In the process of rehabilitation, the objectivity and the accuracy of rehabilitation assessment have an obvious impact on the follow-up training. To improve this problem, using a multi-sensor source, this paper attempts to establish a comprehensive assessment method of the finger rehabilitation effect, including three indicators of finger muscle strength, muscle fatigue degree, and range of motion. Firstly, on the basis of the fingertip pressure sensor of the End-Effector Finger Rehabilitation Robot, a mathematical model of finger muscle strength estimation was established, and the estimated muscle strength was scored using the entropy weight method. Secondly, using an sEMG signal sensor, a fatigue monitoring system was designed in the training process, and the fatigue degree was determined on the basis of the change trend of the eigenvalues of MAV and RMS. Lastly, a human–machine motion coupling model was established, and the joint range of motion acquisition and scoring model were obtained on the basis of the motor encoder. According to the above three indicators, using the AHP assessment method to establish a comprehensive rehabilitation assessment method, the effectiveness of the method was verified by experiments. This paper provides a potential new idea and method for objective, accurate, and convenient assessment of finger function rehabilitation, which is of positive significance for alleviating the burden on rehabilitation doctors and improving rehabilitation efficiency. Rehabilitation assessment is conducted to determine the nature, location, severity, development trend, scope, and prognosis of dysfunction in patients with disabilities ,2. It caIn the field of rehabilitation medicine, the focus of rehabilitation assessment is the assessment of limb motion function ,6. At prRobot-derived measurement technology adds a new dimension to the assessment of motion function . ThroughIn recent years, it has become an active topic to seek more excellent rehabilitation assessment methods based on rehabilitation robots ,15. SomeGenerally speaking, there are no perfect and standardized assessment methods, and this also applies to the rehabilitation assessment of finger function . Using tTo meet the rehabilitation needs of patients with finger dysfunction, a finger rehabilitation robot was designed on the basis of the physiological structure and movement characteristics of fingers. The rehabilitation robot mainly includes four parts: four-finger flexion/extension assembly, four-finger adduction/abduction assembly, thumb movement assembly, and frame. It can realize the flexion/extension and adduction/abduction training of left or right fingers ; the actAs shown in According to the function of EFRR, the electrical control system of the robot mainly includes the central control unit, human–machine interaction unit, patient and doctor operation terminal, and data acquisition unit, as shown in During the rehabilitation training of the human–machine interaction unit, the data acquisition units collect the information from the sEMG, force sensors, and motor encoders, and the central control unit processes the information. The display interface reflects the rehabilitation evaluation on the touch screen. Patients and rehabilitation doctors can adjust the parameters to set the corresponding training strategy so as to realize the closed-loop rehabilitation training of EFRR.The rehabilitation effect of patients is an important index to evaluate the treatment plan . TherefoAfter rehabilitation treatment, the rehabilitation effect of patients is significant for the formulation and adjustment of the follow-up rehabilitation treatment plan . Using tDuring the experiment, the acquisition equipment needs to first be calibrated. When the finger is in a natural state in the finger cot, the zero coordinates of the sensors on the upper and lower sides will be inconsistent due to the influence of gravity. The pressure sensor on the lower side will have a smaller force signal; hence, it needs to first be compensated for in a positive direction. At the same time, since the output of the piezoelectric signal is a voltage signal, it also needs to be converted into a force signal. Therefore, calibration is required before collecting signals. When a single finger is at rest and there is an extension movement, the pressure information on the upper side of the finger-cot is as shown in As can be seen from The anatomical structure of the finger is shown in In this paper, a mathematical model of finger muscle strength was established by measuring the contact force of the fingertip. When the fingers are conducting flexion/extension exercises, they can be set as a plane motion . The joiTo estimate muscle strength, the force arm needs to be solved. The force arm of The force arm of The force arm of The force arm of There are 16 unknowns in the finger balance equation, but only nine sets of equations cannot be solved directly. The problem needs to be transformed into a constraint-based optimal solution. The constraint equation can be constructed according to the biomechanical relationship of fingers , as showPCSA is the physiological cross-sectional area of muscle, as shown in The optimized objective function is based on the principle of the minimum sum of squares of muscle stress, which is expressed as follows:The Lagrange multiplier was constructed, and then the constraint optimization was carried out. Finally, the estimated relationship of fingertip pressure for each muscle group could be obtained, as shown in It can be seen from the table that different muscle groups have muscle strength several times the pressure of the fingertip. According to the constructed corresponding relationship between fingertip pressure and muscle group strength, the rehabilitation assessment can be carried out through the fingertip pressure during training.In this paper, the muscle strength was estimated from the collected fingertip pressure. After that, the estimated muscle strength was scored using the entropy weight method. The rehabilitation fingers were rated according to the score value . The entThe general steps of the entropy method are given below.Firstly, the data need to be standardized. For data Then, the proportion of each item can be determined as follows:Next, the entropy values of each are calculated as follows:After that, the coefficient of difference is expressed as follows:Then, its weights are taken as follows:Finally, it can be scored as follows:According to the above, flexion rehabilitation exercises were performed on the four fingers, and the fingertip pressure of the four fingers were collected. Then, the muscle strength was estimated on the basis of the four-finger pressure; the results are shown in The estimated muscle strength of each finger was scored using the entropy method, and the results are shown in In finger rehabilitation training, muscle fatigue increases with training time, which not only does not guarantee the rehabilitation effect, but also affects the accuracy of rehabilitation assessment. This paper collected the sEMG signals of limb muscles to evaluate the fatigue degree of people during training to adjust the assessment process as a compensation factor. In this paper, the superficial flexor muscles of the forearm were selected , the sEMIn this paper, the electrode used for sEMG signal acquisition was an electrocardiogram(ECG) patch. During the first flexion of the four fingers, the sEMG signal was collected once . The sEMThe collected sEMG signal needed to be filtered first to improve the overall signal-to-noise ratio of sEMG. The filtering could be processed using second-order differential filtering, expressed as follows:i-th sEMG signal. Here, The filtered sEMG signal is shown in This paper selected 20 healthy volunteers  of 19–23) to conduct an experiment to analyze the changes in eigenvalues. All volunteers gave their informed consent for inclusion before starting the experiment. First, the four-finger pressure and the sEMG signal data of the volunteers before training were collected, and then the volunteers carried out continuous active rehabilitation training for 20 min. After training, the finger pressure and sEMG data were collected again. Then, filtering processing and eigenvalue extraction were applied to the two sEMG signals.The changes between the eigenvalues before and after training were analyzed. The extracted eigenvalues of three volunteers are shown in It can be seen that, during training, with the increase in fatigue degree, the eigenvalues of MAV and RMS of the three volunteers showed a certain degree of decline, which indicates that a certain relationship between fatigue degree and MAV and RMS. Therefore, we can judge the state of muscle fatigue evaluated on a four-point scale by analyzing their physiological signal data, corresponding to no fatigue, mild fatigue, moderate fatigue, and heavy fatigue.The simplified model of the motion mechanism of the four-finger flexion/extension motion component is shown in It is stipulated that the joints of DIP, PIP, and MCP reach the maximum angle evenly and synchronously, i.e., the motion angles of the three joints have the following angle relationship :(19)θPIPIn The trajectory parameter equation of point C at the end of the finger could be expressed as follows:Furthermore, the trajectory parameter equation of point B on the finger trajectory constraint board could be expressed as follows:Range of motion (ROM) is the primary indicator for evaluating patients with muscle and nerve injury . The ROMThe angle change value was obtained through the motor encoder, and the moving distance of the rolling bearing B along the axis The comprehensive assessment model was based on the scores of ROM, muscle strength, and fatigue degree. After using the analytic hierarchy process (AHP) assessment method to get the weight comparison value, the maximum eigenvalue was then calculated using column method to determine the weight of the ROM and the three indicators. The normalized ROM weight judgement matrix and the comprehensive assessment weight judgement matrix are shown in According to According to Equation (23), a comprehensive assessment index that can reflect the rehabilitation level of people can be obtained from the score. The relationship between the comprehensive assessment index and the degree at which it is located is shown in The fatigue test data of 20 volunteers were introduced into the comprehensive assessment Equation (23) for correlation analysis, and the results are shown in As shown in This paper designed a finger muscle strength estimation model based on fingertip pressure, a fatigue monitoring system based on sEMG signal, and a joint ROM estimation model based on a motor encoder, which provides a novel assessment method based on multi-sensor data. Compared with the existing common assessment methods, the comprehensive rehabilitation assessment method proposed in this paper can be completed automatically through multi-source data collection to help patients accurately locate their own rehabilitation situations, which has lower requirements for experienced rehabilitation doctors, and the collection method is simple and efficient. This has positive significance for realizing home treatment, thereby alleviating the shortage of rehabilitation doctors, reducing costs, and improving the efficiency of rehabilitation assessment.In order to realize the objective, accurate, and convenient assessment of finger rehabilitation effect, a new finger rehabilitation assessment method was designed using the developed End-Effector Finger Rehabilitation Robot, which integrates muscle strength, fatigue degree, and joint ROM. Firstly, a finger muscle strength estimation model based on fingertip pressure was established, and the estimated muscle strength was scored and graded using the entropy weight method. Then, a fatigue monitoring system based on sEMG signal was designed to determine the fatigue degree of people in the training process by collecting the sEMG signals of muscles. Lastly, combined with the finger-joint ROM indicator, a comprehensive rehabilitation assessment model of finger function was established by using the AHP assessment method, which can achieve real-time assessment using multi-sensor signals in the process of rehabilitation training. The effectiveness of the rehabilitation assessment method was verified by experiment, providing the possibility of helping patients automatically, accurately locating the rehabilitation situations, and realizing convenient and objective finger rehabilitation assessment.In the future, after optimizing the mechanical system and control system, the EFRR will be applied to real patient samples instead of healthy volunteers to further verify the feasibility of the comprehensive assessment method of finger function. Using the results of this comprehensive rehabilitation assessment method, an online system will be designed to realize home-based independent rehabilitation training and real-time rehabilitation assessment of patients.


