Polygonum minus-based products have increased in recent years, for its antioxidant, anticancer, antimicrobial, and anti-inflammatory potentials. Although few reports have indicated the chemical profiles and antioxidative effects of Polygonum minus, no study has been conducted to assess the benefits of micro-environmental manipulation (different shading levels) on the growth, leaf gas exchange and secondary metabolites in Polygonum minus. Therefore, two shading levels (50%:T2 and 70%:T3) and one absolute control (0%:T1) were studied under eight weeks and 16 weeks of exposures on Polygonum minus after two weeks. It was found that P. minus under T2 obtained the highest photosynthesis rate (14.892 µmol CO2 m−2 s−1), followed by T3 = T1. The increase in photosynthesis rate was contributed by the enhancement of the leaf pigments content (chlorophyll a and chlorophyll b). This was shown by the positive significant correlations observed between photosynthesis rate with chlorophyll a  and chlorophyll b . As the shading levels and time interval increased, the production of total anthocyanin content (TAC) and antioxidant properties of Ferric Reducing Antioxidant Power (FRAP) and 2,2-Diphenyl-1-picrylhydrazyl (DPPH) also increased. The total phenolic content (TPC) and total flavonoid content (TFC) were also significantly enhanced under T2 and T3. The current study suggested that P.minus induce the production of more leaf pigments and secondary metabolites as their special adaptation mechanism under low light condition. Although the biomass was affected under low light, the purpose of conducting the study to boost the bioactive properties in Polygonum minus has been fulfilled by 50% shading under 16 weeks’ exposure.The growing demand for high value aromatic herb  Polygonum minus Huds (Family: Polygonaceae), which is commonly known as kesum, is an aromatic herbaceous plant originally located from Southeast Asian countries, such as Malaysia, Thailand, Vietnam, and Indonesia [P. minus is frequently used by the locals in Malaysia as spices and flavouring agents in the delicate local cuisine due to its distinctive and lemony aroma. It has also been traditionally used to treat digestive disorders, dandruff problems and body [P. minus recognised it as an essential oil-producing crop in the Herbal Product Blueprint by the Malaysian government [P. minus has also been reported to exhibit significant reactive oxygen species (ROS) scavenging activities due to its high antioxidant content, and it can be considered to be as one of natural medicinal resources [P. minus was also reported to be able to improve cognitive function and exhibit neuroprotective effect [P. minus or kesum-based products have been commercialised, for its antioxidant, anticancer, antimicrobial, and anti-inflammatory potentials [P. minus as an anticancer agent was recognised by the display of anti-proliferative activity and apoptosis induction in P. minus on selected cancer and normal cell lines [P. minus stems, named Polygonumins A, which was reported to be able to inhibit cancer cells without affecting the normal cells, and have the potential in treating leukaemia [ndonesia . P. minuand body . Previouand body . High levernment . It alsovernment . P. minuesources . P. minue effect . Currenttentials ,5. The pll lines . Anothereukaemia . TherefoOrthosiphon stamineus showed that low light helped the plant to produce higher biomass when compared to high light intensity [Epimedium pseudowushanense exposed to light intensity level of 90.9 ± 2.5 µmol m−2 s−1 [2 in rice leaves [Brassica campestris increased under shaded treatments. This indicates that the effects of shadings or light intensity vary with different plant species. Different irradiance levels exposed to plants will also influence and affect the production and accumulation of secondary metabolites. Ghamzadeh et al., 2010 [Zingiber officinale. Meanwhile, another study conducted by Ibrahim et al., 2014 [Labisia pumila showed an increase in the production of secondary metabolites at low light intensity level, along with a high level of CO2.Light intensity is known to regulate not only plant growth and development, but also the biosynthesis of secondary metabolites ,11. In gntensity . A simil m−2 s−1 . However m−2 s−1 . It was e leaves . Meanwhie leaves  showed tl., 2010  reportedl., 2014  on the pP. minus is still limited. Although various reports can be found on the chemical profiles and antioxidative effects of Polygonum minus [Polygonum minus. A sufficient understanding on the influence of shading towards the growth, leaf gas exchange, and the production of secondary metabolites in P. minus are very important for successful cultivation and optimisation in order to utilise this plant’s benefit efficiently. This current study was conducted with the objective to examine the effects of different light intensity under different shading levels on the growth, leaf gas exchange, and the accumulation of secondary metabolites of P. minus.Currently, the knowledge of different environmental effects on um minus ,5, no stP. minus grown under T2 grew the tallest with PH of 11.23 ± 1.197 cm on the 25th day, followed by T3 (10.94 ± 1.234 cm) and T1 (9.54 ± 0.895 cm) (Plant height (PH) and leaves number (LN) were significantly influenced by the different shading levels. .895 cm) . Data an.895 cm) .P. minus. Meanwhile, a constant increasing trend was observed under T2 starting on the 9th day. PH had positively correlated with LN .T1 resulted in the highest LN (18.75 ± 2.133), which was 52.5% higher when compared to T2 (8.91 ± 1.011) and 54.5% more as compared to T3 (8.53 ± 0.979) recorded on the 25th day . The decp ≤ 0.05), while there are no significant differences among SDW and RDW under time interval of eight weeks excluding LDW. Under eight weeks, the lowest LDW found on T3 and T2. 2 = 0.988, p ≤ 0.01) and RDW .Leaf dry weight (LDW), shoot dry weight (SDW), and root dry weight (RDW) that were harvested under time interval of 16 weeks were significantly influenced by different shading levels (2 m−2 s−1), followed by T3 = T1. The same trend was observed for leaf temperature (Tleaves) with the highest value being recorded in plants under T2 (36.10 ± 1.061 °C) and the lowest temperature under T1 (33.81 ± 0.115 °C), as in p ≤ 0.01). The highest E (0.3399 ± 0.0008 mmol H2O m−2 s−1) and Gs (0.007 ± 0.034 mol H2O m−2 s−1) were recorded under T2 > T1 = T3. Significant positive correlations , with Chl b  and with Chl a + b , which indicates that the increase in leaf pigments would increase the photosynthesis rate. There is also high positive correlation between E and Chl a , and Chl b . Additionally, Gs were also shown to be positively correlated with Chl a . These show that leaf gas exchange properties increase with the increase of leaves pigment content.The highest photosynthesis rate (A) was observed under T2 (14.89 ± 3.65 µ mol COelations  were obs−1 fresh weight (FW) were significantly influenced by different shading levels. The highest Chl a (5.251 ± 0.539 mg g−1 FW), Chl b (5.317 ± 0.785 mg g−1 FW), Chl a + b (10.568 ± 1.324 mg g−1 FW), and Car content (2.771 ± 0.369 mg g−1 FW) were obtained under T2, followed by T3 and the lowest under T1. However, there was non-significant difference between the treatments (p > 0.05) for chlorophyll a/b ratio. The highest in-situ chlorophyll content (SPAD) value was obtained under T2 (33.716 ± 1.198), followed by T3 (30.305 ± 0.916) and the lowest was under T1 (26.258 ± 0.822), where the values were significantly influenced by different shading levels. 