This article discussed the issue of low PA levels among school-aged children and highlights the promising approach of school-based interventions, including physically active learning (PAL), to increase PA levels. The study aimed to co-design and to assess the implementation of a PAL program for 8 weeks in 4 elementary classrooms (82 students and 7 teachers), emphasizing the potential of integrating PA with academic learning and the importance of co-designing programs with teachers to maximize their effectiveness. Technology was found to support PAL practices in promoting PA and academic achievement. The study underscores the need for further research to explore the societal implications of PAL programs, including their potential to improve the health and well-being of children while promoting positive academic outcomes. Physical activity (PA) is essential for the optimal development and well-being of school-aged children (5 to 17 years old). A strong body of evidence has linked PA to a wide range of health outcomes, including reduced adiposity, improved physical fitness, cognitive function, and mental health , 3, highSchool-based PA programs, particularly those involving physically active learning (PAL), have been proposed as a promising approach to increase PA levels in children –10. MoreTo address these challenges, this study aimed to co-design a PAL program and assess its implementation in elementary schools, focusing on teachers’ and students’ perceptions. The co-design process involved collaboration between researchers and teachers to tailor the program to their needs and preferences. The study findings could help overcome the challenges faced in implementing PAL interventions, leading to the successful design, development, and implementation of future programs. These results have important implications for developing effective school-based PA programs, improving the health and well-being of school-aged children, and promoting their academic achievement.To ensure that the PAL program developed for elementary school students is effective, feasible, and consistent with the school’s curriculum and mission , a co-deThe theoretical foundations of the PAL program are based on key elements of three previously published and validated school-based PA programs: ’’Take 10!’’, ’’FUNterval’’ and ’’Fit en Vaardig op school’’. The Take 10! program from the United States  combinesThe FUNterval program from Canada  is a PA The Fit en Vaardig op school program from Netherlands  includesBy drawing on the key elements of these three successful programs, the theoretical foundations of the PAL program are well-established. The co-design process involving school practitioners and an interdisciplinary research team is intended to ensure that the program is tailored to the specific needs of the students and aligns with the school’s curriculum and mission , 25. TheThis study employed an embedded experimental design, a mixed-method approach that concurrently incorporated a qualitative component into a quantitative experimental design . This arThe University du Québec à Chicoutimi’s Research and Ethics Committee (REC-UQAC) approved this research (CER 2020–393). Prior to initiating the co-design of the PAL program, electronic written informed consent was obtained from school practitioners (February 2020), children and parents/guardians before the implementation of the PAL program (October 2020). The study adhered to public health guidelines related to the COVID-19 pandemic, with permission from the University COVID-19 Committee and the Lac-Saint-Jean School Service Centre . Children and parents were informed of these preventive measures in the informed consent form.From the start to the end date, his study involved seven teachers (N = 7): four fourth-grade teachers  and three health and physical education teachers  from three different schools, in addition to the research team. The PAL program was implemented in the classrooms of the 4GTs involved. Of the 99 students who participated in the PAL program, 83 gave informed consent. One participant changed schools before data collection and was excluded, resulting in 82 students  included in the final data analysis  with students. The 4GTs completed an observation grid for each PAL lesson to collect students’ observance and subjective evaluation of the lesson. The 4GTs identified inadequate elements of the program and proposed solutions to address them, while technical bugs  were reported to improve future iterations of the PAL program.After the 8-week intervention period, semi-structured interviews were conducted with teachers using a guide covering major thematic questions present in The four FGs with students were conducted in their respective classrooms and lasted between 35 to 50 minutes each: FG #1, n = 25; FG #2, n = 17; FG #3, n = 18 & FG #4, n = 22 (See The co-design of the PAL program was carried out from October 2019 to October 2020 using a multidisciplinary framework that resulted in constructivist learning . The co-During the first phase (Discover), the research team conducted a scientific literature review to identify an innovative solution to increase PA levels among school-aged children while also improving the development of children with neurodevelopmental disorders, such as attention deficit disorder with or without hyperactivity , which iThe implementation of the PAL program consisted of 24 sessions delivered for 8 weeks, with three sessions per week. A crossover design was used, where the PAL program was initially implemented in two classrooms during January and February 2021, followed by implementation in the remaining two classrooms during March and April 2021 see . To gathThe data collected from the interviews and FGs were transcribed verbatim to ensure accuracy . An induQualitative data were coded and categorized using NVivo 12 software . Students who did not provide consent for the study were assigned the pseudonym ’Student X’ in the verbatim, and their quotes were excluded from the analysis data. This inter-rater agreement process was followed by the main author and a research assistant to ensure consistency in the analysis. The resulting thematic tree map was tested multiple times and validated by the research team , leading to the identification of main themes . NotablyThis section presents the findings of the thematic analysis conducted on the data generated by the semi-structured interviews and the FGs. The main themes were related to the objectives of the study which were 1) to co-design and 2) to implement a PAL program in elementary schools.[the PAL program], and the emotions they experienced during the co-design process. These themes not only provide a comprehensive understanding of the teacher’s role in designing the PAL program but also facilitate the development of strategies to ensure their active participation and engagement in future initiatives.To design an effective PAL program, the involvement of teachers has been recognized as a critical element. In this regard, an in-depth analysis of verbatim data was conducted to gain valuable insights into their perspectives and experiences regarding the co-design process. Through this analysis, emergent themes surfaced in the co-design process such as their level of involvement, the outcome "the opportunity to increase students’ PA behaviour while learning through movement". Other teachers also mentioned "being grateful for the opportunity to participate in the co-design of a useful pedagogical tool, and to be aware of the outcomes afterwards".During the post-experimental interviews, all teachers involved were asked why they chose to become engaged at that point. The interview data showed that some teachers participated in the action research project for their students. HPETs highlighted …it was a motivating project for the students, it was nice to tell them that we were thefortunate involved in this project… I was happy to be part of the research project because this tool could be reapplied and integrated into teachers’ educational practice. " 4GT #2"During the co-design process, the teachers were involved in the key elements of the PAL program, such as the academic content, PA integration, and artistic creation of the avatar. The 4GTs worked mainly on academic content. After agreeing on academic themes see , they wo"easy-to-use and fun way to promote learning through movement" that "combines physical and academic activities into 15-minute video clips". It "helps to review academic material and consolidate learning by incorporating movement into the classroom". They highlighted the program as a "motivator for the children" and "a good way to move in the classroom" that "helps with concentration and learning". Finally, the teachers noted that Cogni-Actif is "an end-to-end solution that does not require any additional preparation from them". This feature eliminates the need for teachers to spend extra time creating activities, enabling them to focus on delivering high-quality instructions.The active involvement of teachers in the co-design process led to the development of a unique PAL program called Cogni-Actif. According to the teachers, Cogni-Actif is an "stress and pride". The perceived stress during the process was mainly attributed to the pandemic context, while the feeling of pride was strongly associated with the active involvement of teachers and students in the co-design process.The co-design process resulted in the emergence of two distinct emotional states: Yes, it was stressful [COVID-91 period], but while we were working on the co-design of the PAL program, we weren’t thinking about the pandemic, it kept us busy…" 4GT #1"…it required more work than I initially expected when the project have been presented to us… honestly, I didn’t expect that, but am I’m proud I did it [the co-design]… Every time I had visitors in my classroom, I showed them the program, and they were all very surprised that we were doing this in my classroom. They all told me that they wished their children could have experienced it too, to motivate them to go to school. I really think it’s a great program and our students are lucky to experience it, I would definitely do it again… When they [the students] talk about their experience, it’s always with great joy. The pride I felt, they felt it too…". 