11,12,13fication , AR-V7 ification ,15, AR-Vfication . We willAR intragenic rearrangements is the castration-resistant CWR22Rv1 cell line. In CWR22Rv1, tandem duplication of a 35-kb segment harboring exon 3 and CEs is linked to AR mRNA including AR-V7 [v567es variant in LuCaP 86.2 and LuCaP 136 xenograft, respectively [AR genomic rearrangements also drive the expression of AR-Vs in human CRPC specimens [AR DNA sequencing has revealed that intricate AR genomic arrangements are occurring in CRPC specimens, some of which are associated with AR-V expression [Within a subset of PCa, intragenic rearrangements are implicated in the genesis of AR-Vs. The first well-characterized model of ng AR-V7 . Similarectively ,17. Likeectively . Consistectively ,16,17, ATo summarize, AR-Vs generated either by intragenic rearrangements or aberrant RNA splicing show varying degrees of transcriptional activity and some of them, especially constitutive active AR-Vs such as AR-V7, are likely the result of altered hormonal environment where canonical AR-FL signaling is suppressed as well as the permissive genomic and epigenomic features acquired in the development of CRPC, as we elaborated in a recent review .AR-Vs emerge under ADT as an adaptive response to a low-ligand environment ,11,12. FAs for negative regulation of AR-FL and AR-Vs, dihydrotestosterone (DHT) is known to suppress the expression of AR-FL and AR-V7 ,12. An ev567es and AR-FL homodimerize or heterodimerize with each other under ADT conditions [v567es facilitate AR-FL nuclear localization in the absence of androgen and facilitate AR-FL nuclear trafficking even in the presence of enzalutamide [v567es also helps stabilize AR-FL by slowing protein degradation [A few previous studies have investigated how AR-Vs transactivate target genes. Ligand-bound AR-FL dimerizes for DNA binding to chromatin, resulting in the recruitment of cofactors and unlocking the transcriptional machinery . AR-Vs mnditions ,28. Morelutamide . ARv567eradation . In accoradation , suggestv567es appears to induce a unique proliferative program possibly by activating other growth and survival pathways, such as STAT3 [As for the transcriptome regulated by AR-Vs, one key question is whether AR-Vs merely substitute for AR-FL or if they mediate distinctive transcriptional programs. Earlier studies, including ours, suggested that AR-Vs activate a unique repertoire of genes in addition to canonical AR-FL target genes, potentially conferring survival benefit to CRPC cells. In particular, a gene set induced by AR-V7 was enriched for cell-cycle genes ,31. Likeas STAT3 . On the as STAT3 . Togetheas STAT3 , constitAR-Vs can be utilized as prognostic and potentially predictive markers of resistance to AR-targeted therapies such as abiraterone and enzalutamide. AR-Vs and AR structural aberrations detected in different human specimens are summarized in Our previous proof-of-concept studies demonstrated that AR-V7 mRNA expression in circulating tumor cells (CTCs) is a prognostic marker in the context of AR-targeting therapies ,37. In tA few previous studies evaluated whether CTC AR-V7 can be utilized as a predictive marker by comparing the treatment response of CTC AR-V7 positive patients to two different classes of therapies  . For AR-The PROPHECY  study combined the above two CTC AR-V7 detection assays: CTC AR-V7 mRNA assay ,37 and CAR-Vs are detected not only in CTCs but also in other sample types , and canIn tissues, the prognostic value of AR-Vs is slightly more equivocal in comparison with liquid biopsy, in part because many AR-Vs can be detected at varying levels in benign prostate and pre-abiraterone/enzalutamide primary PCa specimens ,7. HowevGiven that AR-Vs are key players in CRPC progression, the development of AR-V-targeting therapies is important. Although taxanes are currently the primary treatment option for AR-V7-positive CRPC patients, new drugs targeting AR-Vs are under development. Novel agents targeting AR-Vs are either directly or indirectly summarized in Niclosamide, an FDA-approved antihelminthic drug, was reported to selectively inhibit AR-V7 protein expression by enhanced protein degradation via a ubiquitin-proteasome pathway in preclinical study . HoweverEPI compounds directly target the N-terminal domain (NTD) of AR and suppress AR transcriptional activity by inhibiting protein–protein interactions of AR with other co-activators ,72. BecaAR target genes. Thus, disrupting this interaction with BET inhibitors hampers PCa growth [The bromodomain and extraterminal (BET) domain-containing protein 4 (BRD4) interacts with AR-FL and AR-Vs, and their interaction is necessary for transcription activation of a growth . Severala growth ,77,78,79a growth ,77,78,80a growth .AR target gene transcription. Inhibition of p300/CBP by small molecule inhibitors has been shown to suppress PCa growth by several mechanisms, such as abrogation of phosphorylated CREB1 and p300/CBP interaction (compound names: SGC-CBP30 and C646) [SPOP-mutant PCa which carries abundant BET proteins due to impaired degradation [AR target genes in enzalutamide-resistant cell lines [The histone acetyltransferase paralogues, p300 and CREB-binding protein (CBP), are other important coactivators of AR that can serve as therapeutic targets. p300/CBP mediates histone 3 lysine 27 acetylation (H3K27ac) at enhancer regions and increases chromatin accessibility to facilitate nd C646)  and inhind C646) . A Phasend C646) . In addiradation  and suppll lines .Another promising agent is a polo-like kinase 1 (PLK1) inhibitor. PLK1 is a multi-functional serine/threonine kinase that positively regulates critical cell cycle events . In CRPCIn addition to these agents, bipolar androgen therapy (BAT) recently came under the spotlight as a new therapeutic intervention for CRPC ,61. As s+T cell-mediated immune response against CRPC overexpressing AR under ADT conditions [One may also wonder about the efficacy of immune checkpoint inhibitors against PCa. The combination of nivolumab (anti-programmed death 1 antibody) plus ipilimumab (anti-cyto-toxic T-lymphocyte antigen 4 antibody) is known to be especially efficacious against various tumors with a high tumor mutational burden (TMB) . Based onditions . However177Lu-PSMA-617 radioligand therapy [177Lu-PSMA-617 administration [177Lu-PSMA-617 may be another primary treatment option for AR-V7 positive mCRPC in addition to taxanes.Last but not least,  therapy  is expecstration . Althougstration . If this177Lu-PSMA-617 in combination with AR-targeted drugs, may be a good strategy to outsmart PCa’s adaptive ability to its microenvironment.There are several promising agents directly or indirectly targeting AR-Vs, but we need to keep in mind that AR signaling may not be required in later stages of prostate cancer progression when lineage plasticity emerges following AR-targeting therapies, and AR targeting approaches are generally not considered to be effective in the treatment of neuroendocrine/small cell prostate cancers . From thRecent technological advances have facilitated AR-V detection in many different types of human specimens and have shed light on the complex biology of constitutively active AR-Vs and their roles in CRPC progression. We believe that AR-V7 is the most important constitutively active AR-V and can be utilized as a prognostic and potential predictive biomarker. Therapeutic targeting of AR-Vs remains our opportunity and challenge for the future.