Background: With the increasing use of mycophenolic acid (MPA) formulations in organ transplantation, the need for personalized immunosuppressive therapy has become well recognized based on therapeutic drug monitoring (TDM) for avoidance of drug-related toxicity while maintaining efficacy. Few studies have assessed area under the 12 h concentration-time curve of MPA (MPA-AUC0–12h) in heart transplant recipients who received mycophenolate mofetil (MMF) dispersible tablets (MMFdt). The aim of the study was to investigate the pharmacokinetics (PK) of MMFdt combined with tacrolimus and further to develop a practical method for estimation of MPA-AUC0–12h using a limited sampling strategy (LSS).Methods: A prospective study in a single center was performed in patients who continuously administrated with MMFdt or MMF capsule (MMFc) for at least 7 days after cardiac transplantation from 2018 to 2020. A total of 48 Chinese adult heart transplant recipients were enrolled. Blood samples were collected before and 0.5, 1, 1.5, 2, 4, 6, 8, 10 and 12 h after MMF administration. The validated high-performance liquid chromatography combined with tandem mass spectrometry method was used to measure MPA concentrations. Non-compartmental pharmacokinetic (PK) analysis was applied to calculate the data obtained from individual recipients by WinNonlin. LSS models were developed for MPA-AUC0–12h prediction with multivariate stepwise regression analysis.Results: A large inter-individual variability was observed in AUC0–12h, Tmax, Cmax, MRT0–12h, t1/2 and CL/F after multiple dosing of MMFdt. However, no significant differences were observed between main PK parameters of MMFdt and MMFc. The best estimation of MPA-AUC0–12h was achieved with four points: MPA-AUC0–12h = 8.424 + 0.781 × C0.5 + 1.263 × C2 + 1.660 × C4 + 3.022 × C6 (R2 = 0.844). The mean prediction error (MPE) and mean absolute prediction error (MAPE) of MPA-AUC0–12h were 2.09 ± 14.05% and 11.17 ± 8.52%, respectively. Both internal and external validations showed good applicability for four-point LSS equation.Conclusion: The results provide strong evidence for the use of LSS model other than a single time-point concentration of MPA when performing TDM. A four-point LSS equation using the concentrations at 0.5, 2, 4, 6 h is recommended to estimate MPA-AUC0–12h during early period after transplantation in Chinese adult heart transplant recipients receiving MMFdt or MMFc. However, proper internal and external validations with more patients should be conducted in the future. Mycophenolic acid (MPA) is commonly used in combination with calcineurin inhibitors (CNIs), including tacrolimus (TAC) or cyclosporin A (CsA), and glucocorticoids to form a triple immunosuppressive treatment regimen for the prophylaxis of organ rejection. MPA exerts the pharmacological effects by selectively and reversibly inhibiting inosine monophosphate dehydrogenase (IMPDH), thereby preventing denovo synthesis of purine and finally the proliferation of both T and B lymphocytes . Current0–12h]) (MPA-AUC0–12h)  was commonly used for kidney transplantation recipients   or the maximum a posteriori Bayesian method for model development , resulting in an over 10-fold range in MPA exposure  . MPA hasUC0–12h) . AdditioUC0–12h) . In termUC0–12h) . The MPAn of MPA . A defincipients . Measurecipients . An expocipients . Routinegy (LSS) . The LSSelopment .0–12h in heart transplant recipients with MMFc and TAC therapy were reported with relatively small populations  and capsules (MMFc) had no hugely differences in healthy Chinese male volunteers . Little Adult heart transplant patients (aged 18–70 years) from the Department of Cardiovascular Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, who met the following inclusion criteria, were enrolled in the present study. The inclusion criteria were as follows: heart transplantation for the first time, triple immunosuppressive treatment consisting of MMFdt  or MMFc , TAC  and prednisone , treatment with 750 mg MMFdt or MMFc every twelve hours for more than 7 days. Exclusion criteria were: second heart transplantation, co-medication with an immunosuppressive agent other than TAC, MMFdt or MMFc and prednisone, suspected noncompliance, severe adverse drug reactions related to immunosuppressive drugs, especially gastrointestinal reactions, confirmed acute rejection or infection. The study was approved by the Ethics Committee of the Union Hospital of Tongji Medical College, Huazhong University of Science and Technology and all patients signed their written, informed consents.The patients were continuously administrated with MMFdt or MMFc for at least 7 days after cardiac transplantation. Each patient was given MMFdt or MMFc at the dose of 750 mg every 12 h. During the PK study, all patients received liquid soft food at the prescribed time. Blood samples were taken before (0 h) and 0.5, 1, 1.5, 2, 4, 6, 8, 10 and 12 h after administration. The blood samples were collected in ethylenediaminetetraacetic acid tubes and immediately separated the plasma after centrifuging at 2,333 g for 8 min. All the samples were stored at −80°C for MPA determination by a high-performance liquid chromatography combined with tandem mass spectrometry (LC-MS/MS) method, which was validated according to the verification guidelines for quantitative analysis methods of biological samples in Chinese Pharmacopoeia (version 2015).3 was used as the internal standard. The mobile phase was 0.005 mol/L ammonium acetate (0.25% formic acid) aqueous solution and acetonitrile, working in a gradient manner with a flow rate of 0.2 ml/min. Multiple reactions monitoring (MRM) mode was adopted and electrospray ionization was a negative-ion. The precursor ion → product ion transitions m/z was 319.1→191.0 for MPA and m/z 322.1→191.1 for MPA-d3, respectively. The standard curve range for MPA determination is 0.1–40.0 μg/mL. The lower limit of quantitation was 0.1 μg/mL. The intra- and inter-day imprecision was less than 10%; with the intra-day precision d from 4.0 to 7.3% and the inter-day precision from 2.5 to 6.2%.MPA concentrations were measured using the validated LC-MS/MS method which was established previously . In brie0–12h were calculated by the linear-trapezoidal rule. Cmax was defined as the maximum daytime MPA concentration after dosing with MPA within the dosing interval. Tmax was defined as the time to reach the maximum daytime MPA concentration. MRT was defined as mean residence time. t1/2 was defined as the time required for the highest concentration of the drug in plasma to decrease by half. CL/F was defined as the plasma volume of the drug removed per hour.Non-compartmental PK parameters were derived from each individual plasma MPA concentration–time profile using WinNonlin Professional (v.5.2) software . The corresponding AUC0–12h LSS models were established using MRA by the following procedure. Step 1: Random number table was used to divide patients received MMFdt into model building and validation groups. Step 2: The value of measured MPA-AUC0–12h (MPA-AUC0-12h-observed) was regarded as a dependent variable and the concentration of MPA at each time point was used as independent variable. MPA concentration at each sampling time was correlated by linear regression analysis with the MPA-AUC0–12h in model building group. Step 3: Multiple stepwise linear regression analysis was performed to give improved correlations with total MPA-AUC0–12h-observed. These models can be expressed as: MPA-AUC0–12h = X  + b1 × c1 + ⋯ + bn × cn, where b1… , bn are regression coefficients, n is the nominal sample collection time, and c1 … , cn are concentration values measured at times 1 through n. The correlation coefficient (R2) was used to evaluate the regression level of the equation. The prediction bias of these LSS-derived equations was quantified as the percentage of mean prediction error (MPE) and mean absolute prediction error (MAPE). MPA-AUC0–12h-predicted was defined as the value of predicted MPA-AUC0–12h. The two error parameters were calculated by the following equations:MPA-AUC0–12h-predicted and MPA-AUC0–12h-observed. The Bland–Altman difference plots were adequate for estimating bias between MPA-AUC0-12h-predicted and MPA-AUC0-12h-observed. The best model was selected based on account the values of R2, predictive bias, and the Bland-Altman analysis.Step 4: The nonparametric regression proposed by Passing-Bablok regression was used to estimate the relationship between MPA-AUCModel estimation was conducted by both internal and external validation after obtaining the candidate equations. Bootstrap method was used for internal validation. Another set of data is used for external validation.p < 0.05 was considered statistically significant. The Passing-Bablok regression and Bland-Altman analysis were used to evaluate the consistency between MPA-AUC0–12h-predicted and MPA-AUC0–12h-observed.All data were statistically analyzed using IBM SPSS Statistics Version 22.0  and GraphPad Prism software v8.0.2 . Results are expressed as the mean ± standard deviation, or median . Kruskal Wallis test was used for nonparametric test of three or four independent samples. A total of 48 Chinese adult heart transplant recipients  were enrolled between January 1, 2018 and January 1, 2020, among them, 42 patients received MMFdt and the rest population received MMFc. The main characteristics of the study population based on model development and model validation, patients receiving MMFc for model validation (MMFc group) were listed in max in model building group (10.09 ± 6.44 μg/mL) and model validation group (8.49 ± 3.47 μg/mL) of MMFdt were slightly higher than that of MMFc group (7.48 ± 3.22 μg/mL). Additionally, second peaks were observed in some patients between 5 ∼ 12 h after taking MMFdt  had an MPA-AUC0–12h value lower than 30 μg·h/mL, and other patients were within 30 ∼ 60 μg·h/mL. In MMFc group, most of the recipients  had an MPA-AUC0–12h below 30 μg·h/mL and only one recipient achieved the targeted range (30 ∼ 60 μg·h/mL). No patient had an MPA-AUC0–12h value >60 