4GT #1"Despite the challenges posed by the pandemic context, the co-design process involving teachers played a crucial role in developing a PAL program that effectively integrates PA and academic content for elementary school students. The successful collaboration between educators and researchers demonstrated by the co-design process offers a valuable tool for promoting PA and academic learning in elementary school settings.The second objective of the study was to assess the implementation of the PAL program in school classes. The inductive analysis of the PAL program implementation highlighted four main components: 1) Implementation context, 2) Perceived Outcomes, 3) Assessment of the PAL program components, and 4) potential future use of the PAL program.Despite the unprecedented challenges posed by the COVID-19 pandemic, the study continued as it was deemed a priority by the school practitioners involved and their managers. Even if the pandemic was not a planned theme of interviews or FGs, teachers and students repeatedly reported how it affected the study’s processes, and that the pandemic context likely influenced the study’s outcomes. For instance, students who experienced the PAL program from March to May 2021 (n = 40) had to were masks in class, which might have affected their willingness to complete the sessions with the prescribed intensity. In addition, one classroom switched to remote learning during the PAL implementation. These students completed five home lessons supervised by their teacher via computer video.Moving to remote learning was a challenge… It was still going well [implementing the PAL program], I was working with two computers at home, one to share the PAL program with the students and one to watch them perform… I couldn’t watch them all, but it was doable.""* To keep the 4GT name’s anonymous, this quote is not associate to the participant code.Despite challenges caused by the COVID-19 pandemic, the study continued, providing valuable insight into the feasibility of implementing a PAL program during a pandemic and its positive outcomes.This section specifically delves into the perceived outcomes of the PAL program implementation as reported by teachers and students. Participants reported several benefits related to determinants associated with students’ learning, attention and focusing ability, PA levels, and quality of sleep. Examining these outcomes can provide insights into the effectiveness of the PAL program and its potential impact on elementary school students.Learning support. According to the teachers, the PAL program has the "potential to improve students’ learning" as they observed, "students learned faster and retrained more easily, particularly for math concepts." They confirmed that "combining movement and academic effectively consolidates learning and anchors knowledge, particularly for concepts that are easy to learn through practice, such as multiplication tables." The teachers suggested that combined learning, which involved movement, "benefits students in many ways and is effective because it engages them." Students also shared this impression during the FGs. Lastly, teachers reported that the implementation of the PAL program in class was a "good way to review concepts quickly seen in the previous year due to COVID-19, which allowed for the consolidation and deepening of knowledge."I think that when you’re learning and doing a gesture or movement at the same time, it gives an additional anchor." 4GT #1"…for the kids, as long as the learning is through play, it’s clear that the interest is greater because they don’t feel like they’re learning…" 4GT #3"… it makes it easier for me to retain information because I’m having fun at the same time." Student #51"I noticed that it makes us learn more quickly. And I also think that math got into my head faster."Student #28"Improved attention and focus. The PAL program improves students’ attention, focus, and on-task behaviour, which in turn contributed to their learning. The 4GTs reported that the "classroom was quieter after the program" and that "students were more willing to learn at that time. " They also mentioned "teaching more difficult concepts immediately after the program to take advantage of students’ increased attention."I definitely took advantage of it to do a teaching period [immediately after the PAL program] because I had their attention…. That effect faded over the course of the day, as the day went on, it went back to normal." 4GT #1"“…after Ratou [the program character], I always took the opportunity to teach more complex material  … they were more inclined because they just moved." 4GT #4It was a good start to my day. Afterwards, I was ready to work, I had more focus, and the class was quieter." Student #38"Improved PA levels. The PAL program was found to be an effective way to increase students’ PA levels by adding movements during class time. Students reported "enjoying being active in class," and surprisingly, this enthusiasm translated to reported, "increased PA outside the classroom and a reduction in screen time at home."What I liked best about the program is that we are physically active … it’s important for our body to be physically active."student #48"… at home I do more physical activity, I’m more motivated and I go outside more often… I’ve also noticed at home that I’m less connected to my computer or my tablet." Student #45"before the Cogni-Actif project, I wasn’t going outside to play with my friends much, but now I go a lot more, I go almost every day that we go to school. " Student #22" … Ratou gave me idea how to train… it helped me and my sister to respect the instructions of screen time … we went a little more outside. Usually, we were often on our phones, then we turned them of a little more …" Student #32""improvement in their endurance and overall fitness."Despite the increase in PA due to the PAL program, neither the HEPTs nor the 4GTs observed any changes in the children’s physical fitness. However, several students noticed I believe that my endurance has improved." Student #43"The first week we started Cogni-Actif program, I had a lot of pain in my legs. But then, after the first week, it was okay, and by the end, I didn’t feel it anymore." Student #45"I feel that I’m running a little faster." Student #46"I’m more physically fit." Student #24"Improved quality of sleep. Most students reported "experiencing better sleep quality and an earlier onset of sleep on days when day participated in the PAL program." They attributed this to the fact that they were "more physically active and tired on those days." In fact, one parent even contacted the 4GT to share that her daughter was going to bed earlier on days when the Cogni-Actif program was in effect. These observations suggest that while physical fitness improvements may not be immediately apparent, increased PA can have positive effects on sleep quality and duration.The PAL program’s assessment by students and teachers identified three main components: Academic Content, Physical Movements, Graphics and Sound. For each component, they provided key solutions to improve the program to make it more enjoyable and relevant to the school setting.Academic content. According to the 4GTs, the curriculum they selected for the PAL program during the co-design process was "mostly relevant and on target for grade 4." However, they agreed that "Maths material was more relevant than French ones." Students also mentioned that they preferred Math to French lessons while using the PAL program. Only conjugation seemed appropriate for reviewing in a PAL program from the French themes listed in "academic content’s difficulty level was appropriate for most students," but some aspects need to be adjusted for the next iteration. According to the 4GTs, the PAL program was "too difficult for students with special needs ." The students addressed the fact that they "did not have enough time to find the answer" before it appeared on the interactive board on some occasions. Finally, 4GTs proposed "covering fewer academic topics but adding lessons to increase repetition." They stated that more repetition would anchor the knowledge more firmly and make it a better review tool.I would remove some themes and repeat the simpler themes like addition, multiplication, and conjugation … I would use the Ratou session in class once a day as a memorization tool and spend the week on the same theme…"4GT #2"Physical movements. Physical movements are a huge part of the PAL program. When asked which movements they preferred, the students named most of them. Generally, the "intensity was usually adequate except for a few occasions when the intensity was too high for the duration of the exercise." The unanimous ones were the "boxing and the drum solo, which are more playful movements." A lack of variety emerged