Approximately 1 in 8 men will be diagnosed with prostate cancer (PCa) at some point in their lifetime. Five-year survival rate for patients with local or regionally spread disease is near 100%, but this drops to 30% when the cancer has spread to distant sites. Androgen receptor (AR) signaling plays a pivotal role in normal prostate development and PCa cell survival. Therapies targeting the AR pathway are mainline treatments, but resistance is a major clinical problem. From the literature and our own meta-analysis of PCa databases, we aimed to review the connections between PCa genetic alterations and the AR signaling axis at the primary stage. Assessing how combinations of PCa genetic drivers that arise in patients affect AR signaling will aid in stratifying patients who will likely respond to AR-directed therapies, and those who will require other therapeutic agents upfront in order to prevent disease progression.AR gene itself occur at later stages, genomic changes at the primary stage can affect the AR axis and impact response to AR-directed therapies. Here, we review common genomic alterations in primary PCa and their influence on AR function and activity. Through a meta-analysis of multiple independent primary PCa databases, we also identified subtypes of significantly co-occurring alterations and examined their combinatorial effects on the AR axis. Further, we discussed the subsequent implications for response to AR-targeted therapies and other treatments. We identified multiple primary PCa genomic subtypes, and given their differing effects on AR activity, patient tumor genetics may be an important stratifying factor for AR therapy resistance. While many prostate cancer (PCa) cases remain indolent and treatable, others are aggressive and progress to the metastatic stage where there are limited curative therapies. Androgen receptor (AR) signaling remains an important pathway for proliferative and survival programs in PCa, making disruption of AR signaling a viable therapy option. However, most patients develop resistance to AR-targeted therapies or inherently never respond. The field has turned to PCa genomics to aid in stratifying high risk patients, and to better understand the mechanisms driving aggressive PCa and therapy resistance. While alterations to the  Prostate cancer (PCa), the most commonly diagnosed cancer in men in the United States, remains the second leading cause of U.S. male cancer related deaths. The majority of cases (89%) are diagnosed when the disease is localized to the prostate and neighboring organs, providing a five-year survival rate of nearly 100%. However, once the disease has spread to distant sites, patients have a significantly lower five-year survival rate of 30% . Lo. LoPTEN, outcome ,69. Althectively .FKBP5, stabilizes PHLPP1 and PHLPP2, important phosphatases in the pathway, allowing for deactivation of phospho-AKT. This feedback loop can, in turn, contribute to AKT-driven growth in castrate conditions, as androgen deprivation leads to decreased FKBP5, PHLPP1 and PHLPP2 and increased AKT activation. AKT is also able to phosphorylate AR and mark it for ubiquitination and degradation [PTEN loss displayed significantly below average AR scores in multiple cohorts , PARP1 (8–10%), BRCA1 (4–11%) and BRCA2 (6–22%) are some of the most common DNA repair genes deleted or mutated in primary PCa (BRCA1/2 can result in greater dependency on error-prone non-homologous end joining (NHEJ), consequently increasing the mutational burden in PCa [PARP1 and ATM also contribute to the genomic instability of PCa through their critical roles in recruiting repair proteins and coordinating repair with cell cycle arrest, respectively [Many genes involved in DNA repair are altered in PCa, and this in turn contributes to the genomic instability and array of genomic alterations present in PCa. mary PCa . Changesn in PCa . The losectively ,97.PARP1 loss to decrease AR activity in patients. While PARP1 deletions are associated with average AR mRNA levels, they are consistently associated with above average AR scores in multiple cohorts  are promising therapeutic strategies under investigation ,135,136.There are however a few caveats to our own analysis, as well as significant hurdles when it comes to the application of tumor genomics in the clinic. The currently available patient data for PCa, including the cohorts used in this review, largely involve bulk tumor RNA-Seq. This along with tumor heterogeneity limits some of the interpretations that can be made about genomic alterations in patients. It is unclear if some of the co-occurring alterations occur in the same cells, mosaically within the same tumors, or represent independent multifocal areas of disease. The multifocal and heterogeneous nature of PCa poses challenges for applying tumor genomic analysis to inform treatments. The growing application of single cell -omics analysis will hopefully aid in elucidating the nature of co-occurring alterations, as well as their effects on the AR axis. With continued advancements in the field and more clinical studies, tumor genetics could be used to inform treatment decisions. This may help delineate patients who will likely do well on AR monotherapies, be inherently resistant to AR therapies, or need treatment combinations to combat the inevitable acquired resistance to AR single agent therapies.


The technological intervention is considered as an adjunct to the conventional therapies applied in the rehabilitation session. In most high-income countries, technology has been widely used in assisting stroke survivors to undergo their treatments. However, technology use is still lacking in Southeast Asia, especially in middle- and low-income countries. This scoping review identifies and summarizes the technologies and related gaps available in Southeast Asia pertaining to stroke rehabilitation.The JBI manual for evidence synthesis was used to conduct a scoping study. Until September 2021, an electronic search was performed using four databases . Only the studies that were carried out in Southeast Asia were chosen.Forty-one articles were chosen in the final review from 6,873 articles found during the initial search. Most of the studies reported the implementation of technological intervention combined with conventional therapies in stroke rehabilitation. Advanced and simple technologies were found such as robotics, virtual reality, telerehabilitation, motion capture, assistive devices, and mobility training from Singapore, Thailand, Malaysia, and Indonesia. The majority of the studies show that technological interventions can enhance the recovery period of stroke survivors. The consultation session suggested that the technological interventions should facilitate the needs of the survivors, caregivers, and practitioners during the rehabilitation.The integration of technology into conventional therapies has shown a positive outcome and show significant improvement during stroke recovery. Future studies are recommended to investigate the potential of home-based technological intervention and lower extremities. Strokes or a cerebrovascular accident (CVA) is caused by the blockage or bursting of the cerebral blood vessels—the leading cause of neurological disorder globally . Stroke 2 constitute of low-income , middle-income , and high-income  countries  framework : (i) devThe study adopted the Population-Concept-Context (PCC) framework  to deterStudies considered to be included in this scoping review when they fulfill the following criteria:(i) Stroke rehabilitation as defined by Young and Forster  as using(ii) Utilizing technology as a medium of therapy or rehabilitation delivery. Technology is a broad term that refers to how one uses and understands the instruments and craft and how it affects the ability to control and adapt to the social and physical environment. It can also refer to physical objects that people use, such as computers, hardware, or utensils, but may also lead to broader themes such as structure, organizational methods, and techniques. Meanwhile, rehabilitation technology uses technology to meet the needs of people with disabilities. It helps cut the barriers and gives more opportunity to people with disabilities in education, rehabilitation, employment, living at home, and recreation.(iii) The technology investigated is either for the stroke survivors or people surrounding them  or anybody that deals with the stroke cases,(iv) The study is conducted in Southeast Asia, and(v) Any study design  and setting  are eligible to be included.Meanwhile, exclusion criteria are as follows: (i) Non-English, (ii) gray literature , (iii) non-original or review study , and (iv) no full text available . The exclusion of non-English and gray literature is expected to have minimal impact on the findings , 28.