μg·h/mL both in MMFdt and MMFc groups.An overview of the PK parameters of model building group, model validation group, all MMFdt patients and MMFc group were shown in 0–12h were shown in 6 was in a week correlation (R2 = 0.428) with MPA-AUC0–12h.The results of regression equations obtained by sampling time points and MPA-AUC0–12h. The model formula, R2, prediction error of the above models and difference between LSS and full AUC values were shown in 0–12h were depicted in 0.5, C2, C4 and C6) was the best LSS model: MPA-AUC0–12h = 8.424 + 0.781 × C0.5 + 1.263 × C2 + 1.660 × C4 + 3.022 × C6 (R2 = 0.844).Four models with 1-point (model 1), 2-point (model 2), 3-point (model 3) and 4-point (model 4) LSS equations were later developed to estimate MPA-AUCInternal validation was estimated with bootstrapping, where 1,000 sets of data were generated from the original data to evaluate the accuracy of each parameter of the best LSS model. The parameters of model 4 were all within the parameter estimates by repeated sampling, indicating that the accuracy and robustness were acceptable.R2 (Passing-Bablok regression) and prediction error were shown in 0–12h-predicted and MPA-AUC0–12h-observed  and a 2-(C0.5 and C2) time-point model were more applicable to clinical practice  in model 1, 33.33% (10/30) in model 2, 30.00% (9/30) in model 3, 16.67% (5/30) in model 4, 3.33% (1/30) in model 5, respectively. This finding indicated that the more point enrolled, the better predictive ability of the models was. AUC estimation using a 4-point LSS model is likely to lead to inaccurate estimation and outliers. However, such outliers really exist in clinic. Therefore, clinicians should first consider whether the patients belong to the high-risk group and the LSS model is suitable. If a 4-point LSS model is not applicable, increased sample points is recommended, such as using a 5-point LSS prediction model or adopting full-point sampling for estimation.Although the results of the model validation in our research were acceptable, the metrics used for evaluation of the LSS should be extended to more clinically relevant metrics. If a 20% difference is identified as the clinical acceptance of between full curve and LSS MPA-AUCpatients . In the 0–12h is feasible for our population. Further studies should be conducted to investigate the relationship between the MPA-AUC0–12h and the risk of rejection and adverse reactions in Chinese heart transplant recipients.The present study had some limitations. Firstly, MPA samples were collected from a single center and a relatively small number of heart transplant patients after a short-term administration of MMFdt or MMFc. Multi-center studies with large scales should be warranted in the future. Secondly, blood samples were restricted to the first two post-transplant weeks and the MPA concentration may be influence by pathological characteristics of the patient in early post-transplant period. The LSS equation may not extrapolate in long-term follow-up after heart transplantation. Thirdly, no clinical outcomes were reported in the study. It is unknown whether the target range of 30–60 μg·h/mL for the MPA-AUC0–12h in the Chinese heart transplant recipients receiving MMFdt and TAC and validated the model in MMFdt and MMFc patients. 4-point LSS equation was chosen as the best predictive equation for estimation, and MPA-AUC0–12h = 8.424 + 0.781 × C0.5 + 1.263 × C2 + 1.660 × C4 + 3.022 × C6 (R2 = 0.844). The newly established LSS equation with a good consistency is able to be applied in Chinese adult heart transplant recipients receiving MMFdt or MMFc and TAC. Attentions should be paid when using the equation due to the limitation of lacking proper validation in both internal and external cohorts.In conclusion, a large inter-individual variability was observed in PK characteristics of MPA after multiple doses of MMFdt in Chinese adult heart transplant recipients. No significant difference was observed in the PK profiles of MMFdt and MMFc in our population. We developed a predictive equation for the estimation of full MPA-AUC


This work is a continuation and extension of an earlier publication. The method rests on the complete breakdown of the molecules into their constituting atoms, these being further characterized by their immediate neighbor atoms. The group contributions are calculated by means of a fast Gauss–Seidel fitting calculus using the experimental data of 5030 molecules from literature. The applicability of this method has been tested by a subsequent ten-fold cross-validation procedure, which confirmed the extraordinary accuracy of the prediction of ΔH°c with a correlation coefficient R2 and a cross-validated correlation coefficient Q2 of 1, a standard deviation σ of 18.12 kJ/mol, a cross-validated standard deviation S of 19.16 kJ/mol, and a mean absolute deviation of 0.4%. The heat of formation ΔH°f has been calculated from ΔH°c using the standard enthalpies of combustion for the elements, yielding a correlation coefficient R2 for ΔH°f of 0.9979 and a corresponding standard deviation σ of 18.14 kJ/mol.The calculation of the heats of combustion ΔH° The present compilation of data on the heat of combustion and formation of more than 5000 organic molecules and their comparison with theoretical calculations based on a generally applicable atom-groups additivity method is a continuation of theoretical studies on the prediction of various molecular descriptors published in an earlier paper . While tThe calculations rest upon a database of at present 34,380 molecules, recorded in their geometry-optimized 3D conformation, encompassing pharmaceuticals, plant protectors, dyes, ionic liquids, liquid crystals, metal-organics, intermediates, and many more, wherein—among many further experimentally determined and calculated molecular descriptors—for 5560 of them, the published experimental combustion and/or formation enthalpies have been stored. In order to avoid structural ambiguity, all six-membered aromatic rings have been defined by six aromatic bonds, in contrast to the more commonly used single-double-bond alternating style. Furthermore, for the same reason, the positive charge in amidinium, pyrazolium, and guanidinium fragments is positioned on the carbon atom between the nitrogen atoms, incidentally in better conformance with the true situation, as shown in, e.g., Figure 1 in [The principle of the breakdown of a molecule into its atom groups in a computer-readable form has been outlined in detail in . ConsequThe atom groups do not take into account the characteristics of the molecules’ three-dimensional structures, such as intramolecular hydrogen-bridge bonds, intramolecular H-H interactions, or ring-strain forces. These effects have summarily been considered by means of the special groups listed and explained in The parameter values of the atom and special groups are calculated in four steps, outlined in detail in : the firia and jb are the contribution values, iA is the number of occurrences of the ith atom group and jB is the number of occurrences of the special groups.The subsequent calculation of the heat of combustion ΔH°(c) is a simple summing up of the contributions of the atom groups in a molecule using the values shown in Table 4, applying Equation (1), wherein It is immediately evident that these calculations are limited to compounds for which each atom group contained in it  has its corresponding one shown in Table 4. Beyond this, in order to receive reliable results, only “valid” group contributions are to be used, i.e., contributions that have been supported in the group-parameters calculation by at least three independent molecules, i.e., by the number in the rightmost column of Table 4 exceeding 2. As a consequence, the statistics data at the bottom of Table 4 show that the number of compounds for which finally the heat of combustion is calculated  is smaller than that on which the computation of the complete set of group contributions is based (line A).The heat of formation of the molecules is immediately calculated from their heat of combustion by the subtraction of the standard enthalpies of combustion of the elements as given in ,21.In The results of the heat-of-combustion data are immediately tested for plausibility using a 10-fold cross-validation algorithm, requiring 10 recalculations that guarantee that each of the complete set of compounds has been used once as a test sample. The corresponding training and test data are added to each of the molecule files, and the respective statistics data are collected at the bottom of The present list of references encompasses the sources for the experimental standard heats of combustion as well as those of formation, because the input of the heat of combustion into a molecule’s database immediately also triggers the calculation and addition of its heat of formation and vice versa. Experimental data given in kcal/mol are translated into kJ/mol by multiplication with 4.1858.Handbook of Chemistry and Physics [N-oxides [x-heterocycles (where x is 1 to 4) [x-heterocycles [x-heterocycles [A large number of experimental data have been provided by several comprehensive papers; in particular, Domalski’s collection  publishe Physics  included Physics  of this  Physics ,58,59,60 Physics ,72,73,74 Physics ,82,83,84 Physics ,92,93,94 Physics ,111,112, Physics ,134,135, Physics ,153,154, Physics , peroxid Physics ,160,161, Physics ,168,169, Physics ,185,186, Physics ,188, ure Physics ,195,196, Physics , carbama Physics , azides  Physics ,200, nit Physics ,207,208, Physics , oximes  Physics , nitrami Physics , azo- an Physics ,213,214,N-oxides ,229,230,N-oxides  and nitrN-oxides ,262,263,N-oxides , amino aN-oxides ,276,277,N-oxides ,288,289,N-oxides , siliconN-oxides ,293,294,N-oxides . Beyond N-oxides ,356,357. 1 to 4) ,422,423, 1 to 4) ,432,433, 1 to 4) ,437,438,rocycles ,451,452,rocycles ,460,461.rocycles ,470,471.rocycles ,497,498.rocycles ,525,526.2 is even better than the previously published value of 0.9999 and is now indistinguishable from 1  shows the lowest difference between the two forms, which is due to the fact that it carries a less basic dialkylamino group. Similarly, N-phenylglycine differs from the remaining amino acids by an amino group that is conjugated to the phenyl ring, again lowering its basicity. Except for these special cases, the experimental values are in better compliance with the calculated values of the zwitter forms.The average ΔH°(c) difference was calculated as ca. 61.5 kJ/mol, with the non-ionic form exhibiting the more negative value. Cystine is an outlier in that it contains two amino-acid functions. Interestingly, sarcosine .The mentioned software project is called ChemBrain IXL, available from Neuronix Software (