2 = 0.652; p ≤ 0.05), Chl b , and Chl a + b  (Leaf pigment contents were expressed as mg g ≤ 0.05) .P. minus leaves were significantly influenced by different shading levels. Under time interval of eight weeks, T3 recorded the highest TAC (88.597 ± 19.368 μg g−1 dry weight (DW)), followed by T2 (57.055 ± 13.18 μg g−1 DW), and the lowest was obtained by T1 (29.90 ± 3.831 μg g−1 DW) (−1 DW), followed by T3 > T1 .The TAC, TPC, and TFC of  g−1 DW) . However T3 > T1 . Table 2−1 DW) was obtained under T2. Meanwhile, after 16 weeks of treatment exposure, the highest TPC was recorded under T3, with values of 362.323 ± 65.990 mg g−1 DW (−1 DW) after 16 weeks of exposure , followed by T1 eight week time interval (2.041 ± 0.004 mg g−1 DE) and the leaves extract under T3 have the lowest FRAP reducing power (1.457 ± 0.036 mg g−1 DE). The measurement for the highest FRAP reducing power was also parallel to the lowest concentration that is needed in order to inhibit 50% of the non-radical 1,1- diphenyl-2-picryl hydrazine. Leaves extract under T2 time interval of 16 weeks needed only 0.657 mg mL−1 of the extract to exhibit 50% inhibition, followed by T3 under time interval of 16 weeks. The highest IC50 were obtained under T1 time interval of 16 weeks, but the value was not significantly different when compared to the value of IC50 obtained under T1 time interval of eight weeks. Overall, the antioxidant capacities of P. minus were the highest under a T2 time interval of 16 weeks.The dry extract (DE) of the leaves from 2 = 0.734; p < 0.01), Chl b , Car , and TAC . This means that, as the respective values increase, the FRAP reducing power will also increase. Meanwhile, DPPH was only negatively correlated with TAC . A significant negative relationship can also be seen between DPPH and FRAP . No significant correlation can be seen between both antioxidant assays with TPC and TFC. High positive significant correlation can be seen between FRAP with Chl a , which showed that sage plants produced a greater number of leaves and exhibited higher productivity under high light intensity [However, LN was observed to increase under control, zero shading, which showed the highest LDW under T1 on the 25th day . The resntensity .P. minus. An increasing trend could be observed between dry weights of plants from time interval of eight weeks and 16 weeks, even under low light intensity. This suggests the adaptability of P. minus towards low light intensity, as the plants managed to strive in terms of growth. Nevertheless, low LDW can be observed under shaded conditions T2 and T3, which suggests that low light intensities limit the leaves growth of P. minus. The highest SDW obtained under T1 and lower RDW that were obtained under T2 and T3 were parallel to the results obtained in a study on Aloe vera, which obtained twice higher dry mass of shoot under full sunlight and concluded that the reduced dry mass of root was caused by a restriction of carbon allocations to roots under low irradiance [P. minus under light stress from this study. Strong positive correlation can be seen between SDW and RDW   and between LDW and RDW  can also be observed from Besides different shading levels that were subjected onto the plants, the duration of exposure also showed significant results on the biomass of radiance . In addiradiance . RSR wasradiance  where liradiance . The allradiance . There w ≤ 0.01) . High inP. minus exhibit the highest photosynthetic rate under intermediate light intensity T2 , Chl b  and Chl a+b  (The significant influence of the different shade levels on nsity T2 . Plants function . A studyentation . Plants entation . The preunder T2 . A study ≤ 0.01) . It is a ≤ 0.01) , being pP. minus along with the enhancement of chlorophyll content  and Chl b   [Carotenoids are one of plant synthesised secondary metabolites that act as important radical scavengers . This st content , and thi ≤ 0.01) . Similar (LCHII) ,43.P. minus. Low leaf temperature under control, T1 as compared to other shading levels is due to the effect of evaporative leaf cooling that will cause a reduction in leaf temperature, as the temperature of the surrounding will indirectly increase under high light intensity [2 = 0.850, p ≤ 0.01) , as the degree of the opening and closing of the stomata will control the rate of transpiration. This strong correlation also suggests that the transpiration rate in this study was strongly influenced by stomatal regulation. The closing and opening of stomata at the same time depends on the turgor pressure of the guard cells, which could easily be influenced by light changes [2 = 0.653; p ≤ 0.01), Chl b , and Chl a+b   . In-situ changes . Plants  changes . Low lig changes , contrib ≤ 0.05) . These cr vapour . We assuP. minus leaves. P. minus leaves that were grown under T3 were found with the highest amount of anthocyanin (TAC) after eight weeks of exposure, but the highest after 16 weeks of exposure show under T2 as compared to other treatments. This result is in contrast to other few studies, which reported that high light intensity induced the production of anthocyanin [P.minus under intermediate light intensity is able to give a high photosynthesis rate, thus increasing the anthocyanin synthesis. A strong correlation was observed between TAC with carotenoid content in this study, where r2= 0.549, p ≤ 0.05 , 50% shading (T2), and 70% shading (T3) were arranged in a Randomized Complete Block Design with 3 shading levels × 4 blocks × 8 replicates. The percentage of shade levels are based on the density of the nylon mesh of the commercial shade cloth. The manufacturers provided this information. The shade levels (T2 and T3) were prepared in rows where the shade levels were represented by black nylon netting canvas with different mesh percentage. The canvas was installed from wall to wall of the greenhouse, forming horizontal shading above the plants in each treatment row. Inner walls were also installed around the shaded compartments, to make sure that all plants were covered. The light intensities were continuously monitored by using a LI-COR LI-250A light meter to ensure the significant range of differences between treatments. The average light intensity (µmol m−2 s−1) measured under different shading levels during experiment showed that (T1) 0% shading, the control recorded 80.024a ± 6.476, (T2) 50% shading recorded 29.927b ± 4.859, and (T3) 70% shading recorded 11.698c ± 1.018. All of the plants were watered sufficiently every morning and fertilised using NPK green fertilizer (NPK ratio: 10:20:10) once per week.The study was carried out in Rimba Ilmu Botanical Garden greenhouse, University of Malaya. Plant height (PH) and leaves number (LN) were measured every two days until the 25th day after transplant. The plant height measurements were taken on the main stem from the reference point on the soil surface towards the tip of the stem by using a measuring tape with an accuracy of ±1 mm. The number of leaves was recorded in total per plant. All of the data were recorded in eight replicates for each block under all treatments.Plants were harvested after a time interval of eight weeks and 16 weeks of planting to measure the leaves dry weight (LDW), shoot dry weight (SDW), and root dry weight (RDW). One harvest time measured for 4 replicates × 4 blocks of all treatments. The harvested plants were divided into different plant parts . All parts were subjected to freeze-drying process using Labconco freeze dryer  at −50 °C. The dry weights of the plant were recorded as the biomass dry weight. The root-shoot ratio was calculated by dividing root dry weight with the above ground dry weight .−1 CO2 flux, 30 °C standard cuvette temperature, and PAR of 1200 µmol m−2 s−1 [The measurements of photosynthesis rate (A), leaf temperature (Tleaves), transpiration rate (E), and stomatal conductance (Gs) were obtained by a closed infra-red gas analyser LICOR 6400 Portable Photosynthesis System . The measurements used an optimal condition set of 400 µmol mol m−2 s−1 . Leaf gaIn-situ chlorophyll content (SPAD) was recorded using a SPAD-502 meter  once every three days on a mature expanded leaf of each plant. The equipment was calibrated prior to the measurements. The data were recorded in triplicates from each treatment within each block.