*” OR “occupational therapy” OR “physiotherapy” OR “physical therap*” OR “speech therap*”) AND  on those four databases.The electronics search was conducted using the following databases: MEDLINE, CINAHL, Scopus, MyCite, and ASEAN Citation Index on 30th November 2019 and last updated on 22nd September 2021. The keywords used are related to strokes and its associated terminologies , rehabilitation , and Southeast Asia (including each name of the countries members). Boolean operators, parenthesis, exact, and wildcards were used when necessary. Search string used was (“cerebrovascular accident” OR “CVA” OR “stroke”) AND (“rehabilitation” OR “therapy” OR “therapThe titles and abstracts were independently reviewed by two authors (SNSS and HAA), and the eligibility of the studies for inclusion was based on the previously mentioned criteria. Any conflicts between the two authors were resolved through discussions for each article. Studies were included in the first screening stage (titles plus abstract) if any of the two authors agreed that they were eligible for inclusion or if there was a dispute about whether to exclude them. Studies were included in the second screening stage (full text) when both authors agreed to match all the inclusion criteria. When contradictory studies were detected during the full-text screening, an independent arbitrator (MHR) an author with a healthcare background, was consulted. The two authors' pre-consensus agreement on the included full-text articles was calculated using percentages. Because a critical appraisal of each study is not required for scoping reviews, no quality evaluation was carried out.The summary of all the study details, including the citation, nation, study objective, design, setting, interventions, and findings, was presented in a matrix table. The technological intervention was then classified either as advanced or simple.The findings obtained from the review were summarized into observational studies, intervention studies, and qualitative studies. The review syntheses were integrated with the stakeholders' consultation session described extensively in the next section. All the data on the efficacious and validity of using the technological intervention in stroke rehabilitation in Southeast Asia was documented.n = 1), an ergonomist (n = 1), an engineer (n = 1), a physiotherapist (n = 1), an occupational therapist (n = 1) and a physiatrist (n = 1). The consultation session was done virtually via the Zoom teleconference platform. Each participant was given a summary of the preliminary findings of this scoping review and a set of open-ended questions to guide the discussions; (i) What is the current practice of technology-use intervention compared to the gathered literature? (ii) What is the perception of the efficacy of technologies used in stroke rehabilitation? (iii) What is the perception of implementing technologies as a medium of intervention for stroke rehabilitation? and (iv) What improvements and suggestions can be provided for technology-based application for stroke rehabilitation intervention? The discussion was conducted in pidgin languages which were convenient to the participants. The whole session was recorded using a voice recorder and through note-taking. The qualitative data were analyzed by developing a coding excerpt from the session. The themes were generated and selected by comparing with review findings and discussions among the authors. One session was conducted and required two and a half hours to complete.As part of the data analysis, stakeholders were invited to engage in a roundtable discussion or known as consultation. The discussion-like exercise aims to identify stakeholders' priorities and questions to guide the literature review . The sesThe findings were reported narratively, and the literature and stakeholders' consultation information were synthesized. The narrative review is sequenced in themes generated among the authors. The result is combined with external literature—not only from the systematic searching inclusion, to enhance the understanding and synthesis.The initial search yielded a total of 6,873 citations from five electronic databases, and three additional manually founded citations based on A total of 1,470 participants participated from the selected 41 studies with different impairments, types, and stages of stroke severity. The data was narratively summarized according to a pre-defined theme on survivors' diagnosis, rehabilitation intervention available in recovery sessions, and stroke survivors' intervention. The theme was established through discussions among researchers, who compared the findings of various studies. The review's findings were combined with the stakeholders' consultation support.n = 25) (n = 10) (n = 5) (n = 1) (n = 18), clinical studies (n = 7), case report (n = 2), an experimental study (n = 2), a crossover study (n = 1), a pilot study (n = 7), an open-labeled study (n = 2) and a qualitative study (n = 2). Thirty-two studies (n = 32) were conducted in the hospitals and the remaining nine (n = 9) were conducted in the community.The studies found were in the following countries: Singapore (n = 25) , 64–69, (n = 10) , 61, 63, (n = 5) , 68, 71, (n = 1)  and no sThe most complex or newest technology accessible in post-stroke rehabilitation can also be referred to as advanced technological intervention , 73. Simn = 6) types of advanced technological intervention for post-stroke rehabilitation, which are robotics, transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), motion analysis, motion capture, and virtual reality.The study has classified six (n = 7) studies (n = 6) studies  studies (n = 2) studies  studies (n = 2) studies  studies  studies  studies (n = 5) studies demonstrate that the combined intervention has improved both upper limb function and lower limb postural standing balance, while only two (n = 2) studies  types of simple technological interventions for post-stroke rehabilitation, which are telerehabilitation, simple tech assistive technologies (AT), and gait training (GT).Simple technological intervention can also refer to a system or equipment that is non-battery powered and relatively easier to fabricate . This ten = 5) studies   , 61. When = 3) , 36, 61 n = 2) studies  and health sciences . Findings from the stakeholders' discussion are summarized below.The current method implemented in stroke rehabilitation or stroke recovery process is mostly conventional methods. The technological intervention is said to be an adjunct to the current conventional therapies where it can be implemented to help stroke survivors to recover faster. In Southeast Asia countries, however, especially in the less developed nations, there is still a lack of technological interventions applied for rehabilitation purposes even in the tertiary hospitals.In addition, the intervention implemented should be able to motivate the stroke survivors during the rehabilitation session and give meaningful outcome to them. The technological intervention also needs to reduce the labor costs of stroke rehabilitation, while simultaneously allow the survivors to undergo their treatments with minimum supervision. In some cases, however, survivors tend to rely entirely on the interventions and become too dependent on the therapy, which eventually causes other impairments to occur. If this happens, the technological intervention is not much different from the conventional method and could be neglected. The appropriate technological intervention to be implemented should be flexible and not limited to only specific functional impairment and easy to be learned by the practitioners and caregivers.On the other hand, technological intervention in rehabilitation might bring challenges to both practitioners and survivors. For example, the survivors need to be fully assisted during the rehabilitation session when using the advanced technological intervention at the hospitals. It is preferred for the technological intervention with long and continuous practice to be carried out as a home-based therapy to improve the recover process. The technology-based therapy is recommended to be applicable toward most stroke survivors with various stages or severities, and diverse functional impairments. Moreover, the technology should be intuitive, interesting and attractive in terms of functionality and physical appearance to encourage the continuous use .From the consultation session, it can be concluded that the technological interventions are expected to facilitate the needs of survivors, practitioners, and caregivers during the rehabilitation. The intervention should also be user-friendly, safe to use, and easily operated by the clients and healthcare practitioners. In addition, most of the existing interventions found in Southeast Asia were classified as high-tech interventions, and the clients are required to attend the therapy session in the hospital or rehab center. This adds to the financial burden of the survivors and their families. Therefore, it is highly recommended to make full use of the current advanced technology to help reduce the recovery period and provide a more affordable home-based technological intervention for post-stroke rehabilitation.This scoping review addresses a new research area related to the technological therapy implemented in stroke rehabilitation for stroke survivors in Southeast Asia. It provides a comprehensive understanding of this topic and has identified the critical gaps. The consultation session conducted with the stakeholders provides additional value to the review. According to a framework designed by Arksey and O'Malley , a revieThe main goal of rehabilitation is to help stroke survivors be as independent as possible and attain the best quality of life . The treFrom the past decade, new technology is constantly changing the rehabilitation arena. Technological treatment is helping in neuroplasticity and learning progress i.e., the key in the recovery process of stroke . MoreoveIt is pertinent that many countries in Southeast Asia build rehabilitation centres to benefit in stroke rehabilitation treatment. However, most centres rely on conventional therapy rather than utilizing technology for rehabilitation. The critical factor to the lack of technology utilization in rehabilitation facilities is the dearth of urgency and emphasis for clinical rehabilitation by the policy-making authorities . The clin = 25) involving the advanced technological intervention implemented in stroke rehabilitation and followed by Thailand (n = 10), Malaysia (n = 5), and Indonesia (n = 1). In Southeast Asia, Singapore has rapidly developed from a low-income country to a high-income country  due to weakened mobility . A revieEqually important, more attention on other components such as cognitive, social, and emotional support using technology is required, as agreed by the previous review finding . There aAnother essential point, technological interventions reported in the reviewed studies mostly took place in hospitals and rehabilitation centres, with very few in the community-dwelling population. Traveling from home to the hospitals regularly for continuous therapy sessions could be burdensome, especially for rural areas . More imIt is relevant to use technological intervention as an alternative method to provide clients with high-quality therapy to optimize long-term functional outcomes and promote stroke survivors' independence and quality of life. This is particularly for those who have difficulties traveling