from discussions with students and was confirmed by the teachers. It was the walking movement that created the most dissatisfaction because it came back every session to allow students to calm down between moderate or vigorous exercise. It was suggested that "new, lower-intensity movements be identified to replace the walking." The students also suggested "adding some new ones, such as hip-hop moves or basketball shots." In addition, all 4GTs mentioned that when Ratou’s pace was unrealistic (too fast or too slow), it distracted students from the intention of reviewing French or Maths lessons. As a key solution, the "animations must be redesigned for some movements."Graphic and sound elements. The graphic and sound elements of the program were designed to stimulate student motivation and participation. The students unanimously liked the character Ratou. According to the teachers, the program was "visually attractive but would need something more stimulating to maintain students’ interest" because children are used to colourful and animated video games. The students were impressed at the beginning of the program, but this faded as the program went on. Indeed, in the FGs, the students named several solutions to "make the PAL program more stimulating" particularly to "add graphic variety" to the PAL program.Ratou is a prototype that could evolved in a video game." 4GT #2"…at the beginning Ratou was wow, wow, wow, but at some point Ratou had little flaws, ah it’s the same, the colors were the same, Ratou is always dressed the same …" 4GT#4""music might be more relevant to a youthful audience" and less repetitive. Most students said they would prefer music they know and also to be able to select the songs. As mentioned earlier, students would add "narration and sound effects."On another hand, the It could be like in Mario Bros a "DING" sound at the end…" student #50""should be used in the classroom over a long period of time to maximize the benefits, from October to April." The 4GTs suggested avoiding using the program during September, May, and June due to weather conditions in Quebec. The program should be "used daily", reviewing one topic per week. The 4GTs also provided suggestions for optimizing its use. The suggestions included adapting the PAL program into a "video game", incorporating an "individual at home component" to the game, and "adapting the PAL program for other grade levels."The finding of this study indicates that the PAL program has the potential for use in elementary school classrooms. The 4GTs expressed interest in using the PAL program in their classroom in the future. According to them, the PAL program Adapt the PAL program into a video game. The interaction was identified as a crucial component of the PAL program by both the 4GTs and the students. As a result, they suggested adapting the program into a video game that would allow for "increased interactivity." The video game version would allow students to "interact with the character and solve quests." Students suggested incorporating a collection feature, which would add a motivating aspect to the game. "Messages of encouragement" from the character would also be beneficial to students. The video game version should give the teachers the ability to "select the difficulty level and activities".I see Ratou as a prototype of something that evolved … the students are used to video games… and it would allow the teacher to select the activity … to students to see their progress … to become a kind of quest." 4GT #2"They [students] wanted to collect something. … it could be an educational game with pedagogical capsule and something to collect by students." 4GT#1"Ratou could say messages of encouragement as "You did the first part, Bravo" or "That’s good, keep going, you’re well on your way." Student #18"Add an individual component. The 4GTs suggested adding an "individual at home component" to the PAL program in addition to the group sessions conducted in class. This would allow students to "review the material at their own pace" at home via an accessible platform. The teacher would be able to "monitor student progress" and evaluate the level of each student.Adapt the program for other grade levels. The PAL program was designed for students in the 2nd cycle, specifically in fourth grade (9–10 years old). However, teachers suggested "adapting it for other grade levels, including 1st cycle (1st and 2nd grades) for addition and subtraction review, and 3rd cycle (5th and 6th grades) for English second language concepts." To avoid redundancy, different "characters could be created for each cycle"; the concept is easily adaptable for each elementary school levels by "following elementary curriculum."In conclusion, the PAL program has the potential to be an effective tool for PA promotion in elementary school classrooms. The suggestions made by the 4GTs for optimizing the PAL program should be considered for the next iterative co-design process. All teachers involved agreed to be part of the next iteration co-design process of the PAL program. However, they suggested recruiting a larger team to facilitate the co-design process, which hopefully will not occur in a pandemic period.The integration of PA with academic learning is an area of growing interest in education, as schools face the challenge of providing enough opportunities for children to engage in regular PA while also meeting academic objectives , 37, 38.This study provides valuable insights for school practitioners and researchers looking to implement PAL programs. The finding highlights the benefits of integrating PA with academics in the classroom, which can help schools meet both PA and educational objectives. Additionally, the study emphasizes the importance of involving practitioners in the co-design process of PAL programs, which can facilitate the development of effective and tailored solutions that fit within the school setting and address specific needs and challenges. Finally, the study suggests that technology can play a crucial role in supporting PA practice at school, offering promising avenues for future research and program development.À l’école on Bouge! " policy, which requires schools to provide at least 60 minutes of PA per day . Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."If this statement is not correct you must amend it as needed.Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.3. 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Stroke rehabilitation is a lengthy procedure that is necessary for stroke recovery. However, stroke rehabilitation may not be readily available for patients who live rurally due to barriers such as transportation and expenses. This shortage in wearable technology, in turn, causes health disparity among the rural population, which was exacerbated by the COVID-19 pandemic restrictions. Telerehabilitation (TR) is a potential solution for stroke rehabilitation in rural areas. This one-case study aimed to examine the feasibility and safety of a technology-enabled at-home TR program for stroke survivors living in a rural area in Canada. A VR setup was installed successfully in the home of our participant. A tablet was also supplied for the TR program. Each program consisted of 24 sessions to be completed over a 12-week period. Our participant was assessed on day one using the Fugl-Meyer assessment, the Modified Ashworth Scale, the 10 m walk test, and the Mini-Mental State Exam. Three questionnaires were also completed, including the Motor Activity Log (MAL), the Stroke Index Scale (SIS), and the Treatment Self-Regulation Questionnaire. These assessments were completed thrice, on day 1, at week 6, and at week 12. The participant found the tablet and its accompanying exercises easy to use, with a few limitations. The participant found the VR system more challenging to manage independently as a lack of comfortability, the visual contrast during the first trials, and certain technical aspects of the technology created several functional barriers. Although some limitations with the technology were noted, this case study indicates that telerehabilitation is feasible under certain circumstances when used in conjunction with traditional rehabilitation services. Stroke rehabilitation is a lengthy and intensive process that usually occurs over several months, with the first three to six months being a crucial period for recovery ,2. RepetThe intensity of rehabilitation and the many barriers individuals may face in accessing these programs have created a need for accessible outpatient rehabilitation services that can be delivered safely and effectively to ensure equitable recovery for all stroke survivors. Telerehabilitation (TR) is an alternative to conventional in-person rehabilitation that uses information and communication technologies to deliver rehabilitation services . The expThis project introduces the “Active at Home Post-Stroke Program” (or Home PSP) , a novelThis study aims to determine the feasibility and safety of a technology-enabled at-home telerehabilitation program for stroke survivors living in rural areas. The objectives were to evaluate the feasibility and safety of introducing virtual rehabilitation into the home of a stroke survivor, evaluate a participant’s satisfaction with the technology and note any marked improvements in physical function, self-reported quality of life, and motivation, and determine potential barriers and limitations to using the technology to problem solve and correct for future use.This is a functional rehabilitation program based on immersive VR simulations