−1 tissue fresh weight (mg g−1 FW). Next, the total chlorophyll (Chl a + b) and chlorophyll a and b ratio (Chl a/b) were calculated following Li et al., 2018 [The chlorophyll a (Chl a), chlorophyll b (Chl b), and carotenoid (Car) were analysed from young, expanded leaves. Approximately 0.1 g leaf sample was crushed in liquid nitrogen by using mortar and pestle. The sample was ground in 10 mL absolute methanol using chilled mortar and pestle before being incubated under −20 °C in the dark for 24 h. The relative chlorophyll and carotenoid levels were measured in triplicates with a spectrophotometer (Thermo Scientific Multiskan GO) at 665.2, 652.4, and 470 nm wavelengths after 10-fold dilution. The pigment concentrations of chlorophyll a, chlorophyll b, and carotenoid were calculated following the methods by Lichtenthaler and Claus, 2001 , and thel., 2018 .Chl a  assay was conducted, as previously described by Giusti and Wrolstad, 2001  using pHAb = (A510 − A700) pH1.0 − (A510 − A700) pH4.5MW = Molecular weight of cyanidin-3-glucosode (449.2 g/mol)df = the dilution factorε = Extraction coefficient P. minus was prepared after the leaf samples were freeze-dried. 0.5 g of freeze dried leaves were soaked and ground in 30 mL of absolute methanol using chilled mortar and pestle. The sample mixtures were then incubated at −20 °C for 24 h before being filtered using filter paper. The filtrates were pooled and then evaporated under 45 °C using rotary evaporator before adjusted to a concentration of 20 mg mL−1.The extraction and quantification for total phenolic and flavonoid contents followed the methods that were described by Yusof et al., 2018 . The lea−1 dry weight of leaves (mg g−1 DW). For total flavonoid content (TFC), 0.5 mL of the sample was mixed with 1.5 mL of absolute methanol in a test tube that was covered with aluminium foil, and it was left for 5 min. Next, 10% 0.10 mL of AlCl₃ (AlCl₃•6H₂O) was added followed by the addition of 0.1 mL NaOH 1 M and 2.8 mL of distilled water. The absorbance was measured at 415 nm after 40 min. of incubation with quercetin as a standard and the results were expressed as mg g−1 dry weight of leaves (mg g−1 DW).Folin–Ciocalteu reagent (10%) was used to determine the total phenolics content (TPC) of the leaf samples. 0.1 mL of the sample extract was mixed with Folin–Ciocalteu reagent (0.75 mL). 2% aqueous sodium carbonate (0.75 mL) was added into a test tube and then incubated in the dark for 45 min. The blanks were prepared by using absolute methanol and the absorbance was recorded at 765 nm. Standard calibration curve was prepared with a series of gallic acid standards . The results were represented as mg g4) were prepared to generate a standard curve (r2 = 0.9902). The results obtained were expressed as mg of ferrous sulphate equivalent per gram of dried extract.The FRAP assay was performed based on the method that was described by Benzie & Strain, 1999  with sli50). The percentage of inhibition was plotted against the concentration and the IC50 was obtained from the fitted linear curve. A lower IC50 denotes a more potent antioxidant.The 2,2-Diphenyl-1-picrylhydrazyl (DPPH) free radical scavenging activity of each sample was determined according to the method that was described by Yusof et al., 2018 . 50 µL oAll of the data were analysed using the SPSS Processor  for descriptive statistics and one-way analysis of variance (ANOVA) with Tukey’s post hoc test at a 5% level of probability in significant difference. The standard error of differences between the means was calculated with the assumption that the data were normally distributed and equally replicated. The association and relationships between parameters are shown using Pearson’s correlation analysis.P. minus showed adaptation well up to 16 weeks’ exposure. It was found P. minus might tolerate low light intensity by an increase in its chlorophyll content, photosynthesis rate, transpiration rate, TAC, TPC, and FRAP, while reducing DPPH, which indicates high antioxidant properties under these conditions.From the study, it was found that control (0% shading level) produced highest plant biomass; however, a 50% shading level show the highest leaf gas exchange properties, leaf pigment contents, and secondary metabolites , including antioxidant properties (FRAP). Under 50% shading level,


As rne mRNA has not been previously targeted using an antisense approach, we decided to explore using antisense oligonucleotides to target the translation initiation region of the Escherichia coli rne mRNA. Antisense oligonucleotides were rationally designed and were synthesised as locked nucleic acid (LNA) gapmers to enable inhibition of rne mRNA translation through two mechanisms. Either LNA gapmer binding could sterically block translation and/or LNA gapmer binding could facilitate RNase H-mediated cleavage of the rne mRNA. This may prove to be an advantage over the majority of previous antibacterial antisense oligonucleotide approaches which used oligonucleotide chemistries that restrict the mode-of-action of the antisense oligonucleotide to steric blocking of translation. Using an electrophoretic mobility shift assay, we demonstrate that the LNA gapmers bind to the translation initiation region of E. coli rne mRNA. We then use a cell-free transcription translation reporter assay to show that this binding is capable of inhibiting translation. Finally, in an in vitro RNase H cleavage assay, the LNA gapmers facilitate RNase H-mediated mRNA cleavage. Although the challenges of antisense oligonucleotide delivery remain to be addressed, overall, this work lays the foundations for the development of a novel antibacterial strategy targeting rne mRNA with antisense oligonucleotides.The increase in antibacterial resistance is a serious challenge for both the health and defence sectors and there is a need for both novel antibacterial targets and antibacterial strategies. RNA degradation and ribonucleases, such as the essential endoribonuclease RNase E, encoded by the  The emergence of both natural and engineered antimicrobial resistant strains of bacteria poses a significant challenge to the health and defense sectors. Unfortunately, traditional drug development programmes, that successfully provided the antibiotics of the 20th century, are failing to keep pace with emerging resistance ,2. Conserne gene that encodes it, are ideal candidates for antibacterial targeting for a number of reasons .,18.17,18rne mRNA  and as an LNA4-DNA8-LNA4 4-8-4 gapmer (LNA gapmer A2/B2)  B.E. coli rne mRNA, the next step was to determine if they could bind to E. coli rne mRNA in vitro. We decided to use an EMSA to evaluate LNA gapmer binding. We designed an unstructured 45-mer minimal E. coli rne mRNA corresponding to the −30 to +15 translation initiation region of E. coli rne mRNA to use as the target RNA. This region of E. coli rne mRNA has been reported to be unstructured in the context of the complete rne 5′ UTR  is the concentration of LNA gapmer, n is the slope factor, Cap is the theoretical maximal amount of FAM-labelled RNA than can be bound by LNA gapmer, K is the apparent equilibrium dissociation constant  and background allows for any y-axis displacement from the origin.In this equation, E. coli rne and the coding region of the firefly luciferase (luc) gene  to generate pET28[rne-luc]. The sequence was confirmed by DNA sequencing. E. coli DH5α was transformed with pET28[rne-luc]. DH5α, pET28[rne-luc] was grown in LB supplemented with 25 µg/mL kanamycin at 37 °C overnight with shaking. Cells were harvested by centrifugation and pET28[rne-luc] was extracted using the NucleoBond Xtra Midi plasmid preparation kit .A translational fusion of the −397 to +30 region of uc) gene  was syntrne-luc] was performed using the E. coli T7 S30 Extract System for Circular DNA . 50 µL reactions were prepared in a 96-well plate. Each reaction contained 750 ng pET28 [rne-luc], 1 mM luciferin , 5 µL Complete Amino Acid Mixture, 20 µL S30 Premix and 15 µL T7 S30 Extract. The reactions were supplemented with 0.5 nM, 5 nM or 50 nM LNA gapmer, as indicated. The reactions were not supplemented with exogenous RNase H. Reactions were incubated at 37 °C for 2 h in a Hidex Sense plate-reader . The luminescence  was recorded every 2.5 min for a total of 120 min. The total luciferase signal for each LNA gapmer concentration  was quantitated by integrating the area under the curve using a trapezoid method in Excel. Integrated values were normalised to a percentage  and plotted as a bar chart in Grafit5.In vitro transcription-translation of pET28 [E. coli rne mRNA and 0 nM, 2.5 nM, 5 nM, 25 nM, 50 nM or 100 nM LNA gapmer in 1× RNase H Reaction Buffer  were assembled and incubated at 37 °C for 5 min to allow LNA gapmer to bind to the target minimal E. coli rne mRNA and form the RNase H substrate. RNase H, equilibrated at 37 °C, was then added to a final concentration of 0.008 U/µL. The complete reaction mixture was incubated at 37 °C for a further 45 min. Reactions were terminated by the addition of 0.5 volumes of quench buffer (95% (v/v) formamide, 18 mM EDTA). Reaction mixtures were heated at 95 °C for 5 min and reaction products were resolved by 8% denaturing urea-PAGE. Gels were visualised using a GBox UV transilluminator . Digitised images were quantitated using ImageJ and the percentage of cleaved and uncleaved FAM-labelled RNA in each lane was calculated. Data from triplicate experiments were fit to a four-parameter logistic function to estimate the half maximal inhibitory concentration (IC50):Twenty five µL reaction mixtures containing 50 nM minimal y is the percentage of intact FAM-labelled RNA at LNA gapmer concentration x; Range is the theoretical extent of the reaction, IC50 is the concentration of LNA gapmer at half the Range, s is the slope factor and background allows for any y-axis displacement from the origin.In this equation,