to the hospitals or rehabilitation facilities. Therefore, it is undoubtedly that there is an obvious need to further promote the integration of technological aids toward the conventional techniques in stroke rehabilitation, due to positive effect shown on the client's recovery period, a decrease of human labor intensive, reducing the traveling cost, and lessening the hospital visits.This scoping review has several limitations. Firstly, although the exclusion of gray literature gives a small impact, it may still be beneficial in controlling for the overestimation of conclusion , providiSecondly, during the stakeholders' consultation, some panels briefly raised the limitation on utilization and acceptance of technology in practice and limited client preferences. Nevertheless, although it is interesting to explore users' perspectives in understanding the use of technology and how it benefits them, it is beyond the scope of this scoping review.Strokes cause survivors to live with severe disabilities that affect their daily activities due to paralysis and impaired balance and mobility. From the standpoint of rehabilitation, the clients must engage in an extensive and continuous therapeutic exercise for the recovery process. The conventional stroke rehabilitation techniques usually take longer for stroke survivors to fully recover since they rely on the therapy sessions and exercises conducted by the therapists. New rehabilitation techniques, such as constraint-induced, biofeedback, and robot-assisted therapy, have evolved in recent years and have been embraced as an adjunct to conventional techniques.The integration of technological intervention toward conventional therapies has shown a positive outcome to the survivor's post-stroke recovery process. This is indeed a better form of therapy especially during the pandemic, where face-to-face consultation is restricted, which at the same time encourages the survivors to undergo treatments. As a result, they could regain independence on mobility and perform the activities of daily living (ADLs). However, there are several gaps identified in this scoping review, which include the lack of studies on technological intervention toward lower extremities. Besides, most of the interventions were found in the hospitals and rehabilitation units, and only a few studies were done in the community-dwelling or home-based therapy. In addition, many technologies are still yet to be explored since this scoping review only covers Southeast Asia countries and the technologies available are predominated by prosperous countries. International references and collaborations should be further encouraged to promote the use latest technological advancements. Nevertheless, this scoping review reveals that the utilization of technologies in stroke rehabilitation has begun to be acknowledged and established in Southeast Asia.The original contributions presented in the study are included in the article/The inclusion/exclusion criteria and search strategy were developed under the supervision of MR and RC. The search in the databases was carried out by SS, HA, and MR who also led the writing of the methodology section in the manuscript. SS, RC, HA, and MR worked together on data analysis and manuscript writing. SS, MS, and HR contributed information on the direction of the data analysis and revised continuous amendments of the manuscript draft. The final manuscript was read and approved by all the authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Following periods of acute ill-health and injury, older people are frequently assessed and provided with rehabilitation services. Healthcare practitioners are required to make nuanced decisions about which patients are likely to benefit from and respond to rehabilitation. The clinical currency in which these decisions are transacted is through the term “rehabilitation potential”. The aim of this study was to explore information about rehabilitation potential in older people to inform the development of an evidence-based assessment tool.A systematic mapping review was completed to describe the extent of research and the concepts underpinning rehabilitation potential. We searched Medline, CINHAL, EMBASE, AMED, PsycINFO, PEDro, Cochrane Library, Web of Science, ProQuest, Trip and EThOS from inception to December 2020. We included studies which focused on rehabilitation potential and/or assessing for rehabilitation interventions for older people with comorbidities in the hospital and community setting. Reviewer pairs independently screened articles and extracted data against the inclusion criteria. A descriptive narrative approach to analysis was taken.13,484 papers were identified and 49 included in the review. Rehabilitation potential was found to encompass two different but interrelated concepts of prognostication and outcome measurement. 1. Rehabilitation potential for prognostication involved the prediction of what could be achieved in programmes of rehabilitation. 2. Rehabilitation potential as an outcome measure retrospectively considered what had been achieved as a result of rehabilitation interventions. Assessments of rehabilitation potential included key domains which were largely assessed by members of the multi-disciplinary team at single time points. Limited evidence was identified which specifically considered rehabilitation potential amongst older people living with frailty.Current approaches to rehabilitation potential provide a snapshot of an individual’s abilities and conditions which fail to capture the dynamic nature and fluctuations associated with frailty and rehabilitation. New approaches to measures and abilities over time are required which allow for the prognostication of outcomes and potential benefits of rehabilitation interventions for older people living with frailty.The online version contains supplementary material available at 10.1186/s12877-021-02498-y. Older people living with frailty often do not have discrete illnesses that they recover from. Rather they have an array of long-term conditions, which can both progressively worsen and have acute exacerbations resulting in hospitalisation. This can have a devastating impact on their function, well-being and social interactions.Rehabilitation interventions are key in supporting patients’ recovery after periods of acute ill health , 2. HealRehabilitation potential has been described in a number of different ways. It has been used to describe how well a patient’s function improves in response to rehabilitation, , 4 restoThe aim of our study was to identify and map literature on rehabilitation potential to inform the development of a tool to support consistent decisions , 11. It We conducted a systematic mapping review. These are designed to describe the extent of research into a field and the concepts underpinning the research , 13. TheAn electronic, three-step search strategy was used. An initial search was carried out in all databases using the keyword “rehabilitation potential”. A second search was carried out using MeSH combined with the key word “rehabilitation potential” across all included databases from inception to December 2020. Thirdly, a citation search was completed across the reference lists of all identified studies to enhance the rigour of the study . StudiesSearches, title and abstract screening were conducted by a single researcher (AC). Full text screening and data extraction were independently completed by two reviewers selected from AC, PL, SG and ALG. Disagreements were resolved through discussions with the study team. Data were recorded on a standardised data extraction form  which coStudies were included if they focused on rehabilitation interventions delivered in hospitals or community settings for adults aged over 65 with frailty or multiple comorbidities, where recovery trajectories are particularly uncertain. Studies that included assessments of rehabilitation potential and clinical decision-making during assessments for rehabilitation programmes were included. Studies which presented primary research, including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, case series, individual case reports, descriptive cross-sectional studies, phenomenology, grounded theory, ethnography and action research were included.Studies focussing on specialist stroke rehabilitation, fracture care, end of life care or with a terminal diagnosis were excluded. Opinion pieces, editorials and books were excluded.Outcomes of interest included measures of function or activities of daily living (ADL), instrumental activities of daily living (IADL), and access to and provision of services as a consequence of rehabilitation potential assessments.Data were analysed by publication rate by year, country of publication, study type, participant type and study settings. Results were displayed in descriptive tables taking into account a priori themes based on the World Health Organization International Classification of Functioning, Disability and Health (WHO ICF)  and emer13,484 papers were identified through bibliographic searches with an additional 48 found through citation searching. After duplicates were removed, 12,566 records titles and abstracts were screened and 12,452 were excluded. 114 articles underwent full paper screening, at which point a further 65 articles were excluded. 