of tasks related to activities of daily living and a tablet program that provides “follow along” videos of different exercises that target gross and fine motor skills and strength and range of motion. There were 48 sessions for the VR and tablet (24 sessions each) across a total of 12 weeks. Each week, the participant would complete two sessions for each technology, resulting in four sessions each week. A recent systematic review with a meta-analysis recommends that the physical training program should last at least six weeks, with a frequency of three sessions per week and a session duration of at least 30 min . A randoEach participant was given a tablet with the tablet app downloaded to it. Participants logged in and completed the session by completing each exercise. Each session consisted of exercises targeting the upper and lower body and focusing on gross and fine motor skills. The program involves a blend of resistance, balance, and stretching training. Users can complete activities in the order they prefer within two consecutive sessions for ease, comfort, and motivation. They cannot override the second session until the two sessions have been completed. Sessions increase in terms of the complexity and duration of the exercise as the program continues. Activities are to be performed in front of the tablet in a standing and/or seated position to allow the user to do what they can safely and comfortably every time they practice. Help from the family caregiver is not expected, as users can operate the tablet with an unimpaired hand. After each exercise, a questionnaire appears, asking for feedback about how the activity went. The information is then automatically emailed to the principal investigator (no action is required from the tablet user).Module 1: Familiarity with the Environment and TechnologyThe HTC Vive Pro system was used to run the VR program. The setup consists of a headset, two hand-held controllers, and two base stations on a tripod. The VR system was set up in the participant’s home for seated and standing use. The project’s principal investigator designed the environment and the cognitive activities based on a virtual apartment that replicates a newly developed ambient assisted living facility . The actModule 1 aims to instruct the user how to manipulate the material and interact with the VR environment in an incremental way . This module instills the participant’s technical skills and confidence in using VR to perform basic tasks. The activities involve putting on the helmet, learning the basic commands, and getting comfortable moving with the technology.Module 2: Task Management and PrioritizationThe second module has the same structure as the first module. It focuses on task management, the way the user prioritizes actions based on common sense and preferences and the management of the interruptions of a task in progress. The activities are added progressively so that the client can complete an entire day by the module’s last session. The goal is to manage tasks, identify priorities, and sometimes even interrupt a task in progress to meet an immediate need, such as answering the phone.Module 3: Financial ManagementModule 3 aims to enhance budget awareness and money-management abilities. A total of CAD 100 is proposed for the five sessions of this module. Throughout each session, the user will be required to make financial judgements while staying under CAD 100. If they do, they must be able to explain their financial decisions in the questionnaire at the end of the module, because every financial decision must be considered as part of the whole module’s financial management plan. For example, if the user has no laundry detergent left and must pick between three varieties of detergent, they must remember the cost and deduct it from the overall budget for this module (CAD 100). This module asks the customer to recall the expenses incurred during the five sessions. Clients might create their own memorization approach by writing down the costs incurred shortly before the session ends. Clients are free to use whatever method they feel most at ease with.Module 4: Tasks and Financial ManagementThe fourth module continues the format of the previous modules but attempts to provide the client more autonomy to carry out the tasks due to the practice they have completed. This module prepares the client for the final module by improving the abilities needed to understand and manage contingencies and adapt to varied scenarios. In the fourth module, activities are gradually introduced so that, by the end of the module, the user can complete an entire day. The sessions are more sophisticated, combining interpersonal and financial issues. Furthermore, the scripts are done away with to increase task learning and retention because the actions have already been covered in earlier sections.Module 5: Full DayThe fifth module aims to move closer to the reality of daily activities. It consolidates the learning gained in earlier modules, allowing the evaluator to determine whether the client can respond appropriately to complex sessions. The user encounters complex scenarios in this module, as each of the four sessions entails dealing with unexpected everyday life situations and financial situations for an entire day. Therefore, the evaluator will understand the acquired skills and the underpinning cognitive abilities.The protocol was approved by the University of Manitoba Research Ethics Board (REB Registry Number: H2020:069 (HS23654)). The participants signed a consent form electronically before the start of the study. Following participant enrollment, a battery of assessments was performed by a physiotherapist on day 1 (in our laboratory), followed by re-assessments at home during weeks 6 and 12. These assessments included the Fugl-Meyer assessment (FMA) , the MinIn addition to these assessments, the Motor Activity Log (MAL) , Stroke To gain insight into the family caregiver’s perspective, an email was sent to them after the study completion to enquire about their “attitudes and perceptions towards the home-based rehabilitation program and their experience with the research project” (the main question of the email). The responses received were exhaustive and highly organized. We analyzed the caregiver opinions verbatim, using an inductive creation-of-themes method to classify and understand the content shared.Mild stroke, onset over six months before the initiation of the program;Absence of any additional neurological or psychiatric disorders or orthostatic hypotension;Able to walk and move the impaired upper limb;Willing to participate;Living outside the city with access to the internet at home;Living with someone who can help in the operation of a VR system.A participant contacted the principal investigator by email after attending a public presentation. The participant was screened to determine their eligibility for the program according to the following inclusion criteria:Once eligibility to participate in our study was confirmed, the participant was invited to an orientation session, which included an introduction to the VR and tablet program. The tablet running the physical training program was handed out to the participant on the same day and instruction on how to use it was given. The VR platform, comprising a gaming computer and a VR system, was installed in each participant’s home in the following week. The participant and their caregiver received a training session at home on how to use the VR.Our participant is a 55-year-old woman who experienced a stroke in March of 2021. The participant lives in a house a 1.5–2-h drive from the main city in a community of fewer than 15,000 inhabitants. Their home is equipped with reliable internet and has a large and safe space, sufficient to engage in our program. The stroke affected her right upper and lower extremities, increasing the tone mainly in her arm and hand. The stroke also affected her speech, which resulted in aphasia. After the stroke, the participant attended two months of stroke rehabilitation, where an interdisciplinary team worked with her. This team consisted of occupational therapists, physiotherapists, and speech-language pathologists. After discharge, she continued seeking out therapy regularly for her physical functional needs and speech training. At the time of the study, the participant was regularly seeing a private practice physiotherapist, an occupational therapist, a speech and language pathologist, and a personal trainer.In the day 1 assessments, our participant received a score of 30/30 on the MMSE, which is within the normal range . On the Weekly check-ins were performed through informal phone interviews. The purpose of the interviews was to discuss generally what went well and what did not. Additionally, observations and data from the actual performance were automatically uploaded to the principal investigator’s server via the programs.During the first check-in, the participant noted some general sickness that prevented them from being able to continue the first few sessions of the program. The MAL, SIS, and TSRQ were completed. In the TSRQ, the participant reported that it was important for them to exercise and get well soon. The participant also indicated strongly that they would feel guilty if they did not follow through with the program. On the SIS, the participant self-scored an overall value of 60/100 regarding their perceived level of recovery.The participant reported that they were able to complete the first VR session, but they needed the assistance of their caregiver