Background and Objectives: Dropped head syndrome (DHS) is a syndrome that presents with correctable cervical kyphotic deformity as a result of weakening cervical paraspinal muscles. DHS with amyotrophic lateral sclerosis (ALS) is a relatively rare condition, and there is no established treatment. This is the first case report describing the improvement of both dropped head (DH) and cervical pain after the short and intensive rehabilitation (SHAiR) program in an ALS patient with DHS. Case Report: After being diagnosed with ALS in June 2020, a 75-year-old man visited our hospital in October 2020 to receive treatment for DHS. At the initial visit, the patient’s DH was prominent during standing and walking. The pain intensity of the neck was 9 out of 10 on the numerical rating scale (NRS), which was indicative of severe pain. The patient was hospitalized for 2 weeks and admitted into the SHAiR program. DH began to decrease one week after undergoing the SHAiR program and improved two weeks later. Neck pain decreased from 9 to 6 on the NRS. Results: The SHAiR program is a rehabilitation program aimed at improving DH in patients with idiopathic DHS. The program was designed to improve neck extensor and flexor function and global spinal alignment, and the program may have contributed to the improvement of DH and neck pain. Currently, reports of conservative therapies for this disease are limited to the use of cervical orthosis. Although further research is needed on the safety and indications of treatment, the SHAiR program may be a viable treatment option. Dropped head syndrome (DHS) presents as a cervical kyphotic deformity called chin-on-chest deformity that results from a weakening of the cervical paraspinal muscles . DHS devA 75-year-old male patient with ALS presented with DHS. In October 2019, the patient noticed difficulty swallowing and discomfort in the neck. After January 2020, the difficulty swallowing further progressed and he gradually became unable to support the head. The patient was diagnosed with probable bulbar-type ALS according to the Awaji criteria after undergoing a detailed examination at several hospitals in June 2020. The patient’s clinical findings at that time are shown in After the diagnosis of ALS, the DH, neck pain, speech difficulties, and dysphagia further progressed. For the treatment, medication  and conventional rehabilitation were prescribed. Although posture modification and daily walking (4000 steps per day) were provided by a physical therapist for approximately two months with conventional rehabilitation, the patient’s symptoms did not improve. The patient sought to alleviate the daily suffering caused by DH and visited our hospital for additional treatment. The patient’s medical history included ulcerative colitis, dyslipidemia, lumbar canal stenosis, and Bell’s palsy.The patient was referred to our hospital in October 2020 and was diagnosed with DHS caused by ALS by a specialist. The revised ALS functional rating scale (ALSFRS-R) score at that time was 38 out of 48 points. On initial physical examination, the symptoms were prominent during standing and walking. A therapist was able to easily lift the head of the sitting patient. This assessment determined that the patient’s pathology was not a consequence of cervical spine deformity with joint contracture. The patient experienced difficulty standing while maintaining a horizontal gaze a,b. In aTo improve the patient’s symptoms, a prescription for the SHAiR program was suggested. The SHAiR program is a short-term intensive exercise program that includes thoracolumbar physical training to improve global spinal alignment, in addition to strength training of the neck extensors and flexors. Although an approach to improving neck function and correcting posture is often taken in conventional rehabilitation, a structured treatment program has not been established globally. The SHAiR program was considered the most suitable program for the patient’s treatment, because it has been reported with good short-term results and is a non-invasive treatment. The structure of the program is cervical paraspinal muscle exercise, deep cervical flexor muscle exercise, range of motion exercise with cervical and thoracic mobilization, hip lift exercise, anterior pelvic tilt exercise, and walking exercise. Although some of the training has been reported to be performed in the supine position , traininThe individualized SHAiR program was conducted by a physical therapist and an occupational therapist, one session each day, six times a week for two weeks. The patient received 20 min/day of speech therapy in addition to the SHAiR program. Furthermore, SHAiR program-based voluntary training and walking were also added by the patient. Voluntary walking was gradually implemented in the range of approximately 4000 to 7000 steps/day. The patient understood the rehabilitation and complied to participation in all sessions. During the duration of the program, there was no increase in Riluzole and NSAIDs that were prescribed in the past, and no additional medication was administered during hospitalization.One week after starting the SHAiR program, the patient experienced a change in his own gait posture and subsequently noticed an improvement in the symptoms. The patient’s symptoms and outcome change were reassessed after 2 weeks of treatment. The patient’s standing posture improved significantly after the two-week program c,d. In aNeck pain was gradually relieved during the first week and eventually improved from 9 to 6. Neck dysfunction indicated by the neck disability index (NDI) improved from 23 points to 10 points. The health-related quality of life (QOL) assessed using the 36-Item Short-Form Health Survey version 2 (SF-36) acute version were improved in all subscales except for bodily pain. No adverse events such as the appearance of myalgia and/or in-creased fasciculations were observed during the follow-up period. The patient’s treatment process is summarized in DHS is secondary to primary diseases such as PD, MG, and ALS, with the exception of idiopathic DHS . AccordiOrthoses and rehabilitation are the first-line conservative therapies for DHS . HoweverIn this report, an ALS patient with DHS showed improvement in symptoms after undergoing the SHAiR program. The concept of the SHAiR program is to improve the function of the cervical extensor and flexor and global spinal alignment . The patAlthough this report presents a successful example of the SHAiR program, there are some notable points to consider regarding its implementation. The first is safety. Previous studies have reported that exercise for ALS does not accelerate the progression of symptoms . TherefoThere is no established treatment for ALS with DHS due to the rarity of the disease. Our report suggests the potential efficacy of the SHAiR program for this patient. Further research on the efficacy, safety, and indications of the SHAiR program needs to be developed in the future.


