The current project results suggest that a remote physical rehabilitation program, supported fortnightly by video calls, represents an effective way of conducting a remote physical therapy intervention for this population and that it can be easily carried out at home by primary caregivers, promoting positive functional changes, without bringing feelings of frustration due to the required workload. The strategies that families have learned during the program to support the motor activities of their daughters represent an easily performed set of tools that they can maintain and use in everyday life even after the cessation of the program.Individuals with Rett syndrome (RTT) experience impaired gross motor skills limiting their capacity. Therefore, they need support to participate in physical activities, and it is crucial to work with primary caregivers when developing appropriate strategies, thereby leading to an active lifestyle. There is limited evidence supporting the effectiveness of remotely supported physical activity interventions. This project aimed to evaluate the effects of a skype-based, telehealth-delivered physical activity program carried out by participants’ parents at home. This article will focus on parental points of view. A mixed-methods design evaluating parental satisfaction was conducted. Forty participants with a confirmed genetic diagnosis of RTT and their families were recruited. The intervention included a 12-week individualized daily physical activity program carried out by participants’ parents and bi-weekly supervised by expert therapists. Parents’ impressions and feelings related to the program implementation were collected throughout semi-structured interviews, and an  Individuals with disabilities present complex diagnostic and therapeutic challenges. These challenges require intense intervention programs . One sucThe current paper aims to describe parental satisfaction emerging from implementing an individually tailored, telehealth-delivered, and physical activity program for a cohort of people with RTT, carried out by participants’ parents at home from both quantitative and qualitative points of view.The present research was conducted following the Declaration of Helsinki principles.Ethical approval was achieved through the Ariel University IRB (AU-HEA-ML-20190326-1), and all parents signed an informed consent form after understanding and agreeing with the specifics of the research program.Power calculation analysis for sample size based on previous research assessing the response of individuals with RTT to physical activity program was conducted, suggesting a sample size of 40 participants to perform solid statistical analysis and reject the null hypothesis. As indicated by power calculation, 42 girls and women with genetically confirmed classic RTT living at home and their parents were involved in this project. Participants were recruited from the Italian Rett Association database.A mixed-method design was applied, evaluating parental satisfaction from a qualitative as well as a quantitative point of view. The researchers used the Participatory Action Research (PAR) method. PAR involves clients  throughout the research process, working as a team with the researcher to identify problems and disentangle them. The steps representing the progression of a PAR process involve numerous cycles of:assessment (of each participant’s therapeutic needs in this case);mutual goal attainment ;action (the program implementation by the families);reflection (each program was discussed and revised bi-weekly through Skype meetings between a trained supervisor and parents); andevaluation (the program is modified if necessary and re-implemented).Action research assumes that the participant’s involvement empowers them, resulting in greater welfare for the person with RTT and her family. Action researchers seek change and develop solutions in collaboration with the participant while maintaining sensitivity to the family’s needs and desires . PAR desBefore the start of the intervention, informed consent was collected for all participants. Then, participants were randomly divided into two groups (Group 1 and Group 2) who followed the same procedure, starting it 6months apart from each other. All participants underwent four assessment sessions at three-month intervals . During each meeting, passive joint mobility and gross motor skills were assessed for each participant. The participants’ evaluations were conducted by two authors experienced in the rehabilitation of people with RTT (AR and ML). AR is an Italian developmental therapist and researcher who evaluated more than 250 girls and women with RTT around Italy and ML is a world-known researcher, consultant, and physical therapist who have seen more than 600 individuals with RTT across the globe and is working as a clinician with 12 girls with RTT on a weekly basis.In the first meeting (T1), relevant information was collected on participants’ clinical conditions  and on ongoing therapeutic interventions , and the expectations and wishes of the parents regarding the improvement of motor function for their daughter were discussed together with researcher and referred professionals. During this meeting, a draft of the individualized rehabilitation goals for the intervention phase was discussed with participants’ parents and rehabilitation professionals. Rehabilitation goals were selected within four areas: (a) passive limb joints range of motion improvement; (b) functional motor abilities; (c) hand functioning; and (d) general physical health .No changes were made to participants’ daily activities between the first and second evaluation meetings (baseline phase).In the second assessment/baseline session (T2), the rehabilitation goals were again discussed with each family and referred rehabilitation professionals and corrected if necessary.Between the second (T2) and third (T3) evaluation meetings (intervention phase), for each participant, an individualized program of simple therapeutic activities was drawn up by two authors (AR and ML) and shared with the family. Such programs aimed to persecute the identified therapeutics objectives through easy physical activities to be carried out in the girl’s daily life for a total time of about one non-continuous hour a day for 5days a week. Each family was able to organize the activities during the week according to their routines and habits. The rehabilitation activities foreseen in the programs included but were not limited to: (a) maintaining passive postures to prevent the onset or worsening of musculoskeletal problems secondary to RTT; (b) maintaining active symmetrical and asymmetrical postures to rebalance the trunk muscles and improve balance; (c) exercise of residual functional skills ; and (d) functional use of hands. The goals and activities identified were markedly different among participants in content, difficulty, and intensity to best suit each individual. After 2weeks from the delivery of the program, necessary for familiarization with the activities and the finding of any therapeutic material needed , a cycle of supervisions was started and carried out remotely every 2weeks for 1hour each through a videoconference platform (Skype) until the end of the intervention. The skype meetings were conducted by one author (AR) together with the participants and their parents and therapists (when available). The first supervision meeting was mainly used to clarify doubts relating to the practical implementation of the activities proposed in the program. The subsequent supervision meetings were aimed at supporting the execution of the programs by answering the parents’ questions, adapting the program to emerging needs, solving problems, rearranging the timetable, adapting the proposed exercises, evaluating, and sharing the achievement of objectives and, if necessary, setting new goals, following the PAR model.At the end of the intervention phase, during the third evaluation meeting (T3), the level of achievement of rehabilitation goals was assessed, and the parents’ point of view relating to the intervention phase was collected. Within this meeting, parents’ remarks regarding the intervention difficulty were collected by two authors (EI and MF) through the use of a semi-structured interview. The above-mentioned researchers are Italian developmental therapists and researchers with prior knowledge of RTT, which introduced themselves to the parents as external professionals having no previous connection with the therapists who carried out the evaluations and the interventions. Those conversations with parents lasted for 1hour each, as time was devoted to allowing parents to acclimate and create an environment conducive to sharing the positive and negative aspects of implementing the program.Between the third (T3) and fourth (T4) evaluation sessions (wash-out phase), the telehealth supervision meetings were suspended, and the families were informed that they could, at their discretion, continue or interrupt the program of activities.via e-mail to EI within 1week from the end of the meeting.During the fourth evaluation meeting (T4), the parents’ points of view were collected again by EI and MF using the same modalities used at T3. Moreover, each family was given a satisfaction questionnaire concerning the carried-out project to be returned The severity of clinical manifestation of RTT was assessed at T1 with the Rett Assessment Rating Scale RARS; . Each itThe Goal Attainment Scaling (GAS) was administered to assess the degree of achievement of the rehabilitation objectives identified for each participant. This scaling system represents a mathematical technique used to quantify the identified objectives’ achievement (or nonachievement) and can be used in rehabilitation . The GASThe Rett Syndrome Motor Evaluation Scale (RESMES) was used to assess the gross motor functioning of all participants at each evaluation meeting. This tool is a 25-item RTT-specific scale investigating subjects’ gross motor performance across six sections: (a) standing; (b) sitting; (c) transitions; (d) walking; (e) running; and (f) walking up/downstairs. A total score is obtained by summing up the item score with a maximum obtainable score of 82 points  adherence and workload (three items); (b) perceived usefulness of the intervention (three items); (c) compliance with the rehabilitation team (two items); and (d) general satisfaction (two items). Questionnaire items were constructed to best represent parents’ satisfaction within the areas of interest. The “Adherence and workload” area referred to the presence or absence in the program implementation; the area of “Perceived usefulness of the intervention” concerned a recognizable improvement of the participant’s motor functional abilities; the “Compliance with the rehabilitation team” area was related to the ability of the researcher to plan and adapt the program to the specific family needs; finally, the “General satisfaction” area was about the parents’ intention to prosecute the program after the project termination. Each item consists of a sentence referred to program implementation or rehabilitative goals achievement. Six sentences were structured in a negative way to support the internal consistency of the questionnaire. The same questionnaire was used in a previous analysis of the satisfaction of parents involved in a similar project , level of motor functional abilities , level of therapeutic goals achievement (measured with GAS at T3 and T4), and parents’ and participants’ ages. The threshold for significance for this analysis has been assumed as  applied .Among the 42 families involved in the first evaluation (T1), two families (4.8%) did not complete the research protocol. One dropout occurred in the first group and was due to health problems of the participant’s mother that arose during the baseline period. The other dropout happened in the second group. It concerned a family with senior parents living in a rural area with negative external involvement by local healthcare professionals giving the family contradicting advice regarding the suggested habilitation program for the person with RTT and her family. As a result, data analysis involved 40 participants with RTT. Participants’ and parents’ ages, RTT severity level measured with RARS, and motor functional level at recruitment (T1) measured with RESMES were collected in At T1, 11 participants were younger than 10 years, 19 were younger than 20 years, and 10 were older than 20 years. Twenty participants (50%) were able to stand independently for more than 1min, and 14(35%) can do it with single or double support given at the hands. Six (15%) participants were unable to sit on a stool without feet and back support for more than 1min. Independent walking for more than 10 steps was possible for 21(52.5%) subjects (one of them could not stand still). Eight participants (20%) showed no scoliosis . Twenty-five (62.5%) of them showed some degree of scoliosis . Seven (17.5%) subjects had undergone spinal fusion surgery. Seven participants (17.5%) attended motor rehabilitative intervention for at least 4h a week. Twenty-eight subjects (70%) attended such interventions between one and 3h per week. Five participants (12.5%) were not involved in any motor rehabilitative treatment. All participants lived at home with their parents. Both the participants and their parents were Caucasian and born in Italy. The participants’ and parents’ daily routines and the number of parents’ working hours varied widely among the participating families. In three families (7.5%), the parents were divorced, and the participants lived with their mothers. In cases where participants lived with both parents, both mother and father participated in the program by doing activities with their daughter. Where the participants lived only with their mother, the program was supported by other family members, such as the participant’s grandparents (two cases) or older siblings (one case).As the present article focuses on parental satisfaction and point