Children with disabilities have most potential for salvage rehabilitation, and their rehabilitation results are concerned with their entire life process. Although, the Chinese state has established a targeted Rehabilitation Assistance System for Disabled Children and has expanded the provision of rehabilitation services, a severe deviation between supply and demand remains. Existing studies have focused relatively more on policy content and less on the policy context, at the macro-structural level. However, using the case of the ZW Rehabilitation Center in City J, this study divided the deviation into exclusion errors and inclusion errors, and used the policy context approach to explore the reasons for the deviation. We found that the behaviors of the participants in rehabilitation services exist in a dynamic interaction between the regulatory context, the normative context, and the cognitive context. The joint forces of the three contexts produce both exclusion errors and inclusion errors, which are the underlying reasons for the inaccurate execution of the targeted policy. The results of this research can provide enlightenment for improving rehabilitation policy. Currently, there are 85.02 million persons with disabilities in Mainland China – the maximum number per nation in the world. Rehabilitation has become one of the most important ways to restore or compensate for disabled people's body functions and improve their quality of life, and China is paying increased attention to such rehabilitation efforts. Since 1988, the state has integrated its rehabilitation program for persons with disabilities into national economic and social development plans to protect those individuals .the CPC Central Committee and the State Council on Promoting the Development of the Cause of Disabled People (2008) stated the opinion that salvage treatment and rehabilitation for children with disabilities should be given priority and that salvage rehabilitation projects for poor disabled children by the China Disabled Persons' Federation (CDPF) were to be carried out. Beginning in 2018, guided by the concept of targeted rehabilitation and overseen by the State Council on the Establishment of a Rehabilitation Assistance System for Disabled Children, rehabilitation services have been provided for children aged 0–6In the full plan for rehabilitation of persons with disabilities, rehabilitation for children is the starting point, and is concerned with the children's entire life process. Studies have shown that the most successful time for the rehabilitation is between 0 and 6 years of age, because during that period the brain has the best flexibility, with the best compensatory effects, for restoring an injured brain's structure and function . For chiThe interactions between service providers and service users, reported from their experiences of providing and obtaining welfare, can establish a relational understanding of policy . From thTo answer that question, this study distinguished between two kinds of deviations and investigated them using the perspective of the policy context. Specifically, studies evaluating the effectiveness of social welfare programs have found that two deviations commonly occur in attempts to “target” public expenditures for poor people in poverty reduction policies. One is an “exclusion error” , in which some subjects are eligible to receive benefits but do not receive them, and the other is an “inclusion error” , in which those who receive benefits are not eligible to receive them , 11. In In China, the research on rehabilitation has been conducted mainly in the field of medicine, and studies on the rehabilitation policies for disabled children have been carried out only recently. The proposal in China of the RASDC in 2018 was an important watershed event, and the topic gradually became a hot button in academic circles. Although, some scholars have conducted ongoing research on the issues of rehabilitation services for disabled children, most of them have focused on only the service content. From that approach, the findings have shown that the inaccurate implementation of the RASDC has been caused by ideas, methods, and specific contents of provision.The first aspect of implementation is in regard to the idea of provision, of putting the child first, and maximizing the benefits for the child, but at present in China that idea is not met with consensus among all, and the principle that the state is the supreme guardian and protector of the child is not established. As a result, the RASDC efforts have mainly been survivor-oriented, and have been lacking in inclusive and development-oriented policies . StudiesSecond, regarding the methods for provision, medical rehabilitation services for children with disabilities are currently provided by designated agencies, mainly in the form of “government procurement services.” Among those services, imperfect service skills in agencies are the most important factor, and that problem produces an exclusion error. Poor rehabilitation service networks, lack of professional staff, low professional levels, and slow updating of rehabilitation technologies have all affected the effectiveness of provision of rehabilitation services –18.Finally, some research has suggested that the RASDC policy lacks supporting policies . The RASThose reviews have demonstrated that many exclusion errors occur from the ideas, methods, and specific contents of rehabilitation provision. As a result, a large number of rehabilitation demands of children with disabilities are not satisfied effectively, and that outcome is far from the goal of targeted rehabilitation. The causes of exclusion errors include such main characteristics as insufficient government financial support, a low supply of rehabilitation services, poor quality of rehabilitation services, uneven distribution of services, lack of equipment, large gaps in rehabilitation professionals, inadequate support systems, and so on , 25–27. The discoveries made through the service content approach have attracted widespread attention from scholars, but that is a small portion of the policy context, and it can only find exclusion errors. In addition, the existing literature overemphasizes exclusion errors caused by the policy makers and direct providers. In reality, however, policy implementation is always the interaction between individual factors and environmental factors, and that interaction is exactly what the policy context approach emphasizes. From the policy context approach, we found two types of errors – exclusion errors  and inclusion errors – both of which have led to inaccurate results from the RASDC.Furthermore, the two universally adopted research methods are limited. Existing studies have mainly applied quantitative methods to measure rehabilitation needs , 26, 34,Social policy's “goal-result” is not a simple linear relationship, and complex mechanisms of intermediate phases – policy implementation systems – cannot be ignored. Some seemingly unrelated events in implementation can interfere with the expression of policy objectives, resulting in an imperfect correspondence between the policies and the services actually provided. What factors can affect policy implementation? From Pressman and Wildavsky's research in 1973 , variousResearchers have employed different ways to conceptualize and operationalize the context in which individuals and organizations exist. Parsons was concerned with social norms , whereasvia the process of the state distributing tasks through top-down orders and the rehabilitation agencies providing the services. In that light, we define the regulatory context as mainly the laws and regulations of organization, distribution, constraints, and incentives by the local governments that are responsible for implementing the RASDC. The normative context is embodied in the values of social norms and social responsibility that rehabilitation agencies follow when allocating and delivering specific resources. The cognitive context refers to the long-term-disabled culture in China, and the fact that individual cognition and social cognition of the RASDC by families with disabilities and the public have a vital impact on behavioral choices.Well-targeted rehabilitation programs for disabled children will not achieve their goals because of a specific policy context. This study, drawing on the theoretical framework of policy context and taking Chinese local knowledge into full account, anchors these three factors – the regulatory component, the normative component, and the cognitive component – into an investigation of the provision issues of the RASDC. We focused on the complex interactions of local governments, service agencies, and children with disabilities, through their maintenance of the political power, emphasis on self-interest, and reinforcement of the negative role of the disabled, and we constructed a supplementary and comprehensive perspective for understanding policy implementation. We argue that the policy context approach extends beyond the dualism of the supply-oriented model and the demand-oriented model, and we seek to provide adequate evidence regarding how these interactions produce both an exclusion error and an inclusion error in connection with the targeted RASDC. Although, each subcontext involves the participation of multiple subjects, in China's political-social context, the