49 articles were included in the final review. A PRISMA diagram is shown in Fig. n = 21) and Europe (n = 14). Five were completed in Australasia, three in Asia and six as part of international collaborations. Publication dates ranged from 1959 to 2017 with the greatest number of articles published in 2012 and 2016  Table .Table 2The majority of studies included patients with diverse diagnoses and characteristics who were in receipt of rehabilitation assessments or interventions. Study populations were described in different ways with variables including: frailty, multimorbidity, cognitive status, functional abilities and activities of daily living. Diagnoses commonly identified included: Alzheimer’s diseases and other dementias, orthopaedic diagnoses , cardiac and respiratory conditions, stroke and hip fractures. Where reported, mean ages ranged from 65 to 88.1 years . FourteeFindings coalesced around specific themes which are presented in Table The prognostic indicator of how the patient will perform within a standard inpatient rehabilitation program … involving an estimation of the patient’s personal strengths , medical complications and familial support as they interface with therapies and rehabilitation environment … estimates the individual’s capability of cooperating with a rehabilitation program and making measured functional gains in ambulation and self- care … appraising whether the patient’s current quality of life can be improved upon despite chronic or multiple disabilities.” [“lities.” .A number of authors [Definitions demonstrated considerable heterogeneity and a lack of consensus. The term was used prognostically to describe an individual’s potential for restoration of function , 34, 35  authors , 37–42 a authors  consider authors  and Hart authors  used plaIn contrast, rehabilitation potential was defined as being present if the individual undergoing rehabilitation and/or a member of the continuing care team thought the individual was capable of increased independence in some objectively measured functional areas , 43–46. physiological and psychological possibilities of a disabled person to restore, improve on maintain an optimal level of function and quality of life” [In three studies by Johansen et al. –50 a worof life” . Whilst Three studies were identified which stated that they selected patients for rehabilitation on the basis that they had rehabilitation potential –54 but rn = 367) of residents believed that their physical function would improve, but just 9.8% (n = 57) of their caregivers deemed them to have rehabilitation potential.Rehabilitation potential assessments were completed by: physicians , 34, 40,Assessments took place in outpatient geriatric clinics , 55, intIn studies which specifically explored rehabilitation potential, the decision that an individual did or did not have rehabilitation potential was predominantly made at a single time point. Assessments occurred at the time of deciding on patient suitability for admission to a rehabilitation unit , to guidThe identification of an individual’s rehabilitation potential was said to involve clinical judgement and reasoning , 21, 41,Jupp et al.  developeK-nearest neighbour algorithm [The interRAI ADL and IADL Clinical Assessment Protocols (CAP), developed for acute and community-dwelling populations , 32, 33,lgorithm  and Supplgorithm  had supeTwo studies recommended that holistic assessments were required which addressed biopsychosocial needs and abilities of patients , 45. HowThe evidence suggested a pertinent role for assessing co-morbidities and diagnoses , 58–62 wAssessing and identifying functional abilities was strongly represented in the data. They were largely assessed and understood through assessing ADLs , 63, 64.Establishing an individual’s psychological abilities or deficits was frequently included in rehabilitation potential assessments , 50, 60.“good and practical measure of recovery”. Social situation, where an individual lives and the type of support they received were found to be strong predictors of rehabilitation outcome [An assessment of rehabilitation potential was found to require an understanding of an individual’s social circumstances , 46, 52. outcome . Mosqued outcome  outlined outcome  exploredThe literature highlighted the need to assess an individual’s environment –30, 54. 2 = 0.04, P < 0.001). Cunningham et al. [A number of measures were identified in studies specific to rehabilitation potential. Chang et al.  found sim et al.  proposedOther studies adopted retrospective measures, comparing outcome measures before and after rehabilitation programmes. Measures adopted included changes in individuals ADL functioning , 47 wherNew  developeMost aspects of medical interventions were not measured or categorized in a way that could be easily reported. Those that were quantifiable were largely measures of frailty or symptom scores.Morghen et al.  was the Staff skills, training and experience were found to affect the transaction of rehabilitation potential assessments , 38, 64.Funding and availability of resources were considered in rehabilitation potential assessments. Mosqueda  stated tThe majority of studies identified in this review included patients who had been deemed to have rehabilitation potential, rather than studies which explored or tested the assessment of rehabilitation potential. As a consequence, a successful outcome of rehabilitation potential was frequently linked to rehabilitation outcomes specific to the study design, aims and objectives.Frequently, improvement was identified as the optimum outcome associated with rehabilitation or rehabilitation potential amongst older people. Improvement was described as a return to premorbid abilities or an improvement in function , 60, 64.This study found considerable variations in definitions of rehabilitation potential and in some cases, an absence of definition. Rehabilitation potential was found to encompass two different, but inter-related, concepts of prognostication and outcome measurement. Prognostic rehabilitation potential described the prediction of what could be achieved through rehabilitation, whereas outcome-based rehabilitation potential considered what had been achieved. The locations of rehabilitation potential assessments were highly contextualized by the study designs and aims.Prognosis involves the prediction of the future course and outcome of disease processes concerning either their natural course or outcome after treatment . PrognosRehabilitation potential was also found to be used as a proxy for entry criteria into rehabilitation studies. In that patients deemed not to have rehabilitation potential were excluded from studies based on the belief that they would not benefit or respond to rehabilitation interventions. This frequently included those with moderate to severe levels of cognitive impairment , 52, 64 Rehabilitation potential was used as a measure of rehabilitation outcome, in that individuals ‘had rehabilitation potential’ if they achieved favourable outcomes. Based on retrospective analysis, these variables help inform clinicians’ predictions of what an individual may be capable of, but in isolation they do not capture the complexity of human behaviour and nuances of frailty and multimorbidity. However, Enderby et al.  warn thaUnsurprisingly, domains relevant to the World Health Organization’s International Classification of Functioning, Disability, and Health (WHO ICF)  featuredPersonal and participatory factors are part of the ICF  and thisIt is clear that solely focusing on the physical effects of frailty will not address the complex, highly individualised and fluctuating needs of older people living with frailty. Clinicians need to consider the wider social implications of ageing and the impact these have on continued quality of life and control over individuals lives. The inclusion of environmental and social domains of assessment identified during this review may go some way to remedy this medical and physical bias, but further evidence is needed to understand how these domains relate to rehabilitation potential. Rehabilitation potential was largely assessed at singular time points, with subsequent reviews of outcome measures completed retrospectively.Due to the heterogeneous nature of frailty presentations and rehabilitation interventions a mapping review was ideally suited to map this complex field. This enabled the context and mechanism of frailty rehabilitation to be explored, essential in understanding complex interventions .Of the 49 studies included in this review, 24 were from either Anglophone countries  or from European countries which have a tradition in publishing in English language journals. The predominance of studies from Anglophone countries may represent selection bias by limiting selection criteria to the English language. Asian countries have been found to publish less frequently , but thiThis study excluded evidence from books and hence the most commonly cited definition of rehabilitation potential by Rentz . Whilst It proved challenging to identify studies which solely explored rehabilitation potential in relation to frailty. This may represent a limitation in search terms or engines used, but more likely represents the lack of evidence in rehabilitation decision-making and the emerging field of frailty rehabilitation. The studies included in this review comprised a broad range of clinical conditions and patient groups. This study sought to exclude articles which included patient participants in receipt of specialist stroke, palliative and fracture services. However, many of the studies identified included patients with these diagnoses.This review identified considerable heterogeneity in definitions and use of the term rehabilitation potential and in some cases an absence of definition despite it being used as an entry criterion into a study. It was found to be poorly understood and judged differently by different people at different times. Rehabilitation potential was found to encompass two different but interrelated concepts of prognostication and outcome measurement. Limited evidence was identified which specifically considered rehabilitation potential amongst older people living with frailty. Current tools and approaches provide a snapshot of an individual’s abilities and conditions which failed to capture the dynamic nature and fluctuations associated with frailty and rehabilitation. Snapshot approaches further enhance the risk of age-based rationing of services where those who might benefit from rehabilitation are denied access to interventions. New aggregative approaches to measures and abilities over time are required which allow for the prognostication of outcomes and potential benefits of rehabilitation interventions for older people living with frailty.Additional file 1. Supplementary data file one- Justification for search terms and database selection.Additional file 2. Supplementary file three- Patient participants demographics (where reported).