of view, GAS and RESMES results are only briefly reported.Among 40 subjects, 176 therapeutic goals were identified . Between identified goals, 28(15.9%) were related to passive limb joints range of motion improvement, 126(71.6%) to functional motor abilities, 15(8.5%) to hand functioning, and seven (4.0%) to general physical health. Among 176 goals, at the end of the intervention phase (T3), 50(24.4%) goals were achieved as expected (GAS score=0), and 95(46.3%) goals were achieved slight (GAS score=+1) or much more than expected (GAS score=+2). Moreover, the level of achievement of 35(19.9%) of these goals continues to improve within the wash-out phase. The average GAS value for all goals for all participants is +0.5±1.0 at post-intervention evaluation (T3).Within the baseline phase (T1 – T2), nine (22.5%) participants improved their RESMES score, and one (2.5%) worsened it with an average change of −0.2±1.1 points (range: +5 –−4 points). At the end of the intervention (at T3), 34(85.0%) participants (14 from group 1 and 20 from group 2) have reduced RESMES score (suggesting improvements in motor functioning), and no one increased it with an average change of −2.8±2.5 points (range: 0 –−10 points).ad hoc questionnaire. On average, of the maximal possible score of 50, a high level of satisfaction was reported by all parents . All parents considered the program very helpful for their daughter . Parents who disagreed with the sentence “The program was too hard for my daughter” were 34(85%) while four (10%) agreed with this sentence, and two (5%) reported no opinion related to it . Thirty-eight families (95%) referred that their program was planned correctly  and that it considered the family’s daily routine and lifestyle . Program implementation was reported to be feasible by 39(97.5%) parents . Thirty-two families (80%) approved that the program has changed their daughters’ functional abilities , and 18(45%) referred that the program dramatically changed their daughter functional abilities, while 15 (37.5%) parents disagreed with this sentence . Thirty-eight families (95%) stated that they would continue the proposed activities . These results are described in Quantitative data regarding parents’ satisfaction were assessed through an The output of the conducted correlation analysis is summarized in Within the semi-structured interview, parents spontaneously made important notes and comments related to their participation in this project. Thematic analysis of parents’ answers led to the identification of the following themes: (a) benefits of the program to the child; (b) difficulties of the program to the child; (c) adaptations of the program to the child characteristics; (d) adaptations of the program to child’s and family’s daily routines; (e) changes in child’s functional abilities; (f) continuation of the program after research termination; (g) parents’ perceptional changes; and (h) general reports which emerged at T4 and relate to wash-out phase. The parents’ comments were collected and are presented below divided by themes:Benefits of the program to the participant:Family n°2: “The program was very useful for her ability to sit.”Family n°4: “I did not think our daughter could make such important improvements in such a short time, especially related to her kyphosis.”Family n°9: “We have seen an improvement in her posture and muscle strength.”Family n°18: “Since she got used to walking on the treadmill and sitting without a backrest, she is more active throughout the day.”Difficulties of the program to the participant:Family n°2: “We were advised to have our daughter lie down supine, which was very difficult for her (and for us to put her in the correct position).”Family n°6: “We were asked to make our daughter stand alone leaning against the railing of the staircase, and we were apprehensive about her scoliosis. It was challenging to do that activity, so we did it less than others.”Family n°12: “Carrying out the program was tough and demanding, but all in all, feasible.”Family n°13: “We always received the support and trust we needed; we were encouraged to do what we could despite the organizational difficulties.”Family n°20: “It was too difficult to get my daughter to use her hands as the stereotypical movements extremely compromise it.”Family n°24: “It was difficult to get her to lie on her back to counteract the kyphosis.”Adaptations of the program to the participant’s characteristics:Family n°2: “When they gave the exercises to us, some of them need to be corrected. After talking to the therapist, they were corrected to be well suited to our daughter.”Family n°10: “We felt supported when our daughter showed problematic behavior.”Adaptations of the program to the participant’s and family’s daily routines:Family n°17: “The program for my daughter was planned and created especially for her. It was very personalized. We also managed to bring it within the other contexts frequented by the girl (school and rehabilitation center). This project was useful to my daughter and me because I did not think she could do these things.”Family n°18: “If the professionals of the daily center had not been involved, we would not have been able to carry out all the activities.”Changes in participant’s functional abilities:Family n°4: “Due to kyphosis, my daughter was more and more bent, but, after all the activities, she has now managed to raise her head, and I find her looking at the sky when we go out.”Family n°5: “We have found a remarkable progress in our daughter who has greatly improved her walking ability being able to take some steps even independently.”Family n°7: “My daughter can now walk independently; before the intervention, we must constantly support her from one arm.”Family n°11: “We believe the program has been very positive for our daughter. We have seen a lot of progress and improvements. With the supervisions via Skype, we have always managed to adapt the program to our needs.”Family n°12: “Now she sits alone on the beach when we go to the sea.”Family n°16 (participants with severe scoliosis): “Even her referring physician has noticed that she remains more straight with her back when she is standing.”Family n°18: “It is now much easier to go for walks with our daughter. She walks much longer and stands on her legs.”Family n°40: “Finally, my daughter can look to her right again.”Continuation of the program after research termination:Family n°1: “Seeing the progress that my daughter continues to make motivates us to insist and continue the exercises.”Family n°7: “We have been suggested an excellent way to make our daughter walk more and to make her go up and down stairs; surely we will continue to use them.”Family n°12: “Probably with different rhythms, but we will certainly keep the modalities we have learned.”Parents’ perception changes:Family n°12 (relates to a participant who is a constant wheelchair user at program implementation): “We have changed our perspective on the potential of our daughter. Before the program, we had never thought of making her sit without a back for fear of falling. Now we know that before thinking that she cannot do something, it’s worth a try.”Family n°7 : “Before we did not trust her to walk alone, now we have a strategy to make her more independent.”Family n°13: “The program has been positive for both our daughter and us. It has given us the tools to expand her skills and has opened up prospects for us. Our daughter participated with enthusiasm, and we were given the support and trust necessary to keep us going with the program.”General reports emerged at T4 and related to the wash-out phase:Family n°1 (referring to wash-out phase): “We have now incorporated some of the program’s activities into our daughter’s daily life.”Family n°2 (relates to a participant who is a constant wheelchair user at program implementation and referring to wash-out phase): “We think we can no longer stop her sitting alone because she has become good, and she likes it.”Family n°4 : “Last week she managed to lie on her back with her hands behind her head, she had not been able to do it for many years.”Family n°7 : “Now she walks alone every day even in our home garden.”Family n°8 : “She finally manages to walk downhill alone. A slight slope of course, but she manages to control herself better.”Family n°12 (referring to wash-out phase): “The 3months with all the exercises were tough but very useful. Then we had to bring the activities into our daily lives, and we did not bring everything. Maybe it was more useful for us than for our daughter to develop a new approach. We think it would be useful to repeat this experience in a few months.”Family n°13 (referring to wash-out phase): “It was difficult to maintain the pace of the activities without constant support. For example, in the last few months, we have made her do fewer stairs than within the intervention.”Family n°30 (report collected at T4): “At the end of the intervention, we thought it had been very demanding, now we believe that it would be really useful to be able to repeat this experience after a few months.”This project aimed to support individuals with RTT and their families by assessing the participant and family’s abilities, constructing an intervention program, and providing remote supervision to program implementation. The focus of the present article is on parents’ satisfaction and perspective. To comply with this goal, the authors first analyzed the satisfaction of parents of girls and women with RTT enrolled in the above-mentioned program from both qualitative and quantitative points of view.The findings related to rehabilitation goals achievement and motor functioning improvements suggest that this intervention represents an effective way of conducting a remote physical therapy intervention for this population, and this conclusion is supported by previous similar projects . MoreoveOn average, the scores of the parents’ responses to the satisfaction questionnaire revealed a slightly higher level of parental satisfaction than in previous investigation of the authors . This diAnalysis of data collected through the post-intervention questionnaire showed that all parents believed that the intervention was useful for their daughter. The usefulness of the intervention strongly supports parents’ adherence to program implementation . Four faThe large majority of parents declared the intention to continue with the exercises. Two families stated their intention to stop the program. In one case, the parents were of old age and have reported difficulties in carrying out the proposed activity. The other case concerned a girl who began to show pain in her foot during walking activities and in standing position, reducing her motor functional abilities. These data are coherent with the findings that emerged from the correlation analysis which revealed that, in this sample, parental satisfaction  was affected by parents’ and participants’ age and participant’s motor functional level. Despite the broad consensus in the intention to continue the program after the end of the project, the qualitative data suggest that most interviewed parents preferred to continue it at a different pace (less intense). Moreover, at the end of the follow-up phase, the researchers received numerous requests to repeat the project, saying that, however demanding it was, it would be useful to carry it out again and, in general, to alternate periods of development (related to the supervised program) with a period of integration and consolidation of skills and strategies learned (for both participants and their families) within the family’s life, without the constraint of the program. At the same time, several parents reported that they were unable to return to their previous lifestyle as the improvements achieved by their daughters were maintained and consolidated and that they will maintain the good practices learned during the project.This study has several limitations. The authors did not use a standardized tool to evaluate parental satisfaction. Moreover, the researchers did not collect information related to families’ socioeconomic status, the quality of the relationship between the parents and parents’ occupation, and of daily workload (in hours), which are confounding variables that might affect parents’ satisfaction levels. Finally, the impact of the presence or absence of siblings and other external support availability  was not assessed. The evaluation of the influence of these variables on the satisfaction level of parents involved in a remote supervised home exercise program should be an integral part of the future investigations.alberto.romano01@universitadipavia.it.The data analyzed in this study are subject to the following licenses/restrictions: The data used for the present study are available in anonymized form from the corresponding author. Requests to access these datasets should be directed to Alberto Romano, The studies involving human participants were reviewed and approved by the Ariel University IRB, Ariel University, Ariel, Israel. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.ML coordinated the project and obtained the funds. ML and AR conducted the participants’ evaluations and wrote the article. AR organized the participants’ evaluations and carried out all remote supervision meetings. EI and MF collected the data which AR analyzed. All authors have read the article and suggested improvements and changes until agreement was reached. All authors are therapists and researchers with experience in treating patients with RTT. Particularly, ML is a world-known researcher, consultant, and physical therapist who have seen more than 600 individuals with RTT across the globe and is working as a clinician with 12 girls with RTT on a weekly basis, and AR is an Italian developmental therapist and researcher who evaluated more than 250 girls and women with RTT around Italy.The International Rett Syndrome Foundation funded the presently described project within the HeART Grant no. 3610.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.