RASDC has been implemented The research concept for this study is shown in We used a qualitative study method and selected ZW in City J as the main research site. We collected ethnographic data by participatory observation, in-depth interviews, and a review of government documents, statistical yearbooks, and other files.City J, the provincial capital of Province J, is situated in a rich coastal area of eastern Mainland China. Due to political factors, City J is often the first pilot area for the policy practice by the CDPF. In 2013, the city launched a salvage rehabilitation program for children with disabilities. This city, over time, has moved into the fore front of all of China's cities, and it has rich practical experience.The field work portion of the study started in the summer of 2020. While visiting the rehabilitation agency, the authors gained access to a list of the names and basic information for 51 designated agencies in City J for the RASDC that had been newly established in 2018. Among the 51 agencies, 49 were private non-enterprise units (non-profit organizations). The ZW Child Rehabilitation Center and ZW Chinese Medicine Clinic  was the one with the largest number of disabled children in its services, the largest number of different kinds of disabled children , and the maximum age range of disabled children (aged 0–17 years). It was also the first designated rehabilitation assistance service agency, approved in 2013, and it has a rich level of experience. Therefore, we selected ZW as the primary research site.The founder of the ZW organization, after a business failure in 2003 and with no access to converting to Buddhism, decided to make use of his own traditional Chinese medicine skills to do something good for the country and the people, so he established ZW in 2006. The ZW organization developed rapidly by making full use of the characteristic elements of Chinese medicine: acupuncture, massage, medicinal diet, and other traditional Chinese medicine therapies. At present, ZW is a rehabilitation center for cerebral palsy, mental disability, autism, hyperactivity disorder, hemiplegia, and paraplegia, for which it integrates rehabilitation, education, and family-based rehabilitation guidance. It is now engaged primarily in exercise training, homework training, speech training, sensory training, physical therapy, music therapy, guided education, special education, social work, medicinal meals, medicine baths, a spa, massage, acupuncture, near-infrared brain function imaging technology, and other treatment items. The agency is situated in a relatively marginal area of an urban zone in District B, City J, with convenient traffic and low rent, and it covers an area of 2600 square meters. Currently, it has two Chinese medical rehabilitation specialists, 30 therapists, and 22 teachers for special education.At present, ZW can hold 180 children with disabilities. In July and August, 2020, when we did the research, there were only 139 children at ZW . The organization primarily receives children with disabilities who live in District B, but some children from other provinces, cities, and districts are also attracted by its reputation. The children range in age from 0 to 17 years, and they have different types and degrees of disability. Their family backgrounds also differ from each other, but they have one thing in common — all are children with disabilities.With the help of the head of ZW, we collected ethnographic data in July and August 2020. We used three different methods: participatory observation, in-depth interviews, and a review of government documents, statistical yearbooks, and other files.To begin, the first author had a nearly one-month-long intense participatory observation period within the ZW organization, closely observing each step, including project-setting, implementation, assessment and adjustment, and so on, in the RASDC. Participating as a university volunteer, the author was responsible for the entire work of the RASDC, chiefly handling the issues for parents of disabled children eligible for assistance and also getting an opportunity to dock with the local Disabled Persons' Federation. During that time, three staff members in the administrative office shared with the author their working experiences, feelings, and attitudes toward the implementation of the RASDC. Data from those interviews also were entered into field records of participatory observation, as an important way of data collection.Next, we conducted 15 in-depth interviews, each ranging from 30 min to an hour. Our interviewees were divided into two categories: three members in the management team, including the founder and head of ZW, one therapist and the director of the administrative office, and 12 primary caregivers of families with children with disabilities. The caregivers were selected after consideration of factors such as, gender, age, household registration (Hukou), children's age, children's disability type, and willingness to be interviewed. Owing to City J's extended age for rehabilitation services to 17 years, our research was not limited to children 0–6 years old but also included interviewees whose children with disabilities were aged 7–17. Before the interviews, we provided the interviewees with general information related to our research, including the purpose, subjects, process, duration of the study, and the research schedule. The entire research process followed the procedures of the institutional review committee and took into account serious requirements for confidentiality, non-harm, and informed consent of participants. More information about the interviewees can be found in Finally, we also studied government departments guidelines, statistical yearbooks, working documents, and other files related to the RASDC, to supplement our field data. In this investigation, we selected information from multiple sources to improve validity.We coded the respondents' narratives in two stages: one of open coding and one of theoretical coding. Guided by qualitative analysis techniques , we inteThe RASDC takes place in a specific field, embedded in local institutional situations and constrained by habitus. The results of our empirical survey indicate that in the process of delivering targeted services for children with disabilities, there is wide interaction among local governments, rehabilitation agencies, and families. That interaction exists in a perpetual, dynamic tension between the regulatory context, normative context, and cognitive context. In the following paragraphs, we will discuss (1) the constrained and incentive rules produced by Chinese local governments in the regulatory context, (2) the strong norms and weak social responsibility of rehabilitation agencies in the normative context, and (3) the identity culture of children with disabilities and their families in the cognitive context. Additionally, we will present our analysis of how the three contexts generated errors of exclusion and inclusion, which then led to an inability to execute the RASDC accurately.In the targeted RASDC system in present-day China, the local government plays a crucial role in providing services, supervising the operations of agencies, and guiding policy management with official discourses. The RASDC adopts many kinds of local executive rules, from which the target management responsibility system, the administrative subcontract system, and promotion tournaments are the keys to executing policy and are also the root cause of deviant behaviors in the regulatory context.China assigns and executes tasks through its target management responsibility system, which is a system form created in a highly centralized environment. Its concrete manifestation is to decompose and refine the general administrative goals step by step, forming a set of tasks systems as the basis for management, rewards, and punishments of organizations at all levels . Indeed,In addition, the capacity and preferences of the rehabilitation agencies produce a large number of exclusion errors. The tasks assigned by the target management responsibility system are based not on the number of children with disabilities from District A to L, but on the capacity of rehabilitation agencies to receive children. That is, the capacity is calculated by judging the gross building area, number of therapists, curriculum type, and other factors. The numbers for total tasks in Another important rule in China's regulatory context is that of the administrative subcontract system. It is a product of the soul of the “contract system” placed under the hierarchical shell, and in it, tasks assigned by the superiors are to be accomplished through administrative power distribution and economic incentives , 46. In Unfortunately, the boundaries of different services vary. Rehabilitation services for children with disabilities use the province as the boundary, whereas, education services use the city or even the district as the boundary. Children with disabilities who receive rehabilitation in ZW (District B) also face urgent educational needs, which require non-District B families to go back to their local special education school. As a result, some families must choose between education and rehabilitation. The latest rehabilitation method for the integration of rehabilitation and education excludes children whose place of residence is different from their location of hukou, thus, creating an exclusion error.He cannot do rehabilitation next year. He has to go to school. The special education school in our hometown had been calling us since last year. He will be old to go to school (case 10).People do not understand why rehabilitation services for disabled children aged 0–6 years differ among age groups in different provinces and cities. The available services are determined not only by the local economic development, but also are closely related to promotion tournaments, the third and distinctly informal rule in the regulatory context. In order to encourage each unit within the five management layers in China to work