to press the action button located on the top of the controller. Because of the high tone in the right hand, the participant was not able to press the action button independently. The ergonomics of the controller were not well suited to this particular situation.In the third week, the participant did not complete any sessions due to their unavailability during this time for personal reasons.In the fourth week, no further VR sessions were completed as the caregiver was not available to assist with the right-hand controller. One additional tablet session was completed. The participant noted that it was significantly more difficult due to the inclusion of exercises that required them to move their arm above the shoulder. There was no noted pain during this movement. The participant was also interested in modifying the controller to meet the practice needs. After discussions with the research team, the family caregiver (partner) attached a brace with adhesive Velcro to attempt to make it more functional and a plate to neutralize undesired thumb movement . The parIn week five, the participant experienced difficulty with fine motor tasks as the sessions continued. The participant did not experience difficulty with tasks involving gross motor skills. The participant did not continue with any VR sessions due to issues with the controller. The participant also noted that they experienced difficulty initiating the sessions due to motivation; however, they did not experience any difficulty completing the session. The participant suggested that a research team member send motivational emails daily, and the research team agreed.In week six, the participant noted that their caregiver was able to modify the controller to make it more comfortable to wear and easier to maneuver. However, clicking the button for actions still required help from the caregiver. The participant also completed one additional tablet session. They noted that it was easier as there were no exercises involving fine motor tasks. The motivational and prompting emails were helpful but the participant was not able to continue with many tablet sessions due to their own schedule becoming busier, causing fatigue.In week seven, the three questionnaires were re-administered. For the TSRQ, most of the scoring was the same, except for a few questions that asked whether participant would feel bad if they did not complete the program. This shifted to a “2”, which indicates “not really”. This is different to week 1, where they had answered “4”, which indicates strongly that they would feel guilty. Regarding the SIS, the participant self-scored higher on the overall recovery level with a score of 70/100. Tasks that were originally scored as “very difficult” to perform were now scored as “could not do at all”. This is consistent with certain MAL tasks compared to the first time. There was an increase in the number of tasks that scored a “0” on the amount scale, even though they were scored higher on day 1. Many of the tasks that shifted to a “0” were tasks that were focused on fine motor skills, such as using a doorknob or turning on the faucet. Instead, the participant used their unaffected arm and hand for compensation.The following results were measured in week six.On the 10MWT, the average self-selected velocity was 6.15 s, whereas the fast velocity was 5.9 s, indicating an increase in the participant’s walking speed since day 1. Her score on the Borg scale of perceived exertion was “4”, which indicates “moderate activity: feels like you can exercise for hours, breathing heavily but can hold a short conversation” for the 10MWT. On the MAS, the elbow flexors/extensors, shoulder flexors, wrist, and finger extensors and flexors were reassessed and the participant’s score for each subset was “1”, indicating a reduction in their tone. A score of “1” indicates a “slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected parts are moved in flexion or extension”. For the MMSE, the participant’s score was 24/30, which is a significant reduction from day 1. This score suggests mild dementia. On the FMA, the score increased to 40/66 from day 1.Our participant completed eight home training sessions for the VR within six weeks and five tablet training sessions within six weeks. The participant was not able to complete the recommended two sessions a week for each program due to illness. During the first six weeks, the participant could not work on sessions for two weeks. Through informal interviews, other circumstances were brought up, such as the need for a caregiver to complete the VR with the participant, which meant that they both had to be available and well. Motivation also appeared to have an influence on the number of tasks completed per week. The participant reported that being self-directed in therapy posed a challenge because there was no one physically there to keep them accountable.The following results were measured after the last session of week 12.On the 10MWT, the average self-selected velocity was 6.2 s, whereas the fast velocity was 4.1 s, showing an increase in the participant’s walking speed since week six. Her score on the Borg scale of perceived exertion was “4”, which indicates “moderate activity: feels like you can exercise for hours, breathing heavily but can hold a short conversation” for the 10MWT. On the MAS, the elbow flexors/extensors, shoulder flexors, and wrist flexors/extensors were assessed and given a score of 1, indicating a reduction in their tone from day 1. A “1” indicates a “slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected parts are moved in flexion or extension”. However, the finger extensors/flexors and, wrist extensors, and thumb abductors were reassessed, and the participant’s score for each subset was “0”, indicating “No increase in muscle tone”. For the MMSE, the participant’s score was 24/30, which is the same as that recorded in week six but still a significant reduction from day one. This score suggests mild dementia. The FMA score had increased creased from 40/66 to 51/66 since Week 6.Our participant completed 16 home training sessions for the VR within 6 weeks and 10 tablet training sessions within 12 weeks. The participant was not able to complete the recommended two sessions a week for each program due to illness and managed as best as they could. Motivation also appeared to have an influence on the number of tasks completed per week. The participant reported that being self-directed in therapy posed a challenge because there was no one physically there to keep them accountable. The participant did not fall during any of the practice sessions.one of the biggest challenges is dealing with the swiftness that this change has on [their] life. In [their] case, [his] wife, best friend, and confidant of 35 years was now lying in the hospital paralyzed and unable to speak”… and crying “…all the time and seemingly for no reason at times”… while he is “…running around making plans and decisions on [his] own. Something that [the couple] always did together”. He also mentioned feeling alone in this new struggle without any external support, since the stroke “kicked off in the blink of an eye and totally without warning”, but he emphasized they are fortunate to have a comfortable financial situation: “I am fortunate that we have good insurance coverage, and I was able to close my business without worrying about finances or outside commitments. I can’t imagine what this would be like while still trying to hold down a job and put bread on the table”.We asked the family caregiver to share their opinions about their situation, their attitudes and perceptions toward the home-based rehabilitation program, and their experience with the current research project. The following themes emerged from the extensive essay they (the husband) shared by email. The caregiver felt devastated by the new situation, mentioning that “needs to catch up”, according to the caregiver. “Looking at this from the outside, it has been a challenging road that we have travelled in that the local hospital lacks the resources to give any meaningful aftercare or rehab to Stroke survivors”. He emphasized that the situation is worse for someone living in a rural area where hospitals “need to be updated to enable constructive and easily accessible treatment and rehabilitation” and lack quality programs, according to the caregiver: “A visit to the Occupational Therapy department of your local hospital once every two months is not good enough and the exercises prescribed are not always appropriate”. The family caregiver also shared that he felt left behind by the entire health system, which is not prepared to care for patients in the city, almost absent in rural settings, heavily bureaucratic, and more or less unprepared to support the family caregiver. This creates, according to the caregiver, “a myriad of issues for the spouse or family member who is thrust into the role of caregiver” without any support or accompaniment:“You are being asked to do things you have never prepared for. Both in the physical aspect of caring for someone with disabilities and now non-functioning body parts and systems and the emotional side of mourning the loss of your spouse as you know them and your life as you know it.” … “The list of issues begins with having to deal with and navigate your way around hospitals, surgeons, physicians, nurses, travel, and accommodation. These are just a few things that the home caregiver requires within the first few weeks of their partner having a stroke.”We also asked questions regarding access to