BCR-ABL1 transcript via real-time quantitative-polymerase-chain-reaction is the most sensitive approach for monitoring the response to tyrosine-kinase-inhibitors therapy in chronic myeloid leukaemia (CML) patients. Each stage of the molecular procedure has been standardized and optimized, including the total white blood cells (WBCs) and RNA isolation methods. Here, we compare the performance of our current manual protocol to a newly semiautomatic method based on the Biomek i-5 Automated Workstations integrated with the CytoFLEX Flow Cytometer, followed by the automatic QIAsymphony system to facilitate high-throughput processing samples and reduce the hands-on time and the risk associated with SARS-CoV-2. The recovery efficiency was investigated in blood samples from 100 adults with CML. We observe a 100% of concordance between the two methods, with similar total WBCs isolated  and a comparable quality and quantity of RNA extracted . Moreover, by stratifying patients according to their BCR-ABL1 transcript levels, we obtained similar ISBCR-ABL1/ABL1 values and ABL1 copies, and matched samples were assigned to the same group of molecular response. We conclude that this newly semiautomatic workflow has a performance comparable to our more laborious standard manual, which can be replaced, particularly when specimens from patients with suspected or confirmed SARS-CoV-2 infection need to be processed.Molecular testing of the  Abelson1 (ABL1) oncogene juxtaposed to the breakpoint cluster region (BCR) gene on chromosome 22 t  [BCR-ABL1 fusion chimeric gene, encoding an oncoprotein with constitutive tyrosine kinase activity that alters the proliferation rate, survival signalling, immunological interactions, and cytoskeletal dynamics of the hematopoietic stem cell [Chronic myeloid leukaemia (CML) is a stem cell disease characterized by a unique cytogenetic marker, the Philadelphia (Ph) chromosome, arising from the reciprocal translocation between the long arm of chromosomes 9 with the t q4;q11 [3,tem cell ,6,7,8. Ttem cell ,11,12. Item cell .BCR-ABL1-dependent and BCR-ABL1-independent mechanisms [In the current clinical practice, the introduction of tyrosine kinase inhibitors (TKIs) in the treatment of CML patients has generated unprecedented rates of haematological, cytogenetic and molecular responses, increasing overall survival and improving disease outcome ,15,16,17chanisms ,22,23,24chanisms ,26,27. Pchanisms ,28,29. Ochanisms ,31,32,33BCR-ABL1 transcript [BCR-ABL1 mRNA and monitor patient outcomes [BCR-ABL1 transcript by Q-PCR should be done every 3 months after TKIs therapy initiation, then at least every 3–6 months. However, this interval may vary according to the clinical context. Mainly, CML patients with TFR require monthly Q-PCR determination during the first six months after drug discontinuation, in order to determine that the desired level of molecular response is maintained over the time [In the last years, qualitative and quantitative molecular techniques have been developed to evaluate and measure anscript ,9,34,35.outcomes ,37,38,39outcomes . Overallthe time ,41,42,43BCR-ABL1 molecular monitoring is currently performed using a manual method for total WBCs isolation and RNA extraction. However, this manual workflow is laborious, can only process small number of samples simultaneously, increase the hands-on time and the risk associated with the use of specimens from patient with suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Hence, laboratory practices aimed to increase the number of processed human blood samples and to mitigate the SARS-CoV-2-mediated biohazard risk could be required.In our laboratory, In this study, we compared the performance of our standard manual workflow to a newly semiautomatic method based on the Biomek i-5 Automated Workstations integrated with the CytoFLEX Flow Cytometer, followed by the automatic QIAsymphony system, to determine whether the semiautomatic workflow can reduce hands-on time, improve high-throughput sample processes, isolate comparable total RNA and obtain accurate and reproducible Q-PCR data.Between January 2021 and April 2021, we carried out a research study on a total of 100 adult chronic phase CML patients . PeripheAll patients received a TKI  as a first-line treatment. Treatment response was evaluated according to the 2020 ELN criteria .One hundred CML patients provided 28 mL of PB within a single blood draw. Matched PB samples were collected in sterile 4 × 7 mL EDTA tubes , according to the manufacturer’s instructions. The blood samples were stored at room temperature and further processed within 24 h from blood draw. Total WBCs from matched 14 mL of PB were isolated and lysed in RLT buffer . Two isolation methods were investigated , the man7cells were lysed in RLT buffer , according to the manufacturers . Then, the entire WBCs were washed and collected in phosphate buffered saline (PBS). Cells were diluted and a count was carried out using the haemocytometer counting-chamber with a microscope. Next, 1 × 10acturers . RLT lys7 cells were lysed in RLT, as above described.In the semiautomatic method, we used the Biomek i-5 Automated Workstations integrated with the CytoFLEX Flow Cytometer to enables sample processing and data acquisition . Deck sp7 WBCs lysed in RLT buffer using two different methods: the manual method . RNA purity was calculated by A260/280 ratio (~1.9–2.0) and A260/230 ratio (~2.0–2.2). The RNA integrity was verified by electrophoresis running samples on 1.2% denaturing agarose gels. Total RNA samples were stored at −20 °C until their use. A total of 1 µg of RNA was used to perform complementary DNA (cDNA) synthesis by using random hexamer primers  and moloney murine leukaemia virus reverse transcriptase , as previously reported [Total RNA from matched samples was extracted from 1 × 10reported .BCR-ABL1 and ABL1 transcripts were quantified using Q-PCR in the laboratory at the Centre of Experimental Oncology and Haematology, as previously reported [ABL1 was used as the reference gene for the entire group of samples. The BCR-ABL1/ABL1 determinations were assessed according to the international scale (IS) as the ratio of BCR-ABL1 transcript to ABL1 transcript. The value was expressed as a percentage on the log scale and using a conversion factor calculated every year, as previously described [3 was defined by ISBCR-ABL1/ABL1 ≤ 0.1% (3-log reduction from the standardized baseline), MR4 was reported by ISBCR-ABL1/ABL1 ≤ 0.01% (≥4-log reduction from standardized baseline), and MR4.5 was indicated by ISBCR-ABL1/ABL1 ≤ 0.0032% (≥4.5-log reduction from standardized baseline) with >32,000 ABL1 transcript copies [ABL1 gene copies, as previously reported [ISBCR-ABL1/ABL1 transcripts below 10% were included in this research study.The reported , and ABLescribed . Moleculescribed . In partt copies ,48. Quanreported . Only thThe Biomeck Software (version 5.1 9.0 (i5)) was used to process samples in the Biomek i-5 Automated Workstations. The CytExpert program  performed a count of the white blood cells in the CytoFLEX Flow Cytometer.ISBCR-ABL1/ABL1 and ABL1 transcript level in matched samples were calculated using Prism software v. 8.4. Statistical significance was evaluated using the Wilcoxon signed-rank test. A p value below 0.5 was considered statistically significant.Differences between cells counts, To evaluate the bias between the mean differences of the two methods and to estimate an agreement interval within 95% interval, a Bland–Altman plots was used.9/L (range 3.04–21.8) and the median of haemoglobin was 12.8 g/dL (range 10.8–14.7). Thirty-eight patients showed an e13a2 (b2a2) BCR-ABL1 rearrangement, 54 individuals presented an e14a2 (b3a2) BCR-ABL1 fusion transcript and 8 exhibited both e13a2 and e14a2 isoforms. According to ISBCR-ABL1 transcript levels, we selected the patients with a stable molecular response which were distributed in 4 groups of 25 subjects each: Group A (10% > ISBCR-ABL1/ABL1 > 0.1%), Group B (0.1% > ISBCR-AB1L/ABL1 > 0.01%), Group C (0.01% > ISBCR-ABL1/ABL1 > 0.0032%) and Group D (ISBCR-ABL1/ABL1 < 0.0032%).Patients characteristic are summarized in 6 (range 3.23 × 105–3.07 × 106) with the manual method and 1.076 × 106 (range 3.00 × 105–2.78 × 106) with the semiautomatic platform  and A260/230 .Next, we evaluated whether the RNA isolation method could impact on the downstream analysis for the molecular monitoring of CML patients. Therefore, we compared the quantity and quality of the RNA obtained by the column-based RNA isolation kit to the automated silica-based QIAsymphony technology. We observed that the RNA concentration measured by BioSpectrometer was comparable for both the methods in all the 100 CML patients. In detail, the median RNA concentration was 103 ng/μL (range 75–273.5) using the manual isolation kit and 99.95 ng/μL (range 75–359.4) by the QIAsymphony instrument . No statISBCR-ABL1/ABL1 values depends on the accuracy of the used method [ISBCR-ABL1/ABL1 transcript and produce different values for scoring molecular response. Therefore, we compared the Q-PCR data obtained by the manual and the semiautomated platforms to investigate whether similar ISBCR-ABL1/ABL1 values can be reliably measured. To this purpose, we first stratified the CML patients according to their ISBCR-ABL1/ABL1 transcript value into four groups  and then we compared Q-PCR measurements obtained from matched samples. Overall, measured ISBCR-ABL1/ABL1 transcript levels, BCR-ABL1 transcript copy numbers (data not shown) and ABL1 control gene copies revealed a good concordance between the two platforms. By considering the ISBCR-ABL1/ABL1, we observed that matched samples obtained a similar “IS” score and the patients were assigned to the same group of molecular response. Specifically, we observed that in Group A the ISBCR-ABL1/ABL1 medians were 0.32180% (range 0.1088–7.655), for the samples performed with the manual methods and 0.42102% (range 0.1022–6.3447) for the semiautomatic platform (p = 0.6). In Group B, the ISBCR-ABL1/ABL1 medians were 0.0338% (range 0.012–0.090) using the manual technologies and 0.04588% (range 0.011–0.099) by the semiautomatic instrument (p = 0.8). Patients recruited in Group C showed a median ISBCR-ABL1/ABL1 of 0.008% (range 0.0037–0.009) when processed with the manual platform and median of 0.005% (range 0.0038–0.009) with the Biomeck i-5 system (p = 0.1). Both methods gave a ISBCR-ABL1/ABL1 undetectable for individuals in Group D (data non shown). The Bland–Altman plot showed no consistent bias between the manual and semiautomatic methods , the total time for RNA isolation is roughly similar . Moreover, the semiautomatic method determined a hands-on time reduction from 210 to 30 min. for WBCs isolation, and from 90 to 15 min for RNA extraction while processing a larger number of samples . Of inteThe Biomeck i-5 instrument is equipped with a closed cabin, which ensure that laboratory procedures remain safe for the technical staff, especially in case of specimens from patient with suspected or confirmed SARS-CoV-2 infection. Additionally, avoiding manual procedures such as samples handling on an open bench, blood transfer, solutions dispensation and white cell count, further reduce the risks deriving from the analysis of suspected viral specimens. This finding is valid not only SARS-CoV-2, but