effectively, a competition mechanism has been formed in which the competition depends on a performance measurement. Distinguishing it from many Western countries, China's performance measurement of the unit is actually an evaluation of the principal person in charge of the unit , meaningThe Disabled People's Federation in City J has broadened the policy criteria for outstanding performance in the assessment process. First, the restrictions on the financial conditions of the applicant's family have been canceled, and full coverage is available for all children with disabilities. Second, the age for eligibility of 0–6 years has been broadened to 0–17 years. However, as the director of the administrative office in ZW has demonstrated, the best time to rehabilitate children with disabilities is during the age range of 0–6 years, with children above the age of 7 not experiencing as great an effect from rehabilitation training as children aged 6 years and under do. Therefore, extending the age for eligibility leads to an inclusion error, and to some extent results in a waste of resources. Nevertheless, this conclusion does not mean that rehabilitation services for disabled children aged 7–17 should be canceled. The authors' viewpoint favors providing the older children with services that are more responsive to their specific needs, and thus, realizing an optimal allocation of resources.For children with disabilities aged 10-17, to be honest, their recovery in rehabilitation will be much worse. Actually, many have given up the rehabilitation. But some parents think that since it is a free service, they should enjoy it, at least the children can have a place to play, with the teacher caring [for] them. But they're crowding out other younger children's resource (case 15).The normative dimension comprises the social norms and social responsibilities necessary for implementation of the RASDC. Social norms dictate how the policy implementation should be completed and determine the legal methods required to achieve the policy objectives, whereas, social responsibility refers to the preferred values in policy implementation and the attitude toward the obligations that are involved. The normative dimension illustrates the values of the rehabilitation agencies as the basic policy provider for children with disabilities.The Communist Party of China's Central Committee and the State Council pay great attention to the RASDC and provide a strong and widely shared norm for rehabilitation agencies, which are the firstline service providers. In present-day China, private non-enterprise units, or non-governmental organizations (NGOs), are often not spontaneous grassroots organizations but instead are heavily influenced by China's policy support and financial support, and therefore, tend to be bureaucratic. That system results in repeated, organized, and institutional norms that emphasize policy outcomes, and such an emphasis creates strong external pressure on the agencies – which are highly dependent on external resources and have the primary task of responding to the requirements of those external organizations. That systemic pressure is not always realistic or effective – on the contrary, in many cases, it only completes the purpose of “ritual” without really meeting the users' needs. In particular, different rehabilitation agencies face different pressures, and the types of deviations that result are also diverse. Our findings revealed that the children's hospital had the largest demands and could only complete its vested tasks through formal or informal methods, such as, modifying standards, screening classifications, and limiting queuing, thus, producing an exclusion error. However, the demands of backward areas or newly established rehabilitation agencies are often small, and they have to fulfill their official tasks by reducing the criteria for eligibility and attracting additional children, thus, generating an error of inclusion. One manager we interviewed described the phenomenon and her ideas about the RASDC.Free rehabilitation assistance in children's hospitals is limited on quotas. The quota is now 6 months away. The children will be given only charged items after they are diagnosed at the children's hospital. Some parents know that they can go to other agencies, but those who don't know have to go home (case 15).Although, rigid norms have been the guidelines for policy implementation, the criteria for comparing and evaluating the behavior of the RASDC's implementors have been insufficient, and that deficiency has caused rehabilitation agencies to lack social responsibility. Rehabilitation services for children with disabilities currently are provided by a form of “government procurement services.” The entities that undertake the government purchasing services are mostly NGOs, which by definition are social organizations organized by enterprises, social groups, and other social forces, as well as individual citizens, using non-state-owned assets to engage in non-profit social service activities. As NGOs, those non-profit organizations still have a “for-profit” need to maintain the operation of the organization. In ZW, “90% of the revenue comes from the support of the RASDC program.” Managers complained more than once in our interviews about funding challenges, such as, insufficient government money and unclear government requirements.One lesson from 2020 has made the head of ZW very cautious this year. That year, a new model, “institution + family + community” rehabilitation, was introduced for children who are more seriously disabled and unable to leave their home. In order to obtain additional public funds, ZW cooperated with a special education school to render rehabilitation services in children's homes. However, the money failed to be delivered at the end of the year, because 3-month centralized institution-based rehabilitation had been lacking (the criteria were emphasized at the time of the assessment). Now, ZW has given up that group of children reluctantly. Clearly, the economic demands of the agency far exceeded the level of social responsibility of the rehabilitation services. The primary aim of the agency was to obtain, as far as possible, children with disabilities who were easily rehabilitated and could acquire the funds from the RASDC. For other children with higher degrees of disability, and inability to provide them with institution-based rehabilitation, and an attitude of neglect, have been adopted toward them. In practice, this behavior that the agencies engaged in to further their own interests was obviously inconsistent with the original purpose of the well-targeted RASDC and has led to numerous cases of exclusion errors.In addition, no criteria have been developed for evaluating policy implementation from the perspective of the disabled children and their households. On the one hand, the local government's management strategies, from incentives to penalties, still seem focused on shaping the rehabilitation agencies into disciplined and efficient implementors of official discourse and have not offered much autonomy or flexibility for the families with disabled children. On the other hand, influenced by difficulties with social supervision, inadequate development of citizens' participation in politics, and a negative disability culture, few people have the opportunity and willingness to pay attention to the RASDC's implementation. The absence of supervision from service users and the public has further reduced the level of social responsibility in rehabilitation institutions, and that situation fosters an exclusion error. The direct evidence from the managers' narratives reveals that:Now it is mainly [up to] the Disabled Persons' Federation, or a third-party organization invited by the Disabled Persons' Federation, to supervise. They don't understand at all, fill out the form and they're done (case 14).In traditional Chinese society, referring to someone as “canji” or “canfei” means the person is disabled and cannot do anything. These words have obvious derogatory and discriminatory implications and do not place the disabled and the abled on equal footing . This noIn ancient China, persons with disabilities did not possess the qualifications to enjoy complete rights. For example, a person with a disability was not allowed to enter the ancestral hall and not allowed to be an official — rules that treated persons with disabilities differently from other people . FurtherIn [our] village, only my child receives rehabilitation service. Others do not and their parents reject rehabilitation, because they don't admit that their child is disabled. They take it to be natural when the child cannot speak at three (case 5).The child of my wife's classmate is also autis[tic]. My wife told her to take her child for rehabilitation in City J, saying that our child is getting better in the ZW. My wife told her once or twice, and later she [wa]s obviously out of touch with us, without coming to our home or talking to us on the way. She feels that we look down on her by always saying that her child is disabled (case 6).One condition by which children with disabilities can obtain free rehabilitation services is to have a disability license, which is an official document for people with disabilities composed of their ID number and two other numbers that refer to their grade of disability and their type of disability. In that negative environment, some parents reject the disability license, which is obtainable after a strict medical diagnosis. Even when they have the desire to get rehabilitation assistance for their children, they can be persuaded to quit because of this paper identification, thus, causing an exclusion error.His father is not willing to have the disability license, saying that the child will complain when he grows up. He feels that the disability card is a child's life shame (case 7).In other cases, family members accept the fact that their children are disabled, but correspondingly, that kind of disability culture fosters a sense of inferiority and