care and systemic barriers. The family caregiver noted difficulties in accessing resources and care in a healthcare system that “Training of Physiotherapists, Occupational Therapists, Speech Therapists, Primary Care Physicians and general staff is sorely lacking. Physiotherapists are trained to treat muscles, tendons and joints. Occupational Therapists are there to get patients back to work and make adaptations to allow for normal day-to-day activities, while Primary Care Physicians are not trained in the care of post stroke patients.” … “Family Physicians and health care workers, in general, need to be trained and informed of procedures and resources available to stroke survivors and their families”.The unpreparedness of healthcare professionals also emerged as a central theme. According to the family caregiver, who is not a healthcare professional, “This study aimed to determine the feasibility and safety of a technology-enabled at-home telerehabilitation program administered remotely as an adjunctive therapy to conventional rehabilitation services for a stroke survivor living rurally in Manitoba (Canada). The program was tested with one participant with a mild stroke who was already able to walk and move the impaired upper limb and does not have any additional neurological or psychiatric disorders or orthostatic hypotension. The participant readily accepted the technology at home and found the tablet exercises enjoyable and easy to follow. The first hurdles in implementing our program in a rural setting were distance and access to the internet, required for the technology to transfer data to the researchers and for the family to interact with the researchers. The researchers were able to travel back and forth in a single day to install the device or conduct an evaluation session; thus, the distance was not an issue. There was no problem at all in communication because the household had internet access. However, this would have been an issue in other contexts where the internet is unavailable, in which case the data recorded by the two devices would not be shared, and the communication between the family and researchers would be more problematic or elementary, without any file-sharing or videoconferencing.Overall, our preliminary results show that the VR environment effectively engages patients in telerehabilitation and is a safe virtual space for stroke survivors to regain neurocognitive skills. Our results are in agreement with the literature on less advanced VR systems offering gamified upper-limb training sessions ,21,22,23Additionally, the VR controller’s shape and the button’s location presented the participant with difficulties in holding it with the affected hand. In consultation with the principal investigator, the caregiver added adaptations to the right-hand controller for the VR setup to make it more functional, since the participant’s high tone created difficulty in completing the VR sessions without the caregiver’s help. One adaptation involved using an aluminum plate to hide the touchpad so that only the hand trigger on the controller’s bottom would receive input from the participant’s index finger . We alsoMotor learning has been shown to be optimized through immediate feedback and the grading of activities . The funThe VR system presented some difficulties regarding a lack of hand function, comfortability, and technical aspects, but it was overall well received by the participant. Each piece of technology presented its own set of barriers and limitations. Our participant attended the required training session before the technology was installed in their home. Still, despite the completion of the VR training, a lack of comfort and a sense of anxiety surrounding the use of the VR system served as a barrier to using the VR system at home. A patient with a stroke is naturally determined to recover bodily functions and eager to return to pre-injury occupations. The determination of our participant and her caregiver helped them to overcome the technical difficulties encountered. For example, the couple assigned all the tasks of monitoring the laptop to the caregiver. The couple also decided to co-practice together and slowly in the beginning, especially for the task of teleportation, as it was initially very difficult for the user as they need to raise hand with the controller while holding a button to move from their current location to the next one. This movement requires a large range of motion of the shoulder, which a hemiplegic patient cannot easily achieve without compensations. Consistently in the literature, technological literacy has been discussed as a barrier to engaging in telerehabilitation amongst older adults using tablets. Vaportzis et al. (2017)  found a There is a significant need for stroke rehabilitation services that eliminate the current barriers to accessibility faced by rural community dwellers ,5, and wAlthough cost-effectiveness was not evaluated in this study, it is an important aspect to consider with TR, as it has the potential to be a considerable limitation. Lloréns et al. (2015)  found thThis study demonstrates that, in conjunction with traditional rehabilitation services, the use of VR and tablet-based TR is feasible in certain circumstances. The lack of comfortability with technology itself amongst the typical stroke population demonstrates the need for a more in-depth training process to ensure that individuals can manage the technology independently and safely once they are at home. Caregivers who are supporting the individuals at home should also attend and participate in the training process, as we learned that reliance on caregiver assistance with both the VR and the tablet technology was an important factor during this study. The degree of physical impairment following a stroke needs to be considered when using both the VR and tablet systems. The use of two controllers to navigate and manipulate items in the VR simulation limits the use of the technology. Although pain was noted while performing some of the tablet exercises, by trusting that our participants are experts in their own bodies and conditions, this program offered them the opportunity to skip the exercises that they felt were problematic for them.


A significant improvement in joint range of motion, life quality (p < 0.001), relief in knee pain (p < 0.001) and in the post-program evaluation at the EG (p < 0.05) was noted. There was no significant difference in PTE and PTF between groups at 60°/s and 180°/s. The IMS in the active mode could be an effective therapeutic modality in managing middle-aged patients suffering from a degenerative meniscal tear.Meniscal injuries are one of the most common intra-articular knee injuries. Different treatments are presented depending on the symptoms and duration of meniscus tears, such as arthroscopic partial meniscectomy, physiotherapy, or even pharmacological treatment. The purpose was to investigate the effect of a concentric isokinetic knee muscle strengthening program on strength, joint range of motion, physical performance, quality of life and pain tolerance in overweight/obese women with chronic meniscal lesions. Twenty-four overweight/obese women were randomized into two groups. A control group (CG) performed a usual rehabilitation program plus isokinetic muscle strengthening (IMS) in the continuous passive motion mode and measured with an isokinetic dynamometer. An experimental group (EG) performed the same program in combination with IMS in the isokinetic active mode. The peak torque of the knee extensors (PTE) and flexors (PTF), sit-to-stand test, stair climb test, joint amplitude, heel-to-buttock distance, Thessaly test, KOOS questionnaire of pain and quality of life were measured pre- and post-protocol. After the intervention, the sit–stand number for both groups was significantly higher ( In middle-aged adults, meniscal injuries are one of the most common intra-articular injuries of the knee and are the most frequent cause of surgical interventions performed by orthopedic surgeons . For insIn individuals with overweight, both a higher prevalence and severity of early degenerative changes in the knee in middle-aged individuals without radiographic osteoarthritis (OA) and significantly increased cartilage lesion progression (of any grade) were noted , therebyDepending on the symptoms and duration of meniscus tears, surgeons may opt for different treatments, including arthroscopic partial meniscectomy (APM) or conservative treatments such as physical therapy (PT) or pharmacological treatment ,8. For mResearchers indicated that isokinetic muscle strength assessment could be used to accurately test muscle strength, adjust the nerve control of muscle function, and enhance joint stability, flexibility and movement coordination ,11. ThisSince performing APM in all patients with knee pain and a meniscal tear is inappropriate, surgical treatment should not be considered the first-line intervention . Consequ2 and a radiological diagnosis indicating stage 2 degenerative meniscal lesions. The meniscal lesion stages and leg dominance were identified by the same physical doctor. Patients were assessed for a clinical determination of footedness to identify their preferential side (if they were right- or left-footed) in accordance with tasks identified by Schneiders et al. [The participants’ recruitment was carried out for six months. For study eligibility, they had to be female, aged between 35 and 55 years, and suffer from knee pain and discomfort for the majority of the previous 30 days prior to the study (one