also for other virus, such as hepatitis C virus or human immunodeficiency virus which can spread by contact with infected blood.Furthermore, the integration of the automatic Cytometer also allowed for the reduction of manual laboratory work and the facilitation of the high-throughput counting of numerous samples, even in the case of infected specimens, without interfering with the downstream analyses. Indeed, data obtained with the semiautomatic isolation methods did not differed from those retrieved with the standard manual method, both in term of quality and quantity of white blood cells. Moreover, the chance to manipulate the live cell gate on the Cytoflex software enabled a more reliable count.Different studies have recommended the selection of an RNA extraction method able to accurately and reproducibly isolate high quality of nucleic acid minimizing the risk of degradation ,35,36. IBCR-ABL1 transcripts levels by Q-PCR during TKIs treatment determine whether therapy should be continued or changed [BCR-ABL1/ABL1 detection. In this contest, it is recommended that a sample have at least 10,000 ABL1 gene copies to pass minimum quality standards. Moreover, the transcript level of the control gene is critical important to determine the kinetics of disease burden reduction and define the sensitivity of the assay independently of the oncogene BCR-ABL1 detection. Therefore, we compared the Q-PCR data obtained from matched samples isolated with both the manual a semiautomatic platform and observed similar qualitative and quantitative results, including BCR-ABL1/ABL1 and ABL1 recovery efficiency. Likewise, matched samples obtained comparable “IS” score and were classified into the same group of molecular response.The monitoring milestones of  changed ,53. HencNowadays, several studies have showed that the automatic procedure is often superior to the manual method, particularly for liquid biopsy ,55.In conclusion, semiautomatic method satisfied all our predefined aims and displayed a similar performance compared to our standard manual method. In this regard, the semiautomatic method tested is able to reduce hands-on time, increase the number of samples processed per run, isolate high quality and quantity of RNA and obtain optimal reliability and sensitivity levels by Q-PCR. Therefore, this system can replace the more laborious manual workflow, particularly when specimens from patient with suspected or confirmed viral infection have to be processed, not only SARS-CoV-2, but also for other virus, such as hepatitis C virus or human immunodeficiency virus which can spread by contact with infected blood.


Children with disabilities often engage in less than the recommended amount of daily physical activity (PA). Classroom-based PA breaks are a favourable method of promoting PA for children. However, evaluations of these programs in specialist schools are scarce, with even less research into their feasibility and acceptability. This may hinder effective implementation and program scalability. This pilot study investigated the feasibility and acceptability of implementing a classroom-based PA break program in Australian specialist school classrooms, using the Australian Joy of Moving (AJoM) program.N = 22; 6 males, 16 females) perspectives of the feasibility and acceptability of the program after implementation through semi-structured telephone interviews (n = 7 teachers), qualitative survey responses (n = 18 teachers) and quantitative survey items (n = 19 teachers). Qualitative data were analysed using predominantly deductive thematic analysis. Quantitative data were analysed using descriptive statistics.Forty primary/junior classes and their teachers across five specialist schools implemented the AJoM program for eight weeks as the intervention group within a pilot cluster randomised controlled trial. A mixed-methods design investigated classroom teachers’  allowing a high level of flexibility in the design and implementation of programs to meet the varying needs of class groups and (2) providing a large variety of resources to cater to the heterogeneity of the children.ACTRN12619000193178) on 11 February 2019.This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (The online version contains supplementary material available at 10.1186/s12889-021-11990-4. The 2020 World Health Organisation guidelines recommend that all children, including those with disabilities, engage in at least an average of 60-min of moderate-to-vigorous physical activity (MVPA) per day and limit the amount of time spent engaged in sedentary behaviour . EngagemChildren with disabilities experience numerous barriers to participation in community-based PA such as unsuitable environments, low perceived levels of community supportiveness and inexperience of coaches in including children with disabilities –14. ThisMajority (approximately 89%) of students with disability in Australia attend a mainstream school   are particularly attractive to teachers given the time constraints they often operate under , and havany length had not been extensively evaluated, identifying only 23 programs involving a PA component that had been evaluated, four of which were implemented through brief sessions by the classroom teacher ). The repetitive aspect (particularly in the storybooks) was also considered appropriate and important to help the students understand the concepts: “the repetitive nature of the books was great - kids liked the familiarity, and reinforced their learning ” (S-T-2). Some further noted that their students recited the repetitive elements of the books, “… the kids were almost ringing it off themselves …” (Interview-Teacher-4 [I-T-4]).Most teachers interviewed (n = 2) and a few survey respondents (n = 4) indicated areas of the program design that were less appropriate for their class. For example, it was noted that while the repetition within the books is good, repeating the same book multiple times per week would not be effective for an upper-primary class , suggesting the current design may better suit junior-primary students . Similarly, S-T-13 said that a student “… became bored with the repetitiveness after the second book”. More generally, some teachers showed concern for the appropriateness of the program for students with higher needs and those that do not engage in regular programs. For example, I-T-5 said “… I think there could be room for some consultation with like, a special developmental education person …” and S-T-13 said “It does not cover all abilities.”. Taken together, this suggests that while fitting for some groups, aspects of the program design may require adaptation to suit a wider range of classes and specific needs.However, a couple of interviewees (n = 4) and a few survey respondents (n = 3) indicated appropriateness of the storybooks for their students. For example, S-T-7 commented, “I loved the books I thought they were a perfect level for all of primary really.”. Other teachers indicated that the stories seem to be at an appropriate level for students, as students were able to read the books themselves. Furthermore, I-T-1 indicated that the storybook activity was an appropriate task for their class to do and for the students to engage with, as “… they [students] all sit and listen to the stories, and they love listening to that book.”.Several teachers interviewed (The stories for the year 5/6’s were tolerated but were a bit below them. They could have handled a more complex story about needing to move for different reasons.” (S-T-6). Conversely, two teachers indicated that young students and those with complex needs may have had difficulty comprehending the story, with one suggesting to have “… a quite simplified version of the story to use with kids that have complex learning needs and complex communication needs.” (I-T-5). It was also suggested that linking the books to currently utilised curriculums  may impn = 11) mentioned a variety of factors that suggest the movement activities are appropriate. One teacher indicated that the activities were familiar to the students. Other teachers described particular activities provided in the AJoM program that they frequently used and why they were suitable for the class . More generally, a teacher mentioned that “… the exercises are suitable for a variety of age groups.” (S-T-6), while another stated “There wasn’t that many that we had to kind of go, ‘No, that’s not going to work.’” (I-T-7).About half of the teachers (n = 2 interviews and n = 8 survey responses) also suggested that certain movement activities provided in AJoM may not be suitable for all students. Some teachers indicated that this was to do with age, “Some of the suggested ideas in the [A]JoM package were too advanced for our young students.” (S-T-1). Another teacher described finding extra resources  to pair with the movement activities when the general instruction/modelling suggested on the activity card may not have been sufficiently engaging for students. Furthermore, despite acknowledging that several activities did work, I-T-7 explained that “There were some of the activities that weren’t really relevant for my classroom or my school setting,” due to the activity complexity and students’ needs. This was also noted in the survey responses, with teachers commenting that activities were not suitable for some student’s abilities. Reasons included that some activities were too complicated, required too much memory power or were not suitable for the children’s physical abilities. Thus, while most teachers were able to find appropriate activities to use with their students, the development of additional resources and provision of further adaptation suggestions may allow the program to offer extra tasks that connect more meaningfully to more students.Nevertheless, despite describing activities that were used, nine participants  demonstrated approval or fondness of the overall program. This was noted from the teacher perspective, “A very well thought out and planned program.” (S-T-18), and child perspective, “My class loved it.” (I-T-2). Teachers also expressed the usefulness of the program, and an overall sense of appreciation, “We thank everyone involved with this program for thinking of this and making a difference to these kids and for their lives.” (I-T-4).Ten teachers (across n = 2) and a few survey respondents (n = 3) demonstrated some dissatisfaction. Furthermore, an additional survey respondent mostly expressed discontent. Dissatisfaction may have been related to implementation expectations not aligning with outcomes, “I think the transfer of the message both in instructions and the stories was not as well received as I thought it might be.” (I-T-5). Discontent also related to students lack of enjoyment of some elements, for example, “Students found some [of] the activities a bit boring and would ask for a different activity.” (S-T-4), and the lack of suitability for all students.In addition to demonstrating satisfaction, a couple of teachers interviewed (n = 14 surveys) demonstrated satisfaction with a specific aspect of the program, such as the design or a particular resource. Additionally, four interviewees and a survey respondent suggested that further approval may depend on certain circumstances or conditions, such as the type of teacher, how the resources are used, time factors or the type of class. For example, “Some of the other activities were a little too difficult for my students to understand or follow but in saying that, fabulous for other classes!” (S-T-18). See Additional file Seventeen teachers  demonstrated intent to continue using the program when asked. For example, S-T-9 wrote: “Would love to continue to use it as a regular part of classroom activities”. Teachers also demonstrated interest in either (a) using additions to the program in the future, if the program is extended, “Happy to do anything in the future that you propose or plan.” (I-T-4), or (b) using the program with a new class in the future, “… I plan on using the books next year with my new class as a program and trying it all again.” (I-T-2). However, in six survey responses, teachers explained that they were either uncertain whether they would continue to use the program, “I am unsure, it would depend on the nature of the class and their understanding levels.” (S-T-5), or indicated that they do not intend to deliver the full program .Twelve teachers  so I would only have 1 or 2 students.”