Traumatic injuries, defined as physical injuries with sudden onset, are a major public health problem worldwide. There is a paucity of knowledge regarding rehabilitation needs and service provision for patients with moderate and major trauma, even if rehabilitation research on a spectrum of specific injuries is available.This study aims to describe the prevalence of rehabilitation needs, the provided services, and functional outcomes across all age groups, levels of injury severity, and geographical regions in the first year after trauma. Direct and indirect costs of rehabilitation provision will also be assessed. The overarching aim is to better understand where to target future efforts.This is a population-based prospective follow-up study. It encompasses patients of all ages with moderate and severe acute traumatic injury (New Injury Severity Score >9) admitted to the regional trauma centers in southeastern and northern Norway over a 1-year period (2020). Sociodemographic and injury data will be collected. Upon hospital discharge, rehabilitation physicians estimate rehabilitation needs. Rehabilitation needs are assessed by the Rehabilitation Complexity Scale Extended–Trauma , Needs and Provision Complexity Scale , and Family Needs Questionnaire–Pediatric Version (FNQ-P). Patients, family caregivers, or both will complete questionnaires at 6- and 12-month follow-ups, which are supplemented by telephone interviews. Data on functioning and disability, mental health, health-related quality of life measured by the EuroQol Questionnaire (EQ-5D), and needs and provision of rehabilitation and health care services are collected by validated outcome measures. Unmet needs are represented by the discrepancies between the estimates of the RCS E–Trauma and NPCS at the time of a patient’s discharge and the rehabilitation services the patient has actually received. Formal service provision (including admission to inpatient- or outpatient-based rehabilitation), informal care, and associated costs will be collected.The project was funded in December 2018 and approved by the Regional Committee for Medical and Health Research Ethics in October 2019. Inclusion of patients began at Oslo University Hospital on January 1, 2020, and at the University Hospital of North Norway on February 1, 2020. As of February 2021, we have enrolled 612 patients, and for 286 patients the 6-month follow-up has been completed. Papers will be drafted for publication throughout 2021 and 2022.This study will improve our understanding of existing service provision, the gaps between needs and services, and the associated costs for treating patients with moderate and major trauma. This may guide the improvement of rehabilitation and health care resource planning and allocation.DERR1-10.2196/25980 Traumatic injuries, defined as physical injuries with sudden onset and a severity level requiring immediate medical attention, are a major public health problem worldwide . The mosWhile acute trauma care is considered to be of high quality in Norway, rehabilitation services remain fragmented ,9. GabbePediatric trauma constitutes an important subset of traumatic injuries, with lower mortality rates than injuries in adults but a high risk of lifelong functional impairment and disability . Gabbe eTrauma rehabilitation should be provided as a set of coordinated, multidisciplinary services tailored to the patient’s needs. Personal factors such as resilience, personality, chronic pain, and access to social support are powerful predictors of outcome ; however“A need for rehabilitation” refers to any needs that can be met with rehabilitation management, interventions, and services in the acute, subacute, and postacute phases of an injury. Such needs relate both to specialized inpatient and outpatient services and those provided in community-based settings . A discrFew studies exist on the cost-effectiveness of rehabilitation services after traumatic injuries . PatientThe main aims of this study are to explore the rehabilitation needs and provided services for patients after moderate and major trauma and to study changes in needs over the first year. The study will evaluate the implementation of recommendations on early rehabilitation and continuity of care, as stated in the National Trauma Plan in Norway , and assThis is a multicenter, population-based study with prospective follow-ups at 6 and 12 months post injury.The regional trauma centers in the southeastern and northern parts of Norway are Oslo University Hospital (OUS) and the University Hospital of North Norway (UNN), respectively. We classify the northern region as more rural due to the long distances to and from hospital and rehabilitation facilities and the low population density. The southeastern region is classified as mainly urban with shorter distances to and from hospital and rehabilitation facilities and higher population density. The prehospital emergency medical services are well organized in both regions .The group eligible for the study will be approximately 600 patients of all ages with moderate and major trauma, including multiple injuries , who were consecutively admitted to the regional trauma centers in the southeastern and northern parts of Norway over a 1-year period and subsequently discharged.All Norwegian residents may be included who were admitted directly to the above hospitals or admitted after transfer from local hospitals within 72 hours after injury, with at least a two-day hospital stay and a New Injury Severity Score (NISS) greater than 9 . Non-Norwegian residents and deceased patients will be excluded.All patients admitted with a trauma alarm will be assessed daily by the participating doctor in the project with formal expertise in scoring the severity of the injuries. Once it is clarified that a patient meets the inclusion criteria, the patient is informed by the research assistant, and informed consent is obtained.All components of the research project will be conducted according to the ethical guidelines of the Declaration of Helsinki and approved by the Regional Committee for Medical and Health Research Ethics  and the Norwegian Data Inspectorate . Data will be handled and stored securely on the research servers at OUS and UNN (patient-related data) and the Service for Sensitive Data at the University of Oslo (cost data). All data will be deidentified when sharing them with partners and in analysis and presentations.Regional research assistants and PhD students will oversee patient recruitment and data collection. The patients will be identified during acute admission to hospital. Trauma patients with NISS>9 are included in both hospitals’ trauma registries and the National Trauma Registry (NTR). It will thus be possible to validate the trauma severity scores of included patients as well as attrition rates in this study. These scores derive from the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), and NISS.Information about the study will be presented to patients in written and oral form with informed consent emphasizing their right to withdraw from the project at any time without requiring a reason. The recruited patients (or their proxy or caregiver) must provide this informed consent. For pediatric patients, the information will be given in written and oral form, and forms adapted to the language of the youngest children will be provided. For children and adolescents younger than 18 years, parents must give written consent. Adolescents aged 16-17 years must sign consent for themselves as well. For adult patients with cognitive or communication difficulties, a family member or caregiver will be identified to provide consent  and assist in completing the questionnaires.Collection and registration will be based on information from medical records. The trauma scores will be validated by data registered by certified AIS registrars in the hospitals’ trauma registries and, if necessary, in connection with other available clinical information about the patients’ stays in hospital departments.Sociodemographic data will include family status , preexisting comorbidity, education or work status, and substance use at the time of injury. Injury-related data include diagnoses ; cause and type of injury; severity of injury as assessed by the NISS, ISS, and AIS; nonsurgical and surgical treatments; treatment complications; time spent on a ventilator; length of hospital stay; and discharge location.The NISS is used to define injury severity in the inclusion phase . The rationale for the inclusion criterion of an NISS >9 is based on guidance from the National Institute for Health and Care Excellence that such patients should be assessed for rehabilitation needs, and a rehabilitation prescription should be provided for all patients who are deemed to have those rehabilitation needs .The Rehabilitation Complexity Scale Extended–Trauma (RCS E–Trauma) is used for identification of needs for specialized inpatient rehabilitation. The RCS E–Trauma is a simple 5-item scale (score range 0-25) that reflects rehabilitation resource requirement for medical, basic care and support, skilled nursing, and equipment needs and therapy inputs . The neeThe NPCS in its clinician version evaluates needs for community-based rehabilitation and health care service delivery . The NPCThe NPCS also includes a self-report version. Patients or carers are asked to report the level of services received within the last 6 months and whether they consider this to be the right amount, too much, or too little (a free-text box is provided for elaboration). The NPCS patient version will be used at 6- and 12-month intervals as an integral part of the telephone interview discussion, measuring the extent to which the self-perceived needs have been met through service provision and informal care. The 6-month report will be used to estimate needs for community-based rehabilitation and health care service delivery for the 6- to 12-month period post discharge. The NPCS will in this study serve as a base for estimation of costs of services received after discharge from the specialist health service.The Family Needs Questionnaire–Pediatric Version (FNQ-P)  will be Primary and secondary outcomes  at 6 and 12 months are presented in All measures exist in Norwegian versions. The estimated time taken for the follow-up interviews and questionnaires at 6 and 12 months is approximately 1.5 to 2.5 hours.Questionnaires for patients, their caregivers, or both will be completed at the 6- and 12-month follow-ups by mail or electronic link supplemented by a telephone interview. This will provide data on changes in sociodemographic characteristics, measures of functioning and disability, mental health, and HRQL, as well as rehabilitation, health and social care service needs, and provision