Federations are concerned about attracting new sportsmen and sportswomen and increasing the number of members. The purpose of this research was to describe karate federations' strategies for attracting and retaining members through happiness. The analysis was carried out by designing a structural equation modeling (SEM), which allowed to analyze the main variables that influenced the happiness of the karate athlete and consequently to study their effect on people's loyalty to sports federations. In particular, Partial least squares SEM was applied in an overall model when it was possible to understand the happiness role in relation with other traditional relevant variables on loyalty. The data were obtained through primary sources employing a survey sent to the autonomous federations in the discipline of karate, obtaining a sample of 682 federated members in Spain. The results of the model revealed that consumer satisfaction, engagement, and meaningful influence on consumer happiness, but engagement was the most important and relevant variable for affecting this variable. Finally, consumer satisfaction and consumer happiness influence loyalty, and consumer satisfaction was the most important variable, but consumer happiness showed a real alternative for improving loyalty in karate sports federations. Then, one of the implications of this work was that it helped to explain how the federations can be managed to achieve loyal consumers together with a more considerable increase in the number of federated members. Consumer loyalty is a strategic variable that ensures the survival of entities in the long term and has therefore been extensively researched in the literature from the point of view of psychology, marketing, and management .A pretest of the questionnaire was carried out in February 2019 on a representative sample of members of karate federations. Some errors were then corrected, and all questions were validated. When the questionnaire had been refined, it was launched online through a discretionary non-probabilistic sampling by quotas, with the objective of completing the distribution of genders as similar as possible to that of the population who are members of karate federations in Spain, which have a total of 75,406 members. The questionnaire was distributed through the main social networks in March 2019 and through karate federation websites from March 2019 to March 2020. The result was that 714 members answered the survey, but 32 surveys were not filled in correctly, so the total number of valid questionnaires was 682, implying a sampling error of 3.81% , members with less than Black Belt (29%), and members with Black Belt 3rd and 4th Dan (21%), and only 8% are members with the highest Black Belt grades .Partial least squares structural equation modeling (PLS-SEM) is an opportunity to advance the development and testing of theory in sport organization management. SEM has become a mainstream method in many fields of business research, and PLS-SEM provides a flexible method in terms of data requirements, model complexity, and relationship specification. PLS-SEM does not require normally distributed data  results for the same variables are 0.63 and 0.56, respectively, where values larger than zero indicate a good model's predictive relevance. Predictive validity is included as the last step of confirmatory composite analysis (CCA), which is a systematic methodological process for confirming measurement models in PLS-SEM. The statistical objective of CCA and confirmatory factor analysis (CFA) is confirmation of measurement theory. To achieve measurement confirmation objectives in developing or adapting multi-item measures, researchers could use either CFA or CCA . The relation between consumer satisfaction and loyalty is strong and positive, with a high coefficient (0.63). Then, H4 and H5 are not rejected.Finally, it is relevant to analyze the results of the total effects on consumer happiness and loyalty. Before, the direct effects were commented on in the hypothesis, but it is also noteworthy to know how indirect effects are influencing the total effects of engagement and meaningful on loyalty .The present study arises with the purpose of deepening the knowledge about the variables that can positively influence loyalty and specifically how happiness can generate loyalty considering each of its dimensions (Aksoy et al., Reichheld  and JoneLikewise, one of the findings of this study is that the happiness variable plays a very important role in the loyalty parameter of sportsmen and sportswomen (Gladden and Funk, In line with this, our quantitative results reveal that happiness needs to be given greater consideration in its association with loyalty in the context of sport. This gap constitutes a great opportunity to put on the academic agenda that happiness is understood as a strategic differential factor that motivates people to be loyal to practice a sport assiduously under the lens of consumer satisfaction, engagement, and meaningful. This is extremely important as the continuous practice of physical exercise contributes to holistically improve people's health and psychological well-being, factors that cushion stress, depression, vascular diseases, etc. (Ronkainen et al., Regarding the practical implications of our work, on the one hand, public institutions can encourage the regular practice of sport to citizens through happiness, as emotional health, self-esteem, cognitive performance, commitment, confidence, socialization, etc. (Jiménez-Marín et al., Among the limitations of this study is that a transversal study has been designed so that in future research, longitudinal studies can be carried out based on panel data to evaluate the impact of the variables evaluated in the model presented in this work. The geographical area studied was Spain, where karate members from all the Autonomous Communities formed part of the sample for this study. However, in future work, the sample could be extended to other countries. Another limitation is the application of the study to the discipline of karate so that, in future research work, the proposed model can be applied to other sporting disciplines.Finally, future research on happiness management in the sports context should be focused on exploring whether the individual happiness provided by the daily practice of sport is significantly correlated with other psychological dimensions or with quantitative indicators of subjective well-being. In this way, we will be able to obtain, on the one hand, empirical evidence of new constructs associated with happiness in the environment of sports participation, both an active and passive nature. On the other hand, we can analyze, in a multidisciplinary and cross-cultural way, how daily physical exercise is linked to a meaningful and healthy life, etc., and therefore full of happiness in the broad sense of the word. Hence, the interest in promoting new works can empirically confirm the subject of this research from our structural equation model, bearing in mind that the practice of sport is an important determinant of people's happiness, which is also affected by other socioeconomic and psychological elements.This study shows how the consumer happiness of the karate federation members could be a good strategy for developing loyalty in this non-profit sports organization. In an overall model, consumer satisfaction is still a well-established variable for influencing loyalty, but consumer happiness plays a mediator role with consumer satisfaction, and it is able to increase loyal members if federations principally work on engagement activities. It would therefore be interesting for karate sports federations to use this information when developing new strategies for improving loyalty.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.EN-B, PC-V, PG-R, and RR-R: conceptualization, methodology, validation, formal analysis, investigation, resources, data curation, writing—original draft preparation, writing—review and editing, and supervision. EN-B and PG-R: software. PC-V: funding acquisition. All authors have read and agreed to the published version of the manuscript.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.


Background: There is a knowledge gap for implementing tele-rehabilitation (telerehab) after hip fracture. We recently conducted a clinical trial  to test a novel online family caregiver-supported rehabilitation program for older adults with hip fracture, called @ctivehip. In this qualitative substudy, our objective was to use semi-structured interviews to explore family caregivers experience with the telerehab program. Methods: Twenty-one family caregivers were interviewed between three and six months after the older adults completed @ctivehip. One occupational therapist with research and clinical experience, but not involved in the main trial, conducted and transcribed the interviews. We conducted a multi-step content analysis, and two authors completed one coding cycle and two recoding cycles. Results: Family caregivers who enrolled in @ctivehip were satisfied with the program, stated it was manageable to use, and perceived benefits for older adults’ functional recovery after hip fracture. They also suggested improvements for the program content, such as more variety with exercises, and increased monitoring by health professionals. Conclusions: This work extends existing literature and generates research hypotheses for future studies to test telerehab content and program implementation. Loss of functional independence , decreasThere are barriers to delivering rehabilitation after hip fracture, such as limited access to health professionals after discharge to home. Telerehabilitation (telerehab) is a promising management strategy to support recovery after discharge, and may be especially important in rural and remote areas with limited access to in-person rehabilitation . Of noteWe previously published results from the main trial —a choiceThe aim of the present exploratory study was to describe family caregivers experience with the @ctivehip telerehab program. We anticipated that family caregivers’ feedback could be used to refine the intervention by identifying implementation opportunities and challenges from a person-centered approach.This was a substudy of a multiple methods clinical trial . We previously published the results of the main study  , and patA description of participant recruitment is provided elsewhere ; please Between October 2017 and December 2018 an occupational