. Notably, no teachers raised space/environment constraints as an issue.While S-T-14 commented that Teachers demonstrated demand for the program by describing the importance of (a) movement breaks and (b) emotional learning for their class.n = 3) expressed that students need movement or movement is important for them. For example, “I think, regardless of the setting students need them [movement breaks].” (I-T-7). One also highlighted the particular importance for children at specialist schools, “I think the program is vital, to be quite honest, and more so in the special needs area which is where I’m teaching.” (I-T-4). Four teachers (including the three that expressed the importance of movement) noted a variety of reasons for using movement breaks, including for management reasons, to give students a break and break down lessons to increase engagement, and to accommodate students’ needs, especially for very active students, “… I’ve got some kids with quite a bit of energy and can’t sit for too long, so the movement and stuff is quite important to us.” (I-T-5). This importance indicates that some perceived demand for the AJoM program may exist.A few teachers , while another mentioned the importance of a social and emotional learning program already provided by the school. A survey respondent further indicated the prominence of emotional learning, commenting that “The stories on different emotions were really great and students have enjoyed listening to them and we do it quite often as and when required.” (S-T-4), suggesting that demand for these learnings or conversations exists. The AJoM program may therefore be of interest to specialist schools, as it addresses concepts that appear to be valued by some teachers and important for students.Two interviewed teachers also indicated the importance of emotional learning, which may be another feature that generates demand for the AJoM program. One teacher stated Teachers demonstrated that the AJoM program appears relevant to their current practice by describing existing use of similar activities/programs including (a) movement in the classroom, and (b) other programs related to AJoM concepts, both of which are explored below. This may further suggest teachers’ interest in using the AJoM program, thus possibly indicating demand for the program.n = 5) commented that they had used movement breaks in the classroom prior to the AJoM program. For example, “With my class, even before we started Joy of Movement [sic] Program, we did a movement break...” (I-T-1). This was also seen in two of their survey responses. Interestingly, three teachers noted that their previous movement breaks were either not conducted in an organised or consistent fashion, or contained less variability in the activities than the AJoM breaks. Furthermore, four of the five teachers that had used movement breaks previously indicated that implementing the AJoM program was not too different from, or complements, existing classroom practice. Survey responses were less conducive to reporting previous classroom practice, as teachers were asked about their use of current programs . While teachers did report use of movement breaks in their survey responses, it is less clear whether these were implemented prior to AJoM. Nonetheless, the previous use of movement reported by several teachers could infer further demand for, and feasibility of, the AJoM program.Most interviewed teachers (n = 4 interviews and n = 14 surveys) mentioned other programs being used and areas of focus for schools and teachers that align with key concepts in the AJoM program. These included relaxation/meditation programs, the Zones of Regulation curriculum  program with my class who are highly autistic and like their set daily routine.”. Other difficulties related to staffing, where the absence of school leaders or classroom teachers could create integration challenges by impacting areas of the general curriculum  or routine. While this is not amendable or specific to the AJoM program, it does present a consideration for ensuring consistent integration of the program. Relatedly, S-T-7 explained that consistent integration was not successful, due to placing emphasis on other areas of the students learning, “Towards the end of term it dropped off in class as honestly we were to [sic] busy focusing on behaviours.”.Several teachers (“And even if the thing is over we’re still doing it …” (I-T-1), as well as specific aspects of the program, such as movement, “I already still like to do a 5-10-minute activity, moving activity during the day with the kids …” (I-T-2), or storybooks, “We have continued to use the stories in our movement break …” (I-T-7). Just one teacher explicitly reported an aspect that was not being used anymore “I’m not using the books anymore. I’m just using the … just, you know, just talking them through it verbally …” (I-T-2). This may suggest that while the tasks themselves are sustainable, the AJoM program may require additional resources  if it is to be used by teachers long-term. Sustainability was not mentioned by teachers in their survey responses, and it is not possible to know whether the remaining interviewed teachers were still using program resources. Nevertheless, the element of sustainability portrayed supports the ability to integrate the program into the school system.Four teachers provided evidence of still using the AJoM activities during their interview , indicating sustainability of the program. This was demonstrated for the overall program, Taken together, although not without challenges, there is evidence to support being able to integrate classroom-based PA breaks in the school routine. However, further research would be useful to better gauge the ability of more teachers to integrate the AJoM activities, particularly in relation to adherence to the prescribed dosage.n = 17) provided evidence of activities that were commonly used. Most teachers (n = 20) indicated that doing a movement activity was possible by describing the use of either an activity provided in the AJoM package, “Sometimes it is Simon Says, which they enjoy, or it’s the Chicken Dance …” (I-T-1), or an external activity, some of which involved unstructured activities, while others commonly involved music, for example, “… copying movements on YouTube music videos, such as Jack Hartmann’s Count to 100.” (S-T-2). Several teachers (n = 10) also demonstrated that the storybook component was doable. For example, “Sometimes I read it three times, but it was basically twice, you know. Once I think at the beginning and then another time at the end of the week.”. (I-T-4).All interviewees demonstrated at least one element of the AJoM program  that was able to be done. Additionally, most survey respondents (“… did not use any activities from AJoM.” (S-T-13), as many were not applicable to the students’ abilities. While teachers are not required to use every (or any) activity provided and are permitted to use their own activities, revising some activities could provide classes with more options and increase the accessibility of the program. Additionally, of note, the program was not always done as intended and therefore may have deviated from the program aims. For example, one teacher reported that it was “… used as a literacy tool as opposed to, you know, movement and dance and addressing the emotions.” (I-T-3).However, seven teachers also reported being restricted in their implementation of some activities. Most instances were related to elements previously discussed as lacking appropriateness. For example, some movement activities provided in the AJoM package were not able to be done by all classes, with one teacher explaining that they n = 5) indicated that the program was easy to implement and identified facilitators of implementation. Facilitators included the program being relatively simple, “The program’s pretty straight forward.” (I-T-7), the teacher being familiar with movement breaks, “Oh it was very easy to implement for me because I’m doing that anyway” (I-T-4) and having variety in the activities, “… you could easily find activities that suited everyone. And most of the activities you could easily scale up or scale down, if needed.” (I-T-7). Elements that were easy or simple to implement were also identified in the survey responses (n = 5), with most focussing on specific movement activities. For example, in describing commonly used activities, S-T-18 said “We repeated these activities quite a lot as they were familiar and easy to follow. My students struggle with too many instructions or ‘rules’ so it was nice to keep it simple.”.Several interviewees .… Four interviewed teachers mentioned additional factors, including resources and teacher attitudes, which may influence the way the program is implemented. Regarding resources, I-T-1 mentioned support staff being involved with implementing the program, although this appears to have been used most when implementing the program with individual students. Additionally, as indicated previously, teachers mentioned frequently using songs or music videos in their implementation of the program, for example:n = 5) survey responses, “We commonly engaged in action songs, both with or without the support of videos/ songs on YouTube.” (S-T-1). While not prescribed as requirements of the program, it is worth noting these factors that may facilitate easier implementation or greater student engagement in the program. Similarly, S-T-1 described creating extra resources that were vital to successful implementation and therefore must be considered for future iterations of the program, “In order to get the program working more effectively, I was required to make up my own class visuals to give students understanding, provide choice and to enable a more predictable routine.”