of those services (Gets). The discrepancy between the scores of RCS E–Trauma and NPCS assessed at discharge (Needs) and the rehabilitation services received (Gets) during the first 6 months represents unmet needs. Unmet rehabilitation needs at 12 months are the discrepancy between NPCS-Needs as evaluated by patients at 6 months and NPCS-Gets (receiving services 6-12 months after injury) at 12 months.We aim to estimate costs of a traumatic injury from a societal perspective, not only as consequences related to medical treatment but also consequences for work and family situations. Health care utilization encompasses in-hospital stays, including rehabilitation and outpatient appointments, as well as home care and contact with community-based rehabilitation services, multidisciplinary rehabilitation, individual rehabilitation plans, and other health care services. Further, use of social support professionals, vocational and educational rehabilitation, equipment and assistive technology, income and accommodation, informal care provided by family and significant others, and other cost-related variables will be registered. In this study, participants will record the type and amount of services received during the previous 6 months after 6 months and 12 months following discharge from the trauma hospital. The NPCS patient version will be used at 6- and 12-month intervals as an integral part of the telephone interview discussion and serves as one of the bases for estimation of the costs of services  received after discharge from the specialist health service. Loss of productivity due to sick leave and absence from work because of treatment, rehabilitation, or follow-up will be estimated together with costs for the family .Total rehabilitation, health care, social support, and societal costs across the periods 0-6 and 7-12 months post discharge will be estimated by combining service utilization and national unit costs. The replacement cost method that evaluates informal care time will be based on the cost of paid professionals at the study time as a “shadow price” for informal care . IntangiBy using the NPCS, an algorithm can be applied to estimate the cost of meeting unmet needs for the purpose of integrating care planning . The cosr=0.50 correlation between the two measurements of the outcome variable, the estimated sample size of 600 participants would generate enough power to detect all large-sized, medium-sized, and small-sized effects with Cohen f2>0.06.According to the estimates from the NTR, 931 and 110 patients with NISS >9 were respectively admitted to the trauma referral hospitals in the southeastern and northern parts of Norway in 2015. The 30-day mortality rate for this group was about 10%. In addition, we expect the dropout rate to be around 30% at the 1-year follow-up, comprising a 20% refusal rate and 10% of patients lost to follow-up. Accounting for mortality and dropouts, this study expects to include approximately 600 participants in the final study analyses. A power analysis was performed for a predictive model with an outcome variable collected at two time points (6 months and 12 months), a predictor variable , and an interaction term between time and the predictor. This type of model would be a common model employed in the proposed study and likely the most power-consuming model given the additional power needed to detect an interaction effect. With 80% power (1–β), and assuming an Descriptive statistics and graphing techniques will be used to describe rehabilitation and health care needs, service use, and functional outcomes over time, as well as to compare these factors across age groups, injury severity levels, and geographical regions. The aggregated data from the NTR will be used to estimate the national prevalence of rehabilitation needs and service use after traumatic injuries, including the total number of trauma patients with moderate and severe injury according to age, gender, and geographical region. Unmet needs for specialized inpatient rehabilitation will be based on the evaluation of RCS E–Trauma compared to received services by the 6-month follow-up. Further, unmet community-based rehabilitation needs will be calculated by subtracting the total NPCS-Gets score from the total NPCS-Needs score.To establish whether the unmet rehabilitation needs differ across subgroups, longitudinal mixed models will be used wherein the nested variable is time . The models will enable identification of factors that predict unmet rehabilitation needs and differences in the needs based on key demographic, injury-related, or service-related variables. Predictor variables in these models will be left as continuous wherever possible in order to maximize potential variability in the predictors . Categorical variables will be dichotomized . Injuries can be grouped as follows: TBI, spinal cord injuries, orthopedic injuries including amputations, thorax and abdominal injuries including hemorrhaging.The mean costs of both formal and informal rehabilitation and health care services used during the first year will be calculated and compared across these variables. In this study we have defined informal rehabilitation as help given by family or friends and quantified by hours per week. Information about this is collected through the telephone interview and the results of the patient version of the NPCS. Costs are typically skewed with heavy right tails due to patients with severe injuries using services to a great extent and incurring high levels of cost; when estimating predictors for total costs, we will apply log-linear and general linear models. Additionally, the NPCS algorithm for calculating the costs of meeting unmet needs will be used for the purpose of integrating care planning.For evaluation of completeness and validity of collected data reflecting hospital admissions and service use during the first year after injury, data linkage will be achieved with the Norwegian Patient Register  and with outpatient consultations in the specialist health service. Additionally, linking will be performed with the registries with costs arising from consultations and other contact with emergency services and various health professionals and medical specialists, and with individual-based health care and rehabilitation use in municipal health care services. Sick leave and other benefits data will be extracted from the Norwegian Labour and Welfare Administration. The applications for extracting these data will be sent to the respective registries.The project was funded in December 2018 and approved by the Regional Committee for Medical and Health Research Ethics in October 2019. Inclusion of patients began at OUS on January 1, 2020, and at the UNN, Tromsø, on February 1, 2020. As of February 2021, we have enrolled 612 patients. The 6-month follow-up has been completed for 286 patients. Papers will be drafted for publication throughout 2021 and 2022.This is the first multiregional study in Norway based on data from the NTR on rehabilitation after trauma. We have not found parallel studies on rehabilitation after moderate and major trauma in an international context. This prospective follow-up project is estimated to collect data from over 600 patients and provide innovative insights into rehabilitation needs and costs, as well as intangible costs for patients and family caregivers and their perception of care provided. The study will establish the national prevalence of rehabilitation needs and costs, highlighting patients at risk of unmet rehabilitation needs. Service provision and unmet needs will be evaluated in lieu of outcomes over a broad array of functional domains, thus providing detailed information regarding specific needs.The results will be of interest across the whole care chain for trauma patients, as there are strong recommendations to plan and initiate the rehabilitation process early in the acute phase. Further, beyond trauma patients, the results will be of beneficial value since this group is representative of patients with long-term disabilities who are expected to have ongoing needs for rehabilitation services and support in general. The results could inform both clinical decision making at the individual level and population-based service planning and delivery in areas capable of improvements.The project aligns with several national policy documents and white papers and the National Trauma Plan ,43,44, aThe project will inform the World Health Organization global disability action plan 2014-2021 to strengthen and extend rehabilitation provision . The impThis study also has some limitations that should be discussed. This is an observational study; thus, the causal inferences will be restricted by the design. However, this longitudinal cohort study has a comprehensive and epidemiological approach, comprising registry data and self-reports from patients and caregivers, and the study design provides a higher external validity than an experimental study. Furthermore, as with any longitudinal study, there will be a risk of dropout. To facilitate study adherence and maintain the lowest possible dropout rates, the research team will be trained regarding the follow-up procedures. Baseline data will be available for all participants, allowing comparisons between those who continue in the study and those who drop out. However, since we include patients who are received by the hospitals with trauma alarms, we will not include all patients with injuries with NISS >9, as some with more moderate injuries are not triaged and met by trauma teams.In conclusion, this study will provide information about rehabilitation needs and service provision for patients who have sustained moderate and major trauma. New knowledge about met and unmet needs will improve the understanding of the existing service provision, the gaps between needs and services, and the associated costs for treating trauma patients, which could guide improvements of rehabilitation and health care resource planning and allocation.