therapist (OT), with related clinical experience but not involved in the main clinical trial, conducted the telephone interviews between three and six months after participants finished the main clinical trial. The virtual interviews were scheduled when family caregivers were at home, to minimalize potential distractions. The OT recorded and transcribed the interviews within two days after each interview and kept field notes for reference during the analysis process. The interview guide is provided in We followed the recommendations of Graneheim and Lundman  to conduWe included several processes to increase trustworthiness of study findings . First, We used NVivo 10  during data analysis to assist with data management . We present participants age and scores for telerehab program utility and satisfaction using median (q25–q75) values.Twenty one family caregivers  age 50 (43–54) years) participated in the present study. Most family caregivers were the offspring of the patients with a hip fracture  supported by other family caregivers , who lived with the patient , and more than half were also working  part-time or full-time. The median age of older adults with hip fracture was 78 (73–82) years; most were women (76%), and their functional level at the end of the telerehab program (12 weeks) was similar to their pre-fracture functional level assessed through the Functional Independence Measure (FIM) . A detaiTen of twenty-one caregivers completed the program as intended (high fidelity at 12 weeks), and an additional six participants completed 8 weeks or more of the program . Half of the caregivers  stated their older family member completed the program, and then continued doing the exercises for a few more months. However, the remaining caregivers reported their family member stopped doing the exercises before the end of the 12 weeks. Most family caregivers  expressed 12 weeks was long enough to learn the program, or they believed their family member did not require rehabilitation beyond 12 weeks.“…We spent about one month doing the exercises with her. Afterwards she continued doing the exercises alone, but I think she did not do them for twelve weeks… She stopped when she felt she did not need to do [any] more…”(Caregiver 8)The caregivers with lower adherence to the telerehab program (5/21) were all women, older than 50 years of age  and had no support from other caregivers  or the support of one additional caregiver to help the patient with ADLs . From the five caregivers with lower program adherence, two were unemployed, two worked part-time, and one worked full-time.There were two categories generated during data analysis: (1) the telerehab program was perceived to be useful for older adults’ functional recovery without being onerous for family caregivers; and (2) there was room for improvement in the telerehab program. A visual summary of the main findings is provided in Caregiver support was essential for implementing @ctivehip. Overall, family caregivers were highly satisfied with the telerehab program and rated it useful : 8 (8-9)/10 points for utility and 9 (8–9.5)/10 points for satisfaction. Though the use of the program required more time and additional responsibilities for the caregivers, most participants stated there was no additional caregiving burden with using @ctivehip:“…At first, it took a while but then we [created a] habit. I came home from work and connected the tablet. I helped her with the exercises that seemed more difficult.”(Caregiver 12)“…You need to [make time] to use the program… my brother and I organized [it] between us and it was not too much burden…”(Caregiver 15)Although most caregivers noted improvement in patients’ health after using @ctivehip, a few family caregivers reported no change in their family member’s function with the program:“…She could almost not walk and now she is completely independent…”(Caregiver 15)“…We started in the hospital, then he spent 3 months in my house doing the exercises and then he went home and continued doing them but without [the] internet… He already memorized the exercises and keeps doing them because he says they are good for him and that the doctor told him he could continue doing them every day… I would say that he is better than before the surgery…”(Caregiver 4)“…No, she won’t be the same person anymore… She is having a setback in general…”(Caregiver 3)Based on the caregivers experience, there was an identified need to develop new approaches for health professionals to support them during the recovery process. Study participants provided valuable insights for how best to implement @ctivehip in the future. Although family caregivers were aware they could request a video-conference session with a health professional, they preferred a regular check-in within the telerehab program to verify everything was proceeding as planned. Some family caregivers further suggested regular health professional monitoring to support older adults’ confidence with completing exercises:“…I [missed] that the staff would call us from time to time to ask us how we were doing and to test if we were doing the exercises properly. …I know we could have called to ask for a video conference, but we felt in some way alone…”(Caregiver 13)There were some differences among suggestions to improve the program content. Many family caregivers suggested the program should include more variety in the exercises to reduce the risk of boredom, and possibly increase older adults motivation. In contrast, some family caregivers were pleased with the repetition of the exercises, as it made them easier to remember:“…All the exercises were very similar and became very monotonous and repetitive after the first week…”(Caregiver 18)“…I’m not an expert but I believe the exercises were [good] because my father memorized them every week and if he did not have internet one day, he would do it himself…”(Caregiver 16)Family caregivers rated the program’s level of difficulty as either low or average. Nevertheless, eight family caregivers stated their family member avoided using weights to perform some exercises due to low confidence:“…She did not do some exercises because she did not feel safe. For example, the exercises with the weights… She did the exercises but without weights…”(Caregiver 13)Almost half of the caregivers stated they liked most components of the telerehab program, while seven family caregivers liked everything about the program. Constructive feedback on the program included difficulty accessing internet in some locations, and the exercises were repetitive (and possibly created boredom). Family caregivers also reported positive attributes of the program, such as usefulness for functional recovery .Telerehab is a rapidly growing mode of health care delivery, but there are known gaps for using ICTs for older adults with hip fracture . RecogniAlthough participants chose to receive the telerehab program, our sample was similar to other studies where the caregiving was mainly provided by women ,5 at midWe observed a high level of satisfaction and perceived usefulness for family caregivers with the @ctivehip program. These factors may contribute to users’ motivation to adopt and persist with the program, a key component of the technology acceptance model . Our finFamily caregivers requested regular communication with health professionals after hospital discharge (using a person-centered approach) to update and progress rehabilitation plans. At present we do not know if the family caregiver “regular check-ins” need to be face-to-face or via ICTs. Technology may provide opportunities for more frequent communication with family caregivers and patients, especially during the transition back home . An autoFamily caregivers in our study requested more and varied exercise options within @ctivehip but, as some of the caregivers recognized, some patients did not use weights during the sessions for safety reasons. More frequent communication with health professionals could have addressed concerns, develop strategies, and explain why using weights (if possible) was recommended to increase strength and physical condition. It is difficult to know how the content of our telerehab program  comparesWe acknowledge that only half of participants completed the full program but overall, three-quarters completed eight weeks or more of the intervention. Reasons to explain the lack of fidelity to the program could be boredom related to the repetitive nature of the core exercises, participants higher level of function (pre-and post-intervention) reported in the main trial , or oldeWe note some limitations within our study. First, due to the study’s inclusion criteria, the older adults with hip fracture did not have cognitive impairment. Future studies should consider expanding the inclusion criteria to reflect a wider population of people who fracture their hip. Second, we conducted interviews three to six months after the telerehab program ended, and this delayed timing may have impacted family caregivers’ responses. Third, we conducted short interviews although provided prompts and cues to explore caregivers’ experience using the program. Fourth, group assignment was by choice, therefore participants who wanted to receive the telehealth program may have a different experience. Although many caregivers liked the program there were some perceived limitations such as the limited variety of exercises and monitoring. Fifth, we did not capture psychosocial factors such as caregivers’ self-efficacy with delivering the telerehab program, but we recognize behavioral factors (for the older adult and family caregiver) are important to include in future research. Despite these limitations, our study provides valuable information to extend the limited evidence for ICTs for older community-dwelling adults with hip fracture ,45 and tTo our knowledge, this is the first study to provide a detailed description of family caregivers’ experience with a post-hip fracture telerehab program delivered before the SARS-CoV-2 (COVID-19) pandemic. Family caregivers who enrolled in the @ctivehip telerehab program were satisfied with the program, stated it was manageable, and reported perceived benefits for older adults’ functional recovery after hip fractures. Family caregivers also provided helpful feedback to enhance program content and its delivery. Taken together, this work extends existing literature, and generates research hypotheses for future studies to test telerehab content and program implementation.