.This was echoed in several .One interviewee commented on the influence that teacher attitudes may have on program implementation, noting:Challenges to implementation related to program design. Despite several teachers noting that the program was easy to implement, four (across n = 3 interviews and n = 1 survey) also reported aspects of the program design and instruction that created potential implementation barriers. Most related to previously mentioned time challenges, “… sometimes the 10 minutes seemed a bit long on days when there is a lot of physical activity anyway …” (S-T-2). Furthermore, despite indicating that the program content specifically was easy to administer, I-T-3 indicated that the program instructions may contribute to overall implementation challenges or confusion. Additionally, I-T-3 said “But with that said, it was something where, yeah I would have liked to have spent more time with knowing how to roll it out. Because I was just left up to my own devices.”. This could contribute to the program not being implemented as intended (as described above). Therefore, the training presentation and manual provided may need to be reviewed to ensure instructions are as clear as possible to support teachers.Challenges to implementation specific to teachers or the class. Again, while various teachers mentioned that the program was easy to implement, just over half (n = 12) identified teacher and class specific circumstances that created barriers to implementation. Most related to elements that were previously covered in the discussion of ‘appropriateness’ , suggesting that some areas of implementation may lack feasibility with particular groups. Another challenge was engaging and motivating students. S-T-2 said it was “difficult to get all students involved if some decided they didn’t want to do it …” . Moreover, while not prescribed by the program, I-T-3 suggested that a lack of collaboration with colleagues may be a barrier to successful implementation, “… with the other, my colleagues, we never discussed what we did.”.Overall, while the implementation findings above suggest that the activities involved in the AJoM program can be delivered in several classes, further adaptations to overcome the noted difficulties could increase the success of implementation and increase the accessibility of the program in the classes that had more significant challenges.Teachers were also given the opportunity to provide suggestions for improvement to the program in the interview and survey, providing further insight into how they perceive the program.n = 2 interviews and n = 2 surveys) suggested changes related to the movement activities. For example, the program could include resources  to engage students that are not interested in doing a particular activity chosen for the class, as explained by I-T-1: “Some children don’t like yoga, when everyone’s doing yoga, but I cannot say that ‘No, we are not going to do this’ so change to something else. Maybe engage those kind of students with some other material …” . The inclusion of ‘hands-on’ and sensory activities may also engage children with a wider range of physical abilities, as suggested by S-T-10, “Sensory activities  perhaps to some of our less active  students.”.Three teachers (in n = 4) and a couple of survey respondents (n = 2) suggested changes related to the psychoeducation component. This included creating a video version of the storybooks and designing more books, “Maybe a variety of more books, because those books are really beautiful …” (I-T-1), which in fact indicates a positive perception of the program. Other areas for improvement were previously mentioned in the discussion of ‘appropriateness’ .Several interviewees (n = 3) and survey respondents (n = 5) suggested changes related to the program design/set-up, some of which were previously identified as implementation considerations and challenges . Additionally, although consultation with specialist school staff was undertaken during program development, a teacher indicated that further consultation may be necessary to increase appropriateness for more students. Other suggestions included introducing indigenous elements, having an optional participation tracking chart for students, matching movement activities with the storybooks and demonstrating an AJoM session prior to teachers beginning implementation, “Maybe a demonstration with the class so that the standard is set and all teachers are under the same impression of what is expected.” (S-T-18).A few interviewed teachers , this study demonstrates preliminary evidence for the feasibility and acceptability of implementing classroom-based psychoeducational active breaks in several specialist classes. However, variation exists between teachers’ perceptions, with common divergences in perceptions appearing to relate to the age and developmental level or needs of the class. This demonstrates the importance of allowing extensive flexibility in classroom-based PA break programs.A variety of positive perceptions indicate there is evidence for a degree of acceptability of the AJoM program. Most teachers expressed satisfaction with at least one element of the program, reported that they would recommend the program to a colleague and several voiced students’ enjoyment of the activities. Intent to continue using the program was also demonstrated both qualitatively and quantitatively. Some teachers that were unsure if they would continue using the program expressed that this depended on the nature of their class, signifying acceptability in some classes but not others. Appropriateness was also only demonstrated for some classes. This appeared to relate mostly to the age of the students  or student ability . This aligns with the only other feasibility study of active breaks in specialist schools to our knowledge, which also found that appropriateness may be related to age . AlthougWhile some challenges to acceptability identified in this study  have been previously acknowledged as factors to consider in implementing school-based PA in both specialist and mainstream schools , 61, othFindings also demonstrate preliminary feasibility of the program. No teachers expressed that the AJoM concepts are irrelevant to their students. In fact, many reported prior use of programs containing similar concepts, demonstrating potential demand for, and the utility of, AJoM in these classrooms. Additionally, the program appears to be practical for some teachers to implement, as none that completed the quantitative program perception questions agreed that it ‘was too long’ and no environmental/space issues were discussed. However, time constraint challenges were described qualitatively, challenging feasibility for some teachers. Time also appeared to challenge the ability of some teachers to integrate the PA breaks, along with other factors . Nevertheless, integration was feasible in some instances, with a few teachers demonstrating how they integrate sessions into their routine and others demonstrating sustainable use. Furthermore, no teachers disagreed that the AJoM program ‘fits well within the daily school routine’. Notwithstanding challenges, findings also show that it is possible for several teachers to sufficiently implement the program. This was seen qualitatively, where some teachers indicated that the program or activities were easy to implement. Quantitatively, no teachers agreed that the program ‘has far too many components to implement’ or ‘caused a lot of extra work’, suggesting that implementation was not overly complex. However, there were barriers to implementation and elements of the program that were not able to be done in some classes, indicating that modifications would be useful.Some challenges to feasibility identified in this study have been previously acknowledged as potential barriers to school-based PA. These include time constraints, lack of student engagement/motivation and disrupting or unsettling the class environment , 64–66. Overall, findings demonstrate that while there is evidence for the classroom-based psychoeducational PA program to be feasible and acceptable in specialist schools, variation exists in teachers’ experiences. Thus, the primary recommendation of this research is that a flexible approach to design and implementation of classroom-based PA breaks that puts choice and variety at the core of the program be adopted to allow for highly tailored classroom PA. Other important recommendations emerging from this study that should be considered in designing and implementing future classroom-based active break programs in specialist schools include (1) program design must include extensive collaboration with special education teachers and experts, (2) visual aids  could be provided to assist classes with adjusting and understanding the routine, (3) it would be useful to build demonstrations into teacher training sessions and ensure instruction materials are as clear as possible to further support teachers.In line with the primary recommendation, the importance of flexibility in the delivery and level of tasks was a recurring idea identified in the results of this study across the AJoM intervention components. This confirms what we would expect in a setting with considerable heterogeneity at both the student and class levels . This rePrior literature supports the importance of designing programs that can be adapted to meet the needs of different student populations to encourage effective implementation , 69 and This recommendation also seems applicable to classroom-based active break programs designed for mainstream schools. Indeed, Watson and colleagues  found thThis study adds to limited knowledge of the feasibility and acceptability of classroom-based PA breaks in specialist schools and investigates a novel program that combines both physical and psychological health constructs in a naturalistic intervention for children with disabilities. However, it is not without limitations. Firstly, given a whole school approach was not required upon enrolment to the study, participating classes may be biased towards teachers that value PA breaks, already conduct them, or thought the program would be suitable for their class after attending the recruitment presentation. This may limit the ability to truly understand feasibility and acceptability. Secondly, a similar bias may be evident in the quantitative program perception questions and semi-structured interviews. Given only 19 teachers completed the quantitative questions and all perceived the program quite positively, it is possible that the teachers with favourable views of PA breaks chose to respond while others did not. Additionally, interview data represent teachers from only two schools. While qualitative survey responses represent all five schools, it would be insightful to have in-depth interview data from teachers at more schools. Thirdly, although schools that cater for students with mild to profound intellectual disability were involved with this study, this did not include any Special Developmental Schools . FurtheThis study demonstrates preliminary evidence that conducting classroom-based psychoeducational PA breaks in specialist schools can be feasible and acceptable in several classes. However, extensive flexibility across all aspects of the program is required. Future research should continue to investigate the feasibility and acceptability of classroom-based PA breaks in specialist schools, as well as evaluate outcomes to determine their effectiveness and associated benefits. Despite the limitations and further research required, classroom-based PA breaks may be a viable method of getting children with disabilities more active during the school day.Additional file 1.