and/or both affected knees), with a body mass index (BMI) above 26 kg/ms et al. . The preFurthermore, patients undergoing meniscal surgery, with health problems, heart diseases, and cancer under treatment, pregnant patients and unavailable patients were ruled out. In addition, exclusion criteria concerned withdrawal from the study, absence in 2 consecutive sessions in a week, injury, and a declaration of demotivation or non-implication in carrying out the protocol. G-Power software (G*Power 3.1.9.6) was used to compute the sample size required. An effect size of f = 0.40, an actual power of 0.85, and α = 0.05 were included in analysis. A minimum sample size of 16 participants was required hence the selection of 24 participants that also met the criteria . The risThis study was randomized controlled and following initial testing, our study population was randomized into two groups. Randomization and allocation to groups were conducted using a random number generator based on the type of procedure undergone . The conBriefly, there were r12 sessions over 6 weeks at a rate of two sessions per week, with 2 rest days between two sessions (Monday and Thursday for some patients and Tuesday and Friday for other patients).After a 10 min warm-up on an ergocycle, dynamic stretching and static stretching of the quadriceps, hamstrings, adductors, gluteal and calf muscles were performed (10 min).Then, IMS in the concentric mode was conducted, with the first session consisting of 1 set of 5 maximum knee flexion/extension repetitions for each knee. Overall, the dominant leg was always trained first on the isokinetic machine.The number of sets increased progressively with the addition of 1 set per session (+1 set/session), to reach 12 sets of five repetitions at the 12th session with 1 min 30 s to 2 min of recovery between sets from the second week.Tolerance was monitored at each session and effectiveness was determined at the end of the program by performing a maximal isokinetic evaluation of knee flexors and extensors.The following training program was performed for all groups :Briefly,General anthropometric data were measured barefoot with as little clothing as possible. Height was tested with a non-deformable measuring scale on the floor, with feet together and looking forwards. BMI, body weight, and percentage of fat were measured with an impedance meter . Patients were familiarized with the test procedures before taking the measurements. Prior to testing, participants performed a standard warm-up consisting of 10 min of pedaling on an ergocycle  with the number of rounds per minute being between 70 to 90, and a heart rate not exceeding 140 beats per minute, followed by muscle stretching. The test durations varied between 1 h 45 min and 2 h 30 min. The testing order was randomized for participants’ motivation and to avoid tampering with the results.We used an isokinetic dynamometer of the isoforce type  to assess muscle strength. The subject was instructed to be seated with their back at 90° with an adjustment seat for thigh length during examinations . The rotFor the sit-to-stand test, a chair with a hard seat whose floor-to-seat height was 45 cm was stabilized by placing it against a wall. The test began with the participant seated in the middle of the chair, with their back straight, and feet approximately shoulder-width apart and placed on the floor at an angle slightly back from the knees, with one foot slightly in front of the other to help maintain balance when standing. The participant was asked to sit with their upper limbs folded across their chest and then to stand up all the way and sit down again without using her arms as quickly as possible . The scoThe stair climbing test consisted of a measure of the time required for participants to climb eleven stairs at the height of 20 cm. It is a valid and reliable test with an Interclass correlation coefficient of 0.94 and good inter-rater reliability . ParticiKnee flexion and extension (amplitude) joint ranges were measured using a goniometer by centering it on the knee’s lateral condyle and aligning one arm of the goniometer along the femur axis toward the greater trochanter and the other along the leg toward the lateral malleolus in the supine position ,36 Figu.Heel-to-buttock distance (HBD) was measured to detect potential loss of muscle size or reduced flexibility, primarily of the quadriceps . The exaThe Thessaly test was originally described by Karachalios et al. . It atteAll clinical tests were conducted by the same physical doctor and they were performed twice, once during the test familiarization week and the other during the pre-training assessment period.The Knee Injury and Osteoarthritis Outcome Score (KOOS) Arabic version questionnaire was used . The subpη2) was examined to investigate the size of the difference between the variables . The level of statistical significance was considered to be at p < 0.05.The STATISTICA 10.0 software  for Windows was used for analysis. The findings are reported as mean values ± standard deviation. The normality of the distribution of all variables was checked with the “Shapiro-Wilk” test to determine the selection of tests (parametric or non-parametric). A two-way repeated measures analysis of variance, ANOVA , was conducted. A comparison by pair was performed using the Bonferroni/LSD post hoc test. The effect size ((1.22) = 0.634; p = 0.434; pη2 = 0.028), pre–post-program (F(1.22) = 0.019; p = 0.892; pη2= 0.0008), group × pre–post-program interaction (F(1.22) = 0.719; p = 0.405; pη2 = 0.032), group × RL interaction (F(1.22) = 0.187; p = 0.669; ηp2 = 0.008), and RL × pre–post-program interaction (F(1.22) = 0.087; p = 0.771; pη2 = 0.004) effects, but a significant effect of RL (F(1.22) = 10.167; p = 0.004; pη2 = 0.316) and pre–post-program × RL × group interaction (F(1.22) = 6.743; p = 0.016; pη2 = 0.235) was observed. The PTEs of the right knee were significantly improved after the program compared to those before for the CG (p = 0.0147). Concerning the left knee, results showed a significant improvement in the post-program evaluation for the EG compared to that in the CG (p = 0.003)  .(1.22) = 1.251; p = 0.275; pη2 = 0.054), pre–post-program (F(1.22) = 0.505; p = 0.485; pη2 = 0.022), group × pre–post-program interaction (F(1.22) = 0.089; p = 0.768; pη2 = 0.004), group × RL interaction (F(1.22) = 1.032; p = 0.321; pη2 = 0.045), RL × pre–post-program interaction (F(1.22) = 0.526; p = 0.476; pη2 = 0.023) and RL (F(1.22) = 3.664; p = 0.069; pη2 = 0.143) effects, but a significant effect of pre–post-program × RL × group interaction (F(1.22) = 5.590; p = 0.0273; pη2 = 0.203) was found. Furthermore, the left knee PTFs were significantly improved after the program compared to those before for the CG (p = 0.028), and they were significantly different between the EG and the CG prior to the program (p = 0.019)  .(1.22) = 0.140; p = 0.711; pη2 = 0.006), group × pre–post-program interaction (F(1.22) = 0.599; p = 0.447; pη2 = 0.027), group × RL interaction (F(1.22) = 3.483; p = 0.075; pη2 = 0.137), RL × pre–post-program interaction (F(1.22) = 2.244; p = 0.148; pη2 = 0.093) and pre–post-program × RL × group interaction (F(1.22) = 1.037; p = 0.319; pη2 = 0.045) effects, but a significant effect of the pre–post-program (F(1.22) = 7.028; p = 0.015; pη2 = 0.242) and RL (F(1.22) = 18.550; p = 0.0002; pη2 = 0.457) was observed. Moreover, a significant improvement of the right (p = 0.0003) and the left (p = 0.00095) knee PTEs were shown after the program for the CG, while the right knee PTEs were significantly different from those of the left knee measured after the program (p = 0.03). Similarly, the EG right knee PTEs after the program were significantly different compared to the left knee PTEs prior to the program (p = 0.008)  .(1.22) = 0.033; p = 0.857; pη2 = 0.002), RL × pre–post-program interaction (F(1.22) = 3.489; p = 0.075; pη2 = 0.137), pre–post-program × RL × group interaction (F(1.22) = 1.634; p = 0.214; pη2 = 0.069) effects. However, significant pre–post-program (F(1.22) = 11.056; p = 0.003; pη2 = 0.334), group × pre–post-program interaction (F(1.22) = 5.098; p = 0.034; pη2 = 0.188), group × RL interaction (F(1.22) = 4.533; p = 0.045; pη2 = 0.17) and RL (F(1.22) = 19.718; p = 0.0002; pη2 = 0.473) effects were found. The right and left knee PTFs were significantly improved after the program compared to those before for the CG  with a significant difference between the EG pre-program and the CG after the program (p = 0.006). For the CG, the right knee PTFs were significantly higher than the left knee PTEs after the program (p = 0.00007)  .(1.22) = 12.492; p < 0.001; pη2 = 0.362), pre–post-program (F(1.22) = 143.690; p < 0.001; pη2 = 0.867) and group × pre–post-program interaction (F(1.22) = 17.935; p < 0.001; pη2 = 0.449) was determined. Moreover, the sit–stand number was significantly higher post than that pre-program for both groups (p < 0.001). A highly significant improvement was registered in the post-program assessment in the EG (p < 0.001) compared to the CG (The highly significant-difference group (Fo the CG .(1.22) = 5.109; p < 0.05; pη2 = 0.188), pre–post-program (F(1.22) = 50.222; p < 0.001; pη2 = 0.695) and group × pre–post-program interaction (F(1.22) = 15.355; p < 0.001; pη2 = 0.411) was noted. The time required to climb stairs was significantly reduced after the intervention compared to that before for the EG (p < 0.001). There was also a significant improvement in the post-program evaluation of the EG compared to that of the CG (p < 0.05) (The highly significant difference group (F < 0.05) .