National immunization programs conduct in-service training of health workers depending on program needs and particularly when new program elements are introduced.we conducted a survey of national and provincial level immunization program staff in 9 countries in the World Health Organization (WHO) African Region to determine the perceived needs and preferred training methods for capacity building in immunisation.nearly all of the respondents (98.3%) stated that there are skill gaps at their respective levels in the immunization program which require training, with 88% indicating that mid-level program management (MLM) training was needed to train new program staff, while 78% indicated program performance gaps and 60% of the respondents stated that refresher training is needed. Program areas identified as top priorities for training included immunisation monitoring and data quality, sustainable immunization financing, adverse events monitoring and community mobilization. More than three quarters of the respondents (78%) think that online MLM training is adequate to address program gaps. Only four of the 9 immunization program managers indicated that they regularly monitor the number of MLM trained staff within their national program.there is a strong need for in-service training of immunization program officers in the countries surveyed, especially at the subnational levels. Program managers should conduct regular monitoring of the training status of staff, as well as conduct detailed training needs assessments in order to tailor the training approaches and topics. Online training provides an acceptable approach for capacity building of immunization program staff. Countries in the African Region have introduced several new and underutilized antigens in their national immunization programs in the past two decades and have made significant progress in vaccination coverage . HoweverCapacity building tailored for service providers at the operational level helps to improve service delivery, while the training of mid-level program managers will be key to improve managerial skills required to optimally utilize available resources and implement strategies. Accordingly, in the past two decades World Health Organisation had introduced the Immunization in Practice (IIP) set of training modules tailored for the service providers, and the mid-level management (MLM) course for immunization managers ,9. As trWe identified 9 countries in the WHO African Region to take part in the quantitative survey. The selection of the countries was purposive, to ensure representation from self-financing countries alongside countries which are eligible for funding support from The Global Alliance for Vaccines and Immunizations (GAVI), the vaccine Alliance; to include countries of varying population sizes, and from the various geographic subregions. The countries selected were Chad, Cote d´Ivoire, Democratic Republic of Congo (DR Congo), Gabon, Liberia, Malawi, Namibia, South Sudan and Togo. We worked with the immunization experts in each of the countries and compiled the list of national and provincial level immunization program staff, who work for the ministry of health and the key partner agencies. We sent structured questionnaires through an online polling platform and collected the responses from 12 - 22 October 2020. In addition, each of the national immunisation program managers received a second set of questionnaires to investigate their specific roles and the immunization program priorities vis-a-vis capacity building. The responses were tabulated and analysed.Training needs in immunization- the perception of immunization program officers in 9 countries: a total of 241 immunization program staff from the 9 countries responded to the questionnaires, 88 of whom were from the national level (37%) while 95 were from the provincial (39.9%) and 55 were from the district levels (23.1%), while 3 participants did not indicate their level of work. Most of the respondents were public health experts (32.5%), disease surveillance officers (28.8%), or program data managers (8.8%). The length of service of the respondents in immunization programs ranged from less than 2 years (9.1%) to more than 10 years (47.3%) ( (47.3%) . Nearly  (47.3%) . The maj (47.3%) . On the  (47.3%) .Capacity building in immunisation-the national program perspective: only four of the 9 immunization program managers indicated that they regularly monitor the number of MLM trained staff within their national program. The last MLM national and subnational training was conducted more than 4 years back in 4 of the 9 countries. Immunization in practice (IIP) training was conducted within the last 2 years in 5 countries, while one program manager stated that IIP training was done 5 years ago. Seven of the 9 program managers estimated that less than half of the national immunization program staff were trained in the mid-level managers´ (MLM) course. At province level, less than half of the program staff had taken the MLM course in 5 countries, while this was true at the district level in 7 countries. Two of the program managers responded that they did not know the proportion trained at province and district levels. The proportion of immunization program staff with access to internet connection and able to take online training was estimated to be less than 50% at province level in one country, while it was less than 50% at district level in 4 countries. In addition to traditional approaches of in-service training, 7 of the 9 program managers stated that they have at some time utilized mass messaging platforms (WhatsApp and/or Telegram apps) to provide training content on immunization to health workers. Six of these stated that they used these approaches for training around special program activities.et al. have identified the regular review of programme and health worker performance as one of the six key drivers of routine immunization coverage [In the past two decades, there have been rapid developments in the uptake of new and underutilized vaccines, in expanding the scope of immunization programs beyond infancy and in the introduction of new tools and technologies for cold chain and immunisation monitoring. There are still multiple new vaccines in the pipeline for countries in the Region to consider in the coming years. Within this dynamic context, it is important to ensure that health workers are regularly trained and updated to be able to meet the changing demands. Lafond coverage . In our coverage . Howevercoverage -17. It mcoverage . On the We found that only 4 of the 9 immunization program managers regularly monitor the number of MLM trained staff within their national program. Moreover, the last MLM national and subnational training was conducted more than 4 years back in 4 of the countries. These findings indicate the need for a more systematic approach to the capacity building of immunisation professionals. National program managers need to choose which of the various courses fit the profile of health workers where the skills gaps need to be addressed. The recent overhaul of the WHO Afro MLM training tools provides the flexibility to use the tools online as well in workshop-based trainings at national and subnational levels, and provides flexibility to select the modules most relevant for the program´s training needs .In recent years, the expansion in internet connectivity in African countries and the development of online training tools have increased the access to and acceptability of online training courses. More than half of our study respondents have taken some online courses in the past, and four out of five think that online MLM training can be used to address the training needs in their country. However, it is noted that limitations to internet access, especially at the district level, may continue to pose challenges to wide-scale launch of online training courses. While the design of the MLM course covers most of the basic elements, the development of skills requires additional training approaches like simulation exercises and drills . Other sThe introduction of COVID-19 vaccines in early 2021 has come with its own demands for health worker training. The pandemic context, the introduction of new vaccine products in use, the different cold chain requirements, the specific population groups that often are not targeted in mass vaccination activities, the need to implement infection prevention and control measures, and the phased approach to implementation render the trainings needs different from previous ones . HoweverLimitations: Our study did not attempt to do an objective analysis of skills gaps. It was aimed at capturing the perceptions of immunisation professionals in the selected countries through a self-reported prioritization of needs. The findings have been presented in an aggregated manner, and attempts were not made to compare the results from the various countries, as there was a wide variation in the number of respondents across the selected countries.There is a strong need for in-service training of immunization program officers in the countries surveyed. However, detailed and country-specific training needs assessments should be done in order to tailor the training approaches and topics to serve the program needs. National immunization program managers should monitor the training levels of staff at national as well as subnational levels. Online training provides an acceptable approach to build the capacity of mid-level program managers.National immunization programs continue to experience high staff turnover and an expansion of program scope, requiring regular training of health workers;Immunisation program reviews in various countries have indicated skills gaps and training needs;Online training courses have provided additional opportunities for capacity development.Immunisation program staff at various levels perceive that major skill gaps which require the training of health workers persist;The proportion of immunization program staff at subnational levels that have taken the MLM training course was less than half in most of the countries;Online training and mass messaging platforms provide acceptable alternative ways of extending training content to program staff; country level training needs assessment should be done regularly in order to tailor the focus of training and to determine the best approaches to serve the program needs.