shame in those families. A family's interactions with others without disabilities play a significant role in constructing the family members' disabled identities and facilitating their negative perspective toward their lives. Female parents, especially, express fear or anger at the eyes of strangers in their workplace. They always reject parties with friends or relatives, feeling that they are “inferior” and “worse than others.” Under this self-cognition, their goal of rehabilitation for their children is to have normal children or children who appear to be normal. If the family members see no hope of recovery for the disabled child, they will refuse to receive rehabilitation.There is no hope to recovery. It is too tir[ing]. We want to send her to a care center. Once she is there, we can leave it alone and just go to see her once a month (case 9).The concept of procreation, under the nation's family planning policy, is closely linked to the idea that persons with disabilities are incomplete and inferior. A family planning policy has been carried out in China from 1982 to the present. From 1982 to 2015, a one-couple-one-child policy, or one child in one couple, was strictly enforced. In some special cases, however, two children were allowed, and one such special case was when the first child of the couple was disabled. Since 2016, a one-couple-two-children policy has been adopted, and in some special cases three children are allowed, including the case in which “the couple gives birth to two children, with one of them identified as being handicapped who cannot grow into a normal labor force according to law” . With thIn Chinese society, the family plays the essential role in providing welfare for disabled children in their living situation and their spiritual life. Throughout the nation's long historical development, the Chinese family system has always preserved great internal stability and formed a solid family care model . ResearcThe first choice is to voluntarily abandon the disabled child and to give adequate care to the healthy one, thus, resulting in an exclusion error.The eldest brother is 23 now and is going to get married soon. I cannot stay here all the time. So next year, we plan to give up rehabilitation. We'll see whether we can send him to a special education school so that I'll have time to manage my family matters (case 11).The second option is to depend on the system of urgently needed care agencies to provide care for the child with a disability. When care agencies and professional care workers are scarce and expensive, such families are forced to transfer the care pressure to rehabilitation agencies, wherein children can have classes every day. In that way, the care burden of the family can be alleviated, thus, resulting in an inclusion error.This child is 15 now. To be honest, he cannot make any progress here. He comes just to play. His mother and father are both working without any time to take care of him. I send him here every day. There's a teacher in class, and we don't have to take care of him every minute (case 4).This research, based on a case study of ZW, in Mainland China, started with a three-dimensional theoretical framework for policy context and conducted a systematic analytic investigation into supply-demand deviations in the implementation of the RASDC, as well as the reasons behind those deviations. The study's major finding revealed that the failure of the rehabilitation policy was not due to just the policy content itself but was also due to the context of policy implementation, with special aspects of the Chinese environment affecting the final result of implementing the RASDC, which have a negative impact on their health. The empirical data we collected presented exclusion errors, in which those who should enjoy the services did not receive them, and also inclusion errors of wasted resources. To be concrete, in the regulatory context, the local government's implementation of the RASDC policy was affected by formal and informal rules, such as, the targeted management responsibility system, the administrative contracting system, and promotion tournaments, all of which caused barriers such as, the exclusion of disability types, exclusion due to inconsistent service availability in the region of the family's residence, and inclusion errors of extra services being given to those who did not need them. In the normative context, the behavior and activity of rehabilitation agencies were limited by strong norms and weak social responsibility. Priority was given to accomplishing the government's tasks formally, not virtually, by showing preference to those with mild disabilities and neglecting those with severe disabilities. Finally, in the cognitive context, children with disabilities were considered as a special group, and were conceived of as being different from healthy people. Households with disabled children felt ashamed and inferior. Those kinds of attitudes prevented the families from actively acquiring the services, or forced them to relinquish the services, or pressured them to transfer the disabled child's care in the dynamic of continuing to have other children. These findings are summarized in the WHO Global Disability Action Plan 2014-2021: better Health for All People with Disability. The action plan puts forward 7 actions to achieve the goal of “strengthen and extend rehabilitation, habilitation, assistive technology, assistance and support services, and community-based rehabilitation”: providing leadership and management, providing adequate financial resources, developing and maintaining a sustainable workforce, establishing a health care system mechanism for effective coordination, making available appropriate assistive technologies, promoting access to a range of assistance and support services, supporting and building the capacity of persons with disabilities, and their family members and/or informal caregivers  is trying to design international standards for rehabilitation services that can be used everywhere, one of which is regivers . AccordiProposed action 1: Revise policies, standards, and implementation managements. First, the government should strengthen policies, strategies and plans on habilitation, rehabilitation, assistive technology, support and assistance services, community-based rehabilitation, and related strategies based on the actual number and needs of disabled children. Secondly, the government should break geographical boundaries and provide adequate financial resources to increase coverage and access to rehabilitation services for non-local children with disabilities. Finally, the evaluation indicators of the Disabled Persons' Federations at all levels should be reformed by comprehensively evaluating the actual service demand and service quality, rather than the policy texts and supply quantity.Proposed action 2: Enhance the social responsibility of rehabilitation agencies. To begin with, a rehabilitation assistance network should be built to exchange information between different rehabilitation agencies and, when appropriate, to provide referral services in order to balance the different pressure of rehabilitation agencies. Moreover, third-party supervision and bottom-up public supervision should be strengthened to improve rehabilitation agencies' social responsibility and to achieve a rational allocation of rehabilitation resources. In addition, it is important to train health personnel for early identification, assessment, and referral of children with disabilities, especially in undeveloped areas.Proposed action 3: Foster an environment of equality, social acceptance, and integration for children with disabilities. We need to internally and culturally change the minds, feelings, and acquired dispositions of the public and families with disabilities, or, in Bourdieu's word, their habitus. During the transformational process, it will be important to build social consensus by publicizing rehabilitation through networks and the media, by popularizing the New Concept toward Persons with Disabilities, and by enhancing people's social sense of responsibility. We also must increase communication with families who have children with disabilities and convince them that those children are not just a drag on the family – that instead, their children can return to their families and society through proper rehabilitation treatments. Psychological support provided for parents with disabled children will improve the quality of care they give to their children and consequently increase the quality of life of children and family .This research had three main limitations. First, it was difficult to obtain much information from the past research, because this was the first qualitative research discussing implementation deviation of the RASDC, and the reasons for it, from the perspective of policy context. Second, the RASDC was a new policy, and there were fluctuations in the task indexes and evaluation methods that might have affected the credibility of the data. Last, this research was based on a single case study, but China's population structure, its urban and rural structures, and its bureaucratic structure are quite complex, meaning that the RASDC differs in different provinces and cities. As a result, the applicability of this study's conclusions to other regions and situations needs further discussion and reflection. In the future, additional qualitative and quantitative research should be conducted to extend the credibility of our existing analysis.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Academic Committee of Jilin University. The patients/participants provided their written informed consent to participate in this study.CQ: conceptualization, methodology, investigation, writing the original manuscript, revising the manuscript, and administration. YW: conceptualization, investigation, writing the original manuscript, and revising the manuscript. All authors: contributed to the article and approved the submitted version.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.