(1.22) = 0.400; p = 0.534; pη2 = 0.018) and group × pre–post-program interaction (F(1.22) = 0.353; p = 0.558; pη2 = 0.016) but a significant pre–post program (F(1.22) = 77.172; p < 0.001; pη2 = 0.778) effect was observed. For both groups, the joint ranges of knee flexion to the right were significantly improved after the intervention compared to those before (p < 0.001). There was a non-significant improvement in the post-program evaluation for the EG compared to that for the CG (p > 0.05)  .(1.22) = 0.521; p = 0.478; pη2 = 0.023) and group × pre–post-program interaction (F(1.22) = 0.873; p = 0.360; pη2 = 0.038) but a significant pre–post-program effect (F(1.22) = 65.409; p < 0.001; pη2 = 0.748). A significant improvement reflected by an increase in the joint ranges of knee flexion to the left after the intervention for the two groups (p < 0.001) was found but there was no significant improvement between groups post-program (p > 0.05)  .(1.22) = 0.486; p = 0.493; pη2 = 0.022) and group × pre–post-program interaction (F(1.22) < 0.001; p = 1.000; ηp2 < 0.001) but a significant pre–post-program (F(1.22) = 13.538; p = 0.001; pη2 = 0.381) effect was observed. The amplitude of the joint ranges of knee extension to the right did not improve for either group after the program or between groups (p > 0.05)  .(1.22) = 1.081; p = 0.309; pη2 = 0.047) and group × pre–post-program interaction (F(1.22) = 2.099; p = 0.161; pη2 = 0.087) but a significant effect of the pre–post-program (F(1.22) = 14.191; p = 0.001; pη2 = 0.392) was noted. The joint ranges of knee extension to the left were significantly improved after the intervention for the CG (p < 0.001)  .(1.22) = 0.002; p = 0.961; pη2= 0.0001) pre–post-program (F(1.22) = 1.683; p = 0.208; pη2 = 0.071), group × pre–post-program interaction (F(1.22) = 0.034; p = 0.855; pη2 = 0.001), RL × group interaction (F(1.22) = 1.030; p = 0.321; pη2 = 0.045), pre–post-program × RL interaction (F(1.22) = 1.678; p = 0.209; pη2 = 0.071) and pre–post-program × RL × group interaction (F(1.22) = 1.678; p = 0.209; pη2 = 0.071) (There was a non-significant effect of the group (F= 0.071) .(1.22) = 2.654; p = 0.118; pη2 = 0.118) pre–post-program (F(1.22) = 0.343; p = 0.564; pη2 = 0.015), group × pre–post-program interaction (F(1.22) = 0.021; p = 0.885; pη2 = 0.0009), RL × group interaction (F(1.22) = 0.328; p = 0.572; pη2 = 0.015) and pre–post-program × RL × group interaction (F(1.22) = 0.328; p = 0.572; pη2 = 0.015), but a significant effect of the RL (F(1.22) = 257.433; p < 0.001; pη2 = 0.921) and pre–post-program × RL interaction (F(1.22) = 5.254; p = 0.032; pη2 = 0.193). Pain sensation was significantly reduced after the intervention for the EG and CG (p < 0.001) when externally rotating their knees (to the left). In addition, it was noted that there was a significant difference between the EG pre-program while internally rotating (to the right) and the post-program while externally rotating (to the left) (p < 0.05). Similarly, there was a significant difference between the EG prior to the program while internally rotating and the CG post-program while externally rotating , as well as a significant difference between the EG prior to the program while externally rotating and the CG post-program while internally rotating (p < 0.001) (The results indicated a non-significant effect of the group (F< 0.001) .(1.22) = 4.479; p = 0.046; pη2 = 0.169) with a significant training effect (F(1.22) = 179.279; p < 0.001; pη2 = 0.890) and a non-significant effect of the group × training interaction (F(1.22) = 0.743; p = 0.398; pη2 = 0.033) was recorded. Indeed, the quality of living was significantly improved after the intervention for both groups (p < 0.001), but did not improve significantly between groups after the program (p > 0.05)  .(1.22) = 2.523; p = 0.126; pη2 = 0.103), of the group × training interaction (F(1.22) = 0.944; p = 0.341; pη2 = 0.041) and a significant training effect (F(1.22) = 152.378; p < 0.001; pη2 = 0.874) were reported. The pain sensation was significantly reduced after the program for both groups compared to that before (p < 0.001) but did not change between groups in the post-program (p > 0.05)  .Collectively, meniscal injuries represent one of the most common intra-articular knee injuries and are one of the most frequent causes of surgical interventions performed by orthopedic surgeons. As far as is known, no previous study has attempted to use an isokinetic muscle strengthening program as a therapeutic approach for middle-aged patients with a degenerative meniscus lesion. Thus, the study’s purpose was to investigate the effect of a concentric isokinetic strengthening training program on knee muscle strength and flexibility, range of motion, motor performance, quality of life and pain tolerance in overweight or obese women with chronic meniscal lesions. We attempted to use an IMS program as a therapeutic approach for middle-aged patients with a degenerative meniscus lesion. As conservative treatment is becoming the preferred treatment, several randomized controlled clinical trials and the ESSKA Meniscus Consensus Project recommend against APM as the first-line treatment for managing knee pain in patients affected by DML with no radiographic knee osteoarthritis ,41.p < 0.05) compared to that in the CG. Like any modality of muscular strengthening, the adequate elaboration of the training load induced by the isokinetic dynamometer causes an increase in the pathological knee muscle strength [With regard to physical performance tests, the number of sit–stands performed during the 30 s for both groups was significantly higher after the intervention than that before. Correspondingly, a highly significant improvement was registered in the post-program assessment in the EG compared to in the CG. Furthermore, the time required to climb stairs was significantly reduced after the intervention compared to that before for the EG. There was a significant improvement in the post-program evaluation in the EG  while conducting the Thessaly test. In addition, the joint ranges of knee flexion to the right/left significantly improved after the intervention for both groups. Accordingly, these findings suggest an improvement in knee function and relief in knee pain. They could be explained by the advantages of resistance training which increases the strength and volume of the motor muscles of the knee joint, reduces its friction, and decreases the biomechanical stresses due to the weight of the body upper part via effect depreciation . PreviouMoreover, knee muscle weakness is thought to be among the earliest and most significant indicators in patients with knee osteoarthritis . Hence, Similarly, compared with APM-treated cases, a 12-week supervised neuromuscular and strength exercise therapy regimen demonstrated clinically applicable and statistically relevant improvements in isokinetic quadricep muscle strength immediately after program completion. Surgery was not associated with changes in muscle strength three months post-surgery, and exercise seems essential to improving muscle strength in these patients. Practitioners can investigate using this valuable therapeutic exercise regimen in the management of middle-aged patients suffering from a degenerative meniscal tear to increase knee muscle strength and improve functional performance . In thisThe study found that patients in both groups had reduced pain with a significant improvement in “quality of life”. Similarly, Herrlin et al.  found thOverall, limitations are identified in addition to the relevant results found. The study was limited to women affected by meniscal lesions and whose results cannot be generalized for all individuals with meniscal lesions. In addition, during the first three weeks of the protocol, muscle soreness was felt by some patients who could not bear it, caused inevitably by the short recovery time between sets from the second training week. This prompted them to consider the extensive effort required for the program. Moreover, the number of sessions/week was limited due to the availability of the isokinetic dynamometer. Additionally, the knee testing order during isokinetic procedures was not randomized due to the times of availability and convenience of patients during the experimental protocol evaluations. Finally, examiner intra-rater reliability could not be provided and calculated due to the lack of time that was allocated to use the experimental area and equipment.Our results are preliminary, and it seems that future studies are necessary that involve a larger number of participants and a longer training duration. A male population and a comparison between surgical procedures and the IMS program should also be possible.Our findings support the isokinetic muscle strengthening (IMS) program in the active mode as an effective therapeutic modality in managing middle-aged patients suffering from a degenerative meniscal tear. We found a significant improvement in physical performance, range of motion, life quality and relief in knee pain. In addition, no significant difference in concentric knee flexor or extensor (body weight adjusted) strength between groups at velocities of 60°/s and 180°/s was noted, which can be explained by the rather short duration of the intervention program (6 weeks). Structures and functional rehabilitation centers in physical medicine with isokinetic dynamometers should introduce IMS programs for the better management of this type of pathology, making the rehabilitation process more effective than the classic one proposed.