Girls on the Run (GOTR) is a PYD program that uses running, motor skills, and other physical activities as a platform for promoting positive psychosocial outcomes and life skills learning among elementary- and middle school-aged girls. The onset of the COVID-19 pandemic challenged GOTR to modify lessons, coach training, and program delivery  to accommodate public health guidelines. The purpose of this study was to assess caregivers' and coaches' perceptions of program effectiveness in light of these changes. Following the Fall 2020 season, caregivers  and coaches (n = 991) from 1,077 teams and 39 councils completed an online survey about program experiences. Both stakeholder groups positively rated program impact regardless of delivery mode, although in-person mode was rated higher for satisfaction with the end-of-season event. Thematic analysis of open-ended responses revealed that caregivers and coaches identified increased physical activity opportunities and life skills learning as well as improved social, psychological, and emotional development as a result of participating. Both stakeholders noted GOTR provided a sense of normalcy during this time of great need. Findings using mixed methods provide evidence of program effectiveness and recommendations for youth programming during challenging times.Afterschool programs have the potential to promote social, emotional, and physical health outcomes among youth participants. The positive youth development (PYD) framework argues that acquiring desirable attitudes and behaviors occurs when skill-building opportunities are explicitly provided within a safe and supportive climate guided by caring, competent, and compassionate instructors.  Girls on the Run (www.girlsontherun.org) is a physical activity-based positive youth development (PA-PYD) program using running, motor skills, and physical activities as a platform for promoting psychosocial development and life skills among girls 8–11 (grades 3–5) and 12–14 years (grades 6–8). The program typically serves 200,000 girls annually and engages 50,000 coaches . The intentional curriculum and systematic coach training are aligned with best practices for PYD programs, including opportunities for skill building, a safe physical and psychological space, appropriate structure, supportive relationships, and feelings of belonging , connectedness , and empowerment (celebrating and sharing one's strengths), while the 6th−8th grade curriculum focuses on lessons related to self, team, and community. Sessions also prepare girls to complete the culminating 5 K, by setting goals, regulating progress, and participating in a practice 5 K to build confidence. To attain program goals, girls and coaches meet twice a week for 75–90 min over a 10-week season. Coaches are trained to deliver the curriculum with fidelity, along with an emphasis on building relationships, creating a positive, inclusive environment, and emphasizing a mastery climate. More information about GOTR is available in other sources The onset of the COVID-19 pandemic challenged GOTR to modify program delivery to accommodate public health guidelines, while continuing to promote PYD in a time of great need. The curriculum was shortened from 20 to 16 lessons and delivery options included in-person, virtual, or hybrid. Health and safety policies were adopted utilizing CDC guidance for all modes. When in person, coaches delivered pre-COVID lessons with modifications for physical distancing  and the use of new journals outlined in a curriculum addendum. Girls also used the journals in the virtual space. If a team was 100% virtual or needed to transition to the virtual space , coaches used the newly developed Virtual Lesson Curriculum, which contained lessons that mirrored the in-person learning objectives. Virtual lessons were shortened to 45–60 min plus a 20–30-min independent workout (modified from 75–90 min in-person lessons), and a variety of physical activities were provided to be inclusive and allow for space constraints (modified from in-person workouts that primarily included running and other locomotor skills). The workout typically completed in person was transitioned to a “separate but together workout” that girls started together at the end of the lesson and continued on their own. Coach training, typically delivered in-person (4.5 h) and online (1 h), was moved to completely online. Three training modules were added: impact of COVID-19, coaching virtually, and coaching for social inclusion. The end-of-season 5 K, typically a large community celebration, became a “K Your Way” event.What information emerges about attitudes, skills, and behaviors? (2) So What do findings imply about program effectiveness? (3) Now What recommendations can be made for making program improvements? The purpose of this study was to answer these questions based on stakeholders' perceptions of COVID-19 safety protocol changes to program delivery.Consistent with GOTR's commitment to ongoing evaluation for improving curricula and program delivery, the organization developed an online survey to seek caregivers' and coaches' perceptions of program effectiveness in light of COVID-19 protocol changes. Based on utilization-focused evaluation, Patton  accentuaFollowing the Fall 2020 season, all GOTR councils (~200) were invited to evaluate the curricular and delivery modifications due to COVID-19 restrictions. Thirty-nine councils elected to participate, consisting of 1,077 teams in all regions of the U.S. GOTR national headquarters distributed an online survey to all caregivers and coaches within the 39 councils.A total of 1,617 caregivers completed the survey. They reported their girls' program delivery mode as virtual (23.3%), in-person (54.3%), and hybrid (22.4%). For girls' race/ethnicity, 73% were white/Caucasian, 7% Black/African American, 7% multiracial, 6% Latina, 3% Asian, 0.4% American Indian/Alaskan Native, 0.3% Native Hawaiian/Pacific Islander, and 1% Other (~2% did not say). Most girls (91%) were in grades 3–5 and 9% were in grades 6–8.A total of 991 coaches completed the survey. They delivered the program as virtual (32.1%), in-person (47.3%), and hybrid (20.6%). The majority were white/Caucasian (84%), with 4% Black/African American, 3% Asian, 3% Latina, 3% multiracial, 0.3% American Indian/Alaskan Native, 0.1% Native Hawaiian/Pacific Islander, and 1% Other (~2% did not say). Most coaches were between 25–44 years old (61%); 39% were first-timers with GOTR, while 61% coached for ≥2 years.For caregivers, 5 statements probed level of agreement on the GOTR experience , rangingGirls on the Run experience, such as something she learned, a favorite moment or activity, or a lasting takeaway.” For coaches, “This is a challenging time for many girls. What do you think was the greatest need met through the program during this time?”One open ended question for each stakeholder was selected for qualitative analysis based on relevance to the COVID-19 protocol changes. For caregivers, “Share one way that your girl has been positively impacted by her p < 0.006 (0.05/9 items) and for coaches using p < 0.005 (0.05/11 items). Student-Newman-Keuls post-hoc tests were used in the event of statistically significant differences. Effect size (ES) was calculated for statistically significant differences using Cohen's d  and coaches (n = 458) due to early saturation of responses. A second researcher randomly selected 100 responses for each stakeholder and independently coded data units and lower-order themes. The researchers then met to discuss convergence and divergence of findings and came to consensus. Together they derived a set of higher-order themes that emerged from the lower-order themes and data units , virtual (22.0%) or other (5.7%). Satisfaction ratings with the event fell between somewhat and completely satisfied for all delivery modes, but caregivers of girls who participated in virtual sessions scored significantly lower than girls who experienced in-person or hybrid lessons. ES's were small.For the before and after questions —“my girl felt/feels lonely”, “I would describe my girl as confident”, and “my girl was/is physically active”—scores improved for all three delivery modes. Caregivers reported girls as less lonely, more confident, and more physically active. No differences in change scores emerged by delivery mode.Responses  fell betIn-person delivery received more favorable scores than virtual delivery for: I formed positive relationships with girls on my team and girls developed positive relationships with teammates; these items were also higher for hybrid vs. virtual. All ES's were small. When asked if coaching GOTR has been a valuable experience, coaches in the hybrid mode scored significantly lower than virtual and in-person modes, but ES's were small.Coaches reported location of the end-of-season event as in-person at site (62.5%), virtual (28.7%) or other (8.9%). Satisfaction ratings with the event were significantly higher for coaches who delivered the program in-person or hybrid than for virtual mode. ES's were small  and medium . No differences emerged between delivery modes for satisfaction with safety protocols and support and communication from GOTR.Coding responses to, “Share one way that your girl has been positively impacted by her GOTR experiences …” resulted in 9 higher-order themes derived from 15 lower-order themes and hundreds of data units. Improved Physical Activity Motivation and Behavior was evident in data units revealing opportunities for being physically active with teammates and looking forward to running and training for the 5 K. As one parent said, “My daughter has grown to love running and wants to run with me now. She sees herself as a runner and this is a positive identity that she will carry with her into the future.” Another parent shared, “My daughter did not like to do any physical activity prior to this program. After GOTR, she would come home in such a positive mood and feeling better about herself. Now she is pushing me to incorporate exercise into our lives and strives to be a healthy person.”Social Development was characterized by opportunities to develop and strengthen friendships, socially interact with peers, and experience group belongingness—various ways that allowed girls to share common bonds with others their age. One parent offered, “This was a wonderful way for SadiePsychological Growth was defined by themes of achieving goals and gaining confidence. Caregivers attested to girls setting goals and developing strategies to successfully complete them . Others highlighted how confidence was enhanced through activities and lessons in GOTR. One parent shared, “My daughter was really struggling and feeling alone during COVID. She lost her motivation and happy spirit … After just one practice she was happy again. She was eager to set goals and achieve them. As she achieved goals her confidence grew. This program was even more important this year!”Emotional Growth entailed themes of being able to express feelings, adopting a positive outlook, and feeling proud of accomplishments. Responses alluded to becoming more open with communicating, engaging in positive talk, and feeling a sense of pride in completing the 5 K. A parent shared, “She was really struggling with COVID and not being able to be with her friends … when she started GOTR back up she was excited, she looked forward to each session, it brought her back to life and her outgoing self again.” Another offered, “GOTR gave her peers to interact with … she was able to share her thoughts on the