To investigate effects of different intervention time points of early rehabilitation on patients with acute ischemic stroke.  We enrolled patients diagnosed with acute ischemic stroke in our hospital's rehabilitation ward from November 2013 to December 2015. Patients were randomly assigned to an ultraearly rehabilitation program (started within 72 hours of onset) or an early rehabilitation program (started from 72 hours to 7 days after onset). The efficacy was assessed by the NIH Stroke Scale (NIHSS) International, Barthel Index, and Fugl-Meyer Assessment at one and three months after rehabilitation. Data were analyzed by variance analysis of two-factor repeated measurement. Covariance analysis was used to adjust confounding factors for the determination of statistical differences. P < 0.001). After adjusting for confounding factors , the significant difference still existed between the two groups at one month and three months (P < 0.001).  41 patients were enrolled in the ultraearly rehabilitation group, while 45 patients were in the early rehabilitation group. There were no differences between the two groups at baseline data. Compared with the early rehabilitation group, patients in the ultraearly rehabilitation group have significantly improved NIHSS score, BMI score, and FMA score at one month and three months ( Our study indicated a higher efficacy in the ultraearly rehabilitation group than the early rehabilitation group. The result suggests an important practical significance in favor of the clinical treatment of stroke. AS the leading cause of disability, stroke imposes a heavy burden on health care system. Epidemiological data shows the prevalence of stroke in China is approximately 336.3 in 100,000 people, and disability-adjusted life years (DALYS) reaches -27.3 to -23.0/100,000 –6. ThereHowever, the optimal intervention time point for early rehabilitation is unclear. To date, the definite theory on the time point of early activities after stroke is not elucidated. Likewise, the researches in this field are insufficient. A study by Bernhardt et al. confirmed the effectiveness and safety of ultraearly activities in either hemorrhagic stroke or ischemic stroke patients . The impTherefore, we launched the study to explore the efficacy and timing of early rehabilitation in stroke patients.ChiCTR1800019305. The Ethics Committee of Shanghai Jiangwan Hospital approved the study. All participants recruited from Shanghai City Hospital of Jiangwan between November 2013 and December 2015 signed written informed consent. The inclusion criteria in this study were as follows: (1) ischemic stroke is confirmed by cranial CT or MRI; (2) patients present with hemiplegia or hemiparesis with muscle power less than or equal to IV class; (3) patients' vital signs and nervous system are stable; and (4) patients consent to participation in rehabilitation training. The exclusion criteria were as follows: (1) subarachnoid hemorrhage or intracranial venous thrombosis patients; (2) patients suffering from a severe lung infection, liver disease, kidney disease, heart disease, or other essential organ damages; (3) unable to receive rehabilitation training for severe cognitive impairment; (4) unable to receive rehabilitation training for mental retardation or conscious disturbance; and (5) patients having neurological or musculoskeletal disorders affecting functional recovery.The clinical trial registration number was Good positioning: families and nursing staff counseled patients using correct posture. Patients were decubitus lateral or supine lateral and were guided to turn over every 2 hours. Patients were asked to avoid abnormal patterns of upper limb flexion, lower limb extension, and varus foot alignment.Bed position and joint training activities: hands and ten fingers cross each other on the ipsilateral hand grip, with the thumb placed on the top; with the healthy limb to limb disease, do elbow lift movement; upper limb joint activity includes side to lift, lower limb flexion, and legs and the bed support hips, namely, the bridge movement.Balance sitting and sit up training: correct hand, arm, and leg movements were shown.Sit up and standing balance training: patients with lower limb muscle strength of grade 3 and above were trained to stand. Patients began stand training using parallel bars, and the standing time gradually increased.Walk training: patients that showed an increase in the weight-bearing strength of their lower limbs started walk training. Gradually, patients were trained to step over different obstacles and up and down stairs.The patients were randomly divided into the ultraearly rehabilitation group (started within 72 hours) and early rehabilitation group (started from 72 hours to 7 days). All patients accepted rehabilitation from professional physical therapists. Rehabilitation of both groups did not start until the patients reached stable conditions. Except for intervention time points, the rehabilitation programs conducted in both groups were the same. Rehabilitation programs mainly included Bobath rehabilitation technique, brain circulation therapy apparatus, and electromyographic biofeedback technique. Bobath rehabilitation technology included the following:Brain circulation therapy apparatus and EMG biofeedback technique were used to increase cerebral blood supply, activate brain cells, and improve local muscle spasticity, tic, and paralysis to improve muscle strength and motor function. The above rehabilitation exercises were performed 20-30 min per day, 2-3 times a day, and 4-5 days a week for a total of three months.Besides rehabilitation, the other therapies followed the guidelines of treatment of acute ischemic cerebrovascular disease. Two weeks after treatment in the ward, the patient continued rehabilitation treatment in outpatient.The U.S. National Institutes of Health Stroke Scale (NIHSS) assessed the severity of neurological deficit. The modified Barthel Index (MBI) was introduced to evaluate daily life activity, and the simple Fugl-Meyer Assessment (FMA) was adopted to determine motor function. Neurologists and rehabilitation physicians in this study accepted specific training in NIHSS, MBI, and FMA assessments. We collected characteristics of patients, including gender, age, NIHSS score, location of the lesion, history of hypertension, history of diabetes, history of coronary heart disease, and history of atrial fibrillation. According to NIHSS 0-5, NIHSS 6-20, or NIHSS greater than 20, respectively, all patients were defined as mild, moderate, or severe neurologic deficit. The locations of the lesions included the right hemisphere, left hemisphere, and brain stem. All data were recorded in a unified form.All eligible patients with acute ischemic stroke were randomized to receive either ultraearly rehabilitation or early rehabilitation with the ratio of 1 : 1. NIHSS, BMI, and FMA were assessed at baseline, one month, and three months by the evaluators who were blind to the outcome of randomization.t-test. The analyses of repeated measurement data used variance analysis of two-factor repeated measurement. Covariance analysis was used to adjust the confounding factors and determine the statistical significance of dependent variables. P < 0.05 was accepted as indicative of significant differences.SPSS19.0 statistical analysis software was used for analysis. The differences in baseline demographic and clinical characteristics were analyzed by a chi-square test and 90 out of 96 eligible participants were recruited and assigned randomly to one of two groups. Among the 96 participants, 88 completed the 1-month trial, and 86 patients completed the 3-month trial. There were two patient dropouts in the ultraearly rehabilitation group at the beginning of rehabilitation. Two cases were lost at follow-up in the ultraearly rehabilitation group at three months .F = 253.433 (P < 0.001)], while MBI scores and FMA were higher in the ultraearly rehabilitation group than in the early rehabilitation group . Covariance analysis showed the differences remained statistically significant after adjusting for confusing factors at 1-month and 3-month  and reducing the penumbra around the lesion. Increasing CBF contributes to reducing ischemic necrosis of neurons in the penumbra zone. Sensory impulse is repeatedly introduced into the central nervous system, which plays an essential role in axon sprouting of neurons, transmission of latent pathways, and synapses. Therefore, ultraearly rehabilitation increases the CBF in the penumbra area and revitalizes a part of the neuron . A studyThe limitations of our study were that it is a single-center study and the sample was relatively small. Therefore, the introduction of bias was possible. However, strict randomized design in our study partly reduced the possibility of bias.Our study showed the efficacy of ultraearly rehabilitation in neurological function, activities of daily living, and motor function in patients with acute ischemic stroke. Further large sample trial is clearly warranted.