Individually, concentrations of pancreatin, bile, and CaCl2, as well as incubation length were tested. To examine the use of this assay to estimate in vitro total tract digestion, a KH2PO4 solution with concentrated amounts to reach the same final concentrations of pancreatin, bile, and Ca were used as the third step in a three-step total tract digestibility procedure. Free glycerol and free fatty acid (FFA) concentrations were measured using colorimetric assays as indicators of digestion. Data wereanalyzed as a completely randomized block design (block = run), using the Glimmix procedure of SAS. For each lipid source, free glycerol increased with increasing pancreatin; however, FFA was lowest at 0 g/L pancreatin but was similar at 6, 8, and 10 g/L. Both glycerol and FFA were greater for 2.5 and 5 g/L of bile than for 0 g/L for each lipid source. Calcium concentration did not affect glycerol or FFA for either CO or CA; however, glycerol and FFA for BT were greater when calcium was included at 5 and 10 mM than at 0 mM. For all fat sources, free glycerol and FFA increased after 1 h until 12 h, but did not increase from 12 to 24 h. When a concentrated mixture was used following fermentation and acidification steps, digestibility using FFA concentration increased as compared to just adding buffer; however, free glycerol concentration was indeterminable. Thus, free glycerol and FFA can be used as indicators of lipid digestion when a lipid source is incubated for at least 12 h in a buffer solution containing 8 g/L pancreatin, 2.5 g/L bile, and 5 mM Ca when only estimating in vitro intestinal digestion; however, when utilizing this assay in a three-step in vitro total tract digestibility procedure, only FFA can be used.The objective of this study was to adapt existing in vitro methodologies to determine the extent of intestinal digestion of corn oil (CO), canola oil (CA), and beef tallow (BT) via manipulation of incubation length and concentrations of lipase, bile, and calcium within a buffer solution. Unless otherwise stated, 0.5 g of each lipid source were incubated separately and in triplicate, with triplicate batch culture runs for each treatment in 40 mL of 0.5 M KH For decades, rumen-protected feed additives have been available to cattle producers to supply their animals with an adequate source of amino acids, vitamins, or minerals without losing a significant portion to alteration by the microbial community of the rumen. Often times, these feed additives are coated with a lipid layer to prevent microbial degradation, which can lead to up to 95% rumen protection . HoweverCurrently, in the ruminant nutrition industry, some work has been done to elucidate lipid digestion in vitro; however, there is no standardized in vitro protocol to determine lipid digestibility. The methodology described by All animal care and handling procedures used in this experiment were approved by the University of Florida Institutional Animal Care and Use Committee.2 × 2H2O) was used to manipulate the concentration of calcium in solution , and BT  were purchased from a local supermarket and were incubated without any further purification. These three lipid sources were chosen due to their use both currently and historically in the dairy industry, and the well-documented literature available regarding their digestibility  in ordersolution .2PO4) buffer solution was completed according to 2PO4 was dissolved in deionized water and corrected to pH 7.6 using 5% NaOH. Concentrations of pancreatin, bile, and calcium as well as incubation length were all tested independently. However, unless otherwise stated, a standard solution of pancreatin (8 g/L), bile (2.5 g/L), and Ca (10 mM) was used, and samples were incubated at 39°C for 24 h , for a total of 2. Serum bottles were flushed with CO2 and inoculated with 52 mL of buffered ruminal fluid and immediately closed and sealed and incubated at 39°C for 24 h.After the final concentrations of pancreatin, bile, and Ca and the intestinal incubation length were determined, six replicated samples (0.5 g) of CO, CA, or BT were used in triplicated incubations for in vitro ruminal fermentation . RuminalImmediately following in vitro ruminal fermentation, serum bottles were opened and acidified with 2 mL of 3 M HCl  to simul2PO4, 16.5 g/L bile, and 9.64 g/L CaCl2) with or without pancreatin (52.8 g/L) in triplicate to determine the effects of ruminal fermentation on the extent of digestion. A smaller volume of concentrated buffer solution was used in this portion of the experiment in order to reach the same final concentrations of pancreatin, bile and CaCl2 as investigated in the previous portion of this experiment, as otherwise they would be diluted by the already present ruminal fluid and buffer solution. Bottles were mixed, re-sealed, and incubated at 39°C for 24 h. After 24 h, bottles were opened and 2 mL subsamples were collected and frozen at -20°C for later analysis of FFA concentrations.Following neutralization, bottles were inoculated with 10 mL of a concentrated intestinal buffer solution  was measured as estimates of digestibility. Free glycerol concentration was measured using a commercial kit  and free fatty acid concentration was determined using the method described by Data for free glycerol and fatty acid estimates of digestibility were analyzed using the GLIMMIX procedure of SAS . Data from each lipid source were analyzed individually as a completely randomized block design, using run as a blocking factor with the following model:Yij is the response variable, µ is the overall mean, R is the random effect of run (j = 1 to 3), T is the fixed effect of treatment , and E is the residual error. Means separation was conducted using a Bonferroni test. Significance was declared at P ≤ 0.05 and tendencies were declared at 0.05 < P ≤ 0.10.In which P < 0.01) from 0 g/L  to 6 g/L  and 8 g/L , but were similar between 8 g/L and 10 g/L  of pancreatin. However, digestibility (%) of CO increased (P < 0.01) as the concentration of pancreatin increased from 0 g/L (7.78), 6 g/L (66.42), 8 g/L (76.4), and 10 g/L (89.3). Digestibility estimated from the release of FFA (P < 0.01) from 0 g/L of pancreatin  to 6 g/L , but did not increase further with concentrations of 8 g/L  or 10 g/L .Digestibility estimated from the release of free glycerol  from CA e of FFA  from CA,P < 0.01) from 0 g/L  of bile to 2.5 g/L  but was similar between 2.5 g/L and 5 g/L . Digestibility estimated from the release of FFA (P < 0.01) from 0 g/L  of bile to 2.5 g/L  but was similar between 2.5 g/L and 5 g/L .The concentrations of bile used in this experiment were obtained from the results of e of FFA  from CA,P > 0.05). However, the inclusion of Ca at either 5 mM (80.3%) or 10 mM (79.8%) increased (P < 0.01) the digestion of BT as compared to when Ca was absent (59.4%). Similar results were observed for digestibility estimated from the release of FFA (P > 0.05). However, the inclusion of Ca at either 5 mM (74.7%) or 10 mM (80.5%) increased (P < 0.01) the digestion of BT as compared to when Ca was absent (27.5%).Digestibility estimated from the release of free glycerol  from CA e of FFA  from CA P < 0.01) between 1 h , 3 h , 6 h , 9 h , and 12 h , but was similar between 12 h and 24 h . Digestibility of BT increased (P < 0.01) as well, but only between 3 h (12.1), 6 h (22.7), 9 h (57.3), and 12 h (81.5) and digestibility was similar between h 1 (8.72) and 3 and then h 12 and 24 (78.6).Digestibility of CA and CO determined with free glycerol release  increaseP < 0.01) between 1 h , 3 h (34.4), 6 h (47.4), 9 h (61.5), and 12 h (76.3), but were similar between 12 h and 24 h (83.2). The pattern of digestibility of BT with FFA was similar to that which was observed with glycerol, and the pattern of FFA digestibility of CA was also similar to BT. Digestibility of CA and BT increased (P < 0.01) only between 3 h , 6 h , 9 h , and 12 h  and digestibility was similar between h 1  and 3 and then h 12 and 24 .Similar results were observed for the digestibility determined with FFA release  from CO.P < 0.01) with the addition of a 24 h pancreatin incubation following both a 24 h in vitro ruminal fermentation and a 1 h acidic, mock abomasal digestion with 3 M HCl. Digestion of CA increased from 15.9% to 80.4%, CO from 16.6% to 78.1%, and BT from 21.1% to 80.1%. When determining digestibility of CA, CA, and BT using the full three-step in vitro digestibility method, only FFA was able to be used as an indicator of digestibility.Digestibility of CA, CO, and BT as determined by the release of FFA  increaseThe objective of this study was to adapt existing in vitro digestibility methodologies to determine the necessary components for the determination of both total tract and intestinal lipid digestibility in vitro. Digestion of lipids in the small intestine is a multifaceted digestion that requires not only enzymatic action from lipase, but also requires bile as an emulsifier and calcium in order to remove freshly cleaved fatty acids from the surface of the lipid droplet . In non-In the field of human nutrition, a common method to determine the in vitro digestibility of lipids is the pH-stat method . This meThe concentrations of pancreatin used in this experiment were obtained from Our results were similar to those obtained by Bile is the main emulsifier of fat in the small intestine  and is rBile, in excess, has been reported to suppress lipase activity at the oil–water interface by blocking the hydrolysis of lipids by lipase . Li et aCalcium concentrations were based on the results obtained by Both The delay in digestion between h 1 and h 3 for BT could be caused by the large droplet size of BT in solution preventing lipase from immediately accessing a large portion of the triglycerides . HoweverGiven that for both free glycerol and FFA for all three lipid sources, there were no differences in digestibility between 12 h of incubation and 24 h; in order to achieve an in vitro digestion of lipids representative of what would be observed in vivo, a 12 h incubation is satisfactory. However, a 24 h incubation may be more convenient and can be used with no difference in digestibility.While the focus of this manuscript was to design an assay to determine the in vitro intestinal digestibility of lipids, the potential for an assay to determine in vitro total tract digestibility had already been investigated by When glycerol was measured following incubation, it was not detected. This is possibly due to the fermentation of glycerol by ruminal bacteria present in solution . The fer2PO4 buffer solution with 8 g/L pancreatin, 2.5 g/L bile, and 5 mM Ca for at least 12 h. While glycerol and FFA are both end products of lipid digestion, FFA provide a more consistent result as an indicator of digestibility than free glycerol due to the potential for partially digested triglycerides. A similarly representative digestion can also be obtained by using a concentrated pancreatin mixture following a three-step in vitro total tract procedure; however, due to fermentation of glycerol, only FFA can be used as an indicator of digestibility. Further studies should consider evaluating other lipid sources, such as calcium soaps of fatty acids, as well as rumen-protecting products. Furthermore, in vivo validation would be needed to assess lipid utilization in the whole animal.Representative digestion of CO, CA, and BT achieved in in vivo studies, can also be achieved utilizing an in vitro assay. In order to do so, we propose that a 0.5 g sample should be incubated in 40 mL of a 0.5 M KH