lesson without hesitation. GOTR has always been a positive, uplifting experience where she feels accepted.”Life Skills Development was prominent, characterized by learning life lessons and helping others. Caregivers confirmed that girls acquired specific “tools” (Take a Breather) and learned important skills  that transferred to many areas of girls' lives. A parent shared, “The lessons have been so helpful for Pria. We have gone back to lessons again and again and generalized for everyday life. Positive self-talk and Take a Breather helped us get through things like the flu shot and a medical procedure that was pretty scary. As a child with anxiety … having those tools in her toolkit helped us more than I can express in words.” Helping Others was a theme reinforcing lessons that emphasize standing up for others (being a “Stand-Byer”) and giving back to community and society. Developing empathy and a sense of civic engagement is accentuated in the curriculum through completion of a community service project.Two higher-order themes revolved around meaningful adult relationships, Positive Coaching Influence and Closer Family Connections. Caregivers were uniformly praiseworthy of their girls' coaches as positive role models, sources of encouragement, and fostering a safe and inclusive climate. In addition, several caregivers commented on how girls' involvement in GOTR fostered opportunities for being physically active as a family and having conversations related to lesson themes. Having Fun was a theme that reflected the sheer enjoyment of running, being with peers, and experiencing the overall program.A Sense of Normalcy during the Pandemic emerged as directly relevant to the COVID-19 pandemic. Caregivers praised the value of the program in light of virtual school and other social activities being canceled. One parent summarized concisely, “She appreciated the time to do something NORMAL in this not-normal year.” Another shared, “My daughter was new to her school and with it being virtual, she hadn't met anyone. Her GOTR experience helped her feel much more connected to the school community at a time of stress and loneliness.”Coding responses to, “… What do you think was the greatest need met through the program during this time” resulted in 7 higher-order themes derived from 9 lower-order themes and hundreds of data units. Some themes were similar to those of caregivers, revolving around opportunities to socialize with peers, be physically active, build confidence, learn life lessons, be surrounded by a positive social environment, and feel a sense of normalcy. One coach nicely summarized how GOTR met girls' needs during this challenging time: “Giving girls the opportunity to get out of the house and develop strong habits/practices in exercise, mental health, confidence, and relationships.”Numerous responses exemplified the theme, Increased Physical Activity, including opportunities to be physically active by getting outside, participating in sports and activities with friends, and as one coach implored, “Encouraged them to get up and MOVE!” Another shared, “Many parents told us that before GOTR, their girls were not getting any physical activity. Not only were they active during the lesson, but it continued at home too.” As a PA-PYD program, GOTR is unique in emphasizing physical activity as a healthy behavior through opportunities to enjoyably experience running, motor skills, and movement activities that are continued outside of the structured program.Social Development entailed themes of socializing with peers and feeling part of a group. Coaches highlighted meaningful interactions and relationships as a crucial need that was achieved through activities promoting teamwork, unity, connectedness, and companionship. One coach shared, “The program provided the girls an opportunity to meet and interact with other girls and school staff (coaches). This gave the girls a much-needed opportunity to socialize with peers/adults during the difficult time caused by COVID .” Another added, “I think social interaction was the greatest need. Girls had a platform to share in their joys, excitement, triumphs and hardships. My girls made valuable connections and even exchanged numbers to keep in touch with one another.”Psychological Growth included lower-order themes of coping with stress and building confidence. Coaches elaborated on how GOTR met these needs, “It gave the girls a sense of calm in all this chaos”, “Having lessons on emotions bridges gaps with how they are feeling and how they can express it”, and “They just needed someone besides people in their immediate households to talk with and to explore the world around them with different people so that they weren't stuck stressing about school. They got the opportunity to put some stress aside to have fun and to become a stronger and more confident girl.”Life Skills Development was characterized by learning life lessons, such as adopting a positive mindset, managing emotions, developing social skills, and helping others. One coach explained, “… the opportunity to develop social skills , given that many aren't in school.” Another said, “Many of the girls developed skills to help them see their strengths, push themselves to reach their goal, and how to support each other.” One elaborated: “The girls were able to build a toolbox of skills through the lessons that helped them in this current odd environment … The girls learned that other girls felt the same way about life/the world. There was safety in knowing they were not alone.”Positive Social Environment was exemplified by having a safe and supportive space for engaging in activities and interacting with peers. A coach stated, “GOTR gave the girls something to look forward to and people to interact with. I think most of them were lonely and hadn't seen any peers in a while. GOTR gave them a space to talk about their lives and how they've been feeling.” Other coaches stated, “This made connection possible outside of the household. Positive, meaningful, and real connection that kept safety the top priority”, and “The program was able to help with providing a safe place for girls to connect while they are experiencing isolation due to the pandemic … the content was encouraging and helped to keep them positive and growing during a challenging time.” The higher-order theme, Having Fun, also reflected a positive and supportive climate—enjoying activities with peers and fun games to take their mind off things .Sense of Normalcy during the Pandemic depicted a theme specific to meeting girls' needs during COVID-19. One coach succinctly characterized GOTR's role, “A piece of sanity in the midst of insane times.” Another exclaimed, “Getting back to something somewhat normal! For the time we were together, besides masks, distancing and sanitizer, it felt good to do something other than be on the computer at home all day.” Another stated, “Normalcy. So many of our girls had things interrupted over the last 8 months and to bring the program back at our school was so helpful and nice to see them involved in an after-school activity”.What … changes in attitudes, skills, and behaviors occur in participants? So What … do the findings imply about the degree to which the program is considered a success? Now What … recommendations flow from the findings? We systematically address study findings relative to these questions based on caregivers' and coaches' perceptions of safety protocol changes to curricula and delivery mode.Utilization-focused evaluation research is a means for bridging evidence-based findings with practical implications . It begiWhat changes in girls' attitudes, skills, and behaviors occurred by participating in GOTR? Quantitative responses by caregivers and coaches were favorable , regardless of the curriculum delivered in-person, virtually, or hybrid. Caregivers reported girls as less lonely, more confident, and more physically active at season's end—for all modes. Qualitative themes provided detail for how girls were impacted by GOTR (caregivers) and what greatest need was met by participating during this challenging time (coaches). Based on these data, GOTR provided a means of sustaining physical activity, strengthening friendships, achieving goals, and building confidence. Girls acquired ability to express feelings, maintain optimism, and take pride in completing the 5 K. Evidence of season-long improvement in physical and psychosocial outcomes align with the mission, vision, and core values of the program . This included, “GOTR has been a valuable experience for my girl”, “I formed positive relationships with girls on my team”, and “girls on my team developed positive relationships with teammates.” Satisfaction with a virtual end-of-season event was rated lowest. GOTR used the findings to recommend areas for improving the Spring 2021 season. First, councils were encouraged to conduct the end-of-season 5 K in person and at site-based locations if possible. Second, to optimize developing positive relationships, virtual session length was extended from 45 to 60 min and ideas were added to the virtual curriculum for coaches to make more informal connections. Third, a team workout option was added to the virtual curriculum (girls and coaches complete it together), which increased time for connection and motivation for physical activity.Despite strengths of this study , we note some limitations. First, 39 councils agreed to participate and, although large samples of caregivers and coaches from over 1,000 teams completed the survey, it is unknown how those in other councils viewed the program experience. Second, the sample was not as diverse as the makeup of the broader organization. Survey responses represented 25% girls of color, whereas the network composition for Fall 2020 was 37%. GOTR remains committed to gathering insights from individuals of diverse sociocultural backgrounds and is pursuing strategies to ensure representation. Third, to maximize return rate the survey length was kept reasonable, which did not allow for more quantitative items. The open-ended questions provided rich data to complement ratings and lent perspective on areas of holistic health and well-being attained through participating.In conclusion, GOTR resourcefully and effectively applied COVID-19 safety precautions with in-person, virtual, and hybrid modes. All modes were received favorably and open-ended narrative revealed the breadth and depth of program impact. Evaluation findings provide GOTR and other youth programs with critical information for improving curricula, coach training, and program delivery while maintaining high safety protocols during a challenging health crisis.mrweiss@umn.edu.The datasets presented in this article are not readily available because the dataset is proprietary to Girls on the Run International. Requests about the data should be directed to Maureen Weiss, The project was reviewed by Research Integrity and Compliance (RIC), Texas State University, San Marcos, TX, USA. Because the study exclusively involved the examination of anonymous, secondary data, the research is not regulated by RIC, and written informed consent for participation was not required.MW and AR conceived the study. AR collected the data. MW and LK drafted the earlier versions of the manuscript and conducted the qualitative data analysis. LK conducted the quantitative data analysis. All authors contributed to revising the manuscript and approved the final 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.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.