AllPlay Dance is founded on a collaborative approach to research between the School of Psychology and the School of Communication of Creative Arts, both of Deakin University. The research is also undertaken in partnership with professional ballet company, Queensland Ballet. This paper describes the development and execution of two pilot projects for children with disability, utilizing a dance studies methodology. The projects were conducted in 2018 and 2019 for children with cerebral palsy (CP) and autism spectrum disorder, as part of the AllPlay Dance program. Participants with disabilities ranged in age from 7 to 12 years. As well as describing the approach to the program development, we discuss the involvement of older and more experienced buddies who were included as a method to support the participation in dance of children with disabilities. We will also describe the diffusion of authorship in the making of group dances as a tool for inclusion and the premise of dance as a social practice in which participants inter-subjectively generate meaning and sense making. The AllPlay Dance projects were developed as a series of dance classes in which participants worked with set or learned movement material, dance improvisation, and tasks for movement generation in order to collectively generate a dance for performance. This paper focuses on the aim of developing inclusive approaches to dance classes that challenge “ableist” notions of dance as spectacle to enable to work toward building transferable programs to allow all children who so desire and to participate in dance in their communities. AllPlay has the broad aim of creating new pathways for inclusion for children with disabilities to participate in activities in the community. The pilot projects discussed sit within the AllPlay Dance arm of the broader AllPlay program. Through the two projects, we aimed to develop inclusive strategies to better support the participation in dance for children with two specific disabilities – cerebral palsy  and autism (2019 project). We employed a methodology which draws on a dance studies approach whereby the practices of dance, that is the teaching, creating, and analysis of dance material and dances are the site of the research. We describe the development of the dance class material and methods, the diffusion of authorship, and, in particular, the use of “buddies”; older and more experienced dancers, as methods of inclusion. We also consider the social elements of dance classes through describing unexpected situations that arose and observations we made, as a way of making sense of what took place in the classes, to inform our future projects, and perhaps the projects of other groups.This paper discusses the development of two pilot dance projects for children with disabilities initiated as part of the AllPlay program of Deakin University . This cross-disciplinary partnership has two broad aims: (1) to develop methods (a program) to enable children with disabilities to participate in dance activities and (2) to measure the benefits of community-based dance programs for children with disabilities. This paper is focused around the first of the two aims. The two aims are interlinked to work toward the long-term goal of allowing dance to be prescribe-able by healthcare professionals for children with disabilities. To enable the benefits to particular disability groups, we are developing and testing the methods and approaches to deliver those benefits. Central to the approach to the AllPlay Dance program is the idea that true inclusion in community-based programs has the potential to offer benefits to physical, cognitive, and psychosocial functioning as an alternative to or in adjunct with therapy in a clinical setting. Notably, the work of AllPlay Dance differs from dance therapy in that it aims to promote the inclusion of children with disabilities in community-based, recreational dance programs and provide equal access to their potential benefits, rather than develop disability-specific interventions aimed at addressing or fixing “problems.”The work of AllPlay Dance is undertaken through collaboration between dance and psychology researchers. The research is also undertaken in partnership with professional ballet company, Queensland Ballet  and Weave Movement Theatre 2014; . MillardFor both pilot projects, we also consulted with experts and members of the dance and disability communities seeking input in the planning stages, during the classes themselves and following the final performances. For the CP project, we consulted with performer and dance maker Dr. Melinda Smith OAM, who lives with cerebral palsy. Smith generously reviewed our written plans, attended one of the classes and offered subsequent written feedback, and attended the final performance. For the autism project, we sought input from community dance teachers and studio owners, scholars who had worked in the area of dance and disability and parents of children with autism who had previously participated in dance programs. We also talked with parents and the buddies regularly throughout both projects as well as observing the children themselves and where possible aimed to accommodate individuals or improve the delivery more generally. As is the case with any creative process in dance, we approached our work in an open-ended way, aiming to respond to possibilities as they arose and making adjustments where they were required.The first of the two projects was developed for children with cerebral palsy, and the second was for participants with autism spectrum disorder. Cerebral palsy refers to a group of disorders of movement and posture that arise from a disturbance to the immature brain; they cause activity limitation and are also often associated with broader difficulties in non-motor domains . Autism,In September and October 2018, we undertook a pilot project in which nine children with CP participated in a series of dance workshops with a group of 17 “elite” classically trained dancers who volunteered to act as the “buddies” for the children with CP. The buddies attended a Buddy Briefing Session, which included an overview of CP , information about being an AllPlay buddy, for example, how to be a buddy, what to do in classes, examples of what to expect, and strategies to help maximize participation.The workshop series included four 45-min classes over a two-week period and culminated in a public performance in which the children with CP performed, accompanied by their buddies. In addition to our focus on the development and assessment of the class material, we aimed to determine whether our newly developed program was feasible and acceptable to this community and to gather initial information about the potential benefits of participating in dance for children with disabilities. We were also interested in the social impact on their buddies. The project took place in the dance studios at Deakin University and was a collaboration with Queensland Ballet and its Artistic Director Li Cunxin  with significant pre- and post-testing. The trial was registered with ANZCTR in May 2019. Participants were allocated to either an Every child with autism spectrum disorder is different, there is no “one size fits all.” Children with autism typically have difficulties with socializing and communicating with others.Although children with autism may have social difficulties, they are usually very keen to join in, but they might not know how. Some kids with autism might have lots of language and others might only use a few words or no words at all.Children with autism may like things to be done in a particular way or order, they may have a favorite activity that they are happy to do over and over again, and they may find it difficult to switch between tasks quickly or without much warning.Some kids with autism may find loud noises or particular sounds or textures uncomfortable. As every child is different, it is important that the teacher gets to know each child’s likes and dislikes, to be able to make dance as inclusive as possible for all kids.As with the CP program, we also provided information about what to expect as a buddy and strategies to help the children participate.While both of these projects were structured in a way that enabled us to collect data on feasibility, acceptability, and preliminary benefits to participation, the purpose of the current paper was not to detail the scientific aspects of the study but to describe the development of the program, discuss considerations for inclusion, and explore dance as a social practice through our impressions as the facilitators of the program.Body, Space, Energy and Time were employed as a structure for dance teaching and choreography, in order to develop a transferable and scaleable program  were asked while improvising:Which part of the body moves?In which direction or where in the space does the movement take place?What is the speed of the movement?How much energy is used? What kind of energy is it?Improvisation was not only used as a warm-up method. We also used improvisation while making small dances in groups, and it was included in the final performance, often as a way for dancers to travel from one part of the stage to another.A series of short phrases were developed and taught over the weeks. With each new phrase or step, there were always options for the way it could be executed and time given to adjust the movement or create a new version of it.In groups, from about the third or fourth week, participants generated their own movement phrases using various tasks such as making new versions of existing sequences, using movement words to create new sequences, and using improvisation scores to structure dance sequences.Each week participants also had a chance to revise, practice, and build on work from previous weeks. Where appropriate, movement material was videoed and shared to aid retention from week to week. Dancers were encouraged to keep the sequences with named movements the same in order to keep continuity across the whole group, but also so that we would have a mechanism  for remembering the material they had made.It was always an option for the dancers to adapt movements to suit/enable all dancers to achieve a version of each word. We also encouraged the dancers to create completely new movements for the words if they desired. Predictably, there was a great range of interpretation of the instructions: Some groups kept their material much the same as the original and varied the timing or the pathways that they travelled on, and others used the original sequences as a kind of holding place and made smaller or larger changes here and there. Some groups made completely new phrases, keeping only the words as guides. As would be assumed, some groups, such as those who had dancers in wheelchairs or walkers, made complex and layered changes, which included dancing with props (scarves) and having different dancers doing different movement with varied timing.Each week, there was a chance to show the material made in small groups while the rest of group watched. Observers were encouraged to watch and identify movements they recognized. Over the weeks, the material built in complexity and worked toward the final dance performance. Observing also aided group decision-making, specifically the shape the dance should take.Although we undertook careful plans for the development of the two projects and consulted with experts as appropriate, there was much we could not anticipate about how individuals might engage with aspects of the program. Not all children responded in the same way to each section of the classes. For example, in one autism session when most of the members of the group appeared to be thoroughly engaged in improvising to music, one child called out “[t]his is boring.” We acknowledged the “boring” and messy moments, we changed approaches for children who seemed unable to join in, and we made space for children who needed to rest. This discussion takes into account the planned elements of our project, including the use of buddies and the diffusion of authorship to support participants to feel included. It also describes unexpected events and observations; aspects of the projects that changed what we understand, which will inform our future planning. As stated above, the three themes were developed through the application of existing theory, although they were equally informed by what took place in the present of the classes.dèrive (drifting) of artists involved with Situationist International in the 1950s and 60s  and the Sonsbeek projects  that were named as activities rather than exhibitions  included workshop situations in which the participants worked together to create movement material, either improvised or set, and small group dances to be included in the larger dance. Undertaking a dance making task is complex, particularly in a group, because it involves following a particular set of instructions, responding creatively to those instructions, finding a physical solution to the task which needs to be learned and remembered, and then being watched while performing the results of that task. In our workshops, many of the group dances that were created included multiple compositional elements such as different material being danced at once, variations in timing, lifts or partner work and travelling in multiple directions. In order to create, remember, and perform those dances, each member of the group needed to engage in complex physical and verbal social interactions, to initiate, and to accept suggestions. The main focus of the creative task meant that any social negotiation happened within the framework of the dance creation.Dance researcher Sherrie When we were running the second of the two autism groups, the dancers participated in a discussion over a period of 4weeks about what their costumes would be. In working with the previous group, it had become evident that, for some children, performing in a costume was very much part of their expectations of participating in a dance performance. While we certainly did not have the time (or the desire) to produce costumes, and it was not part of our approach to dictate what the dancers should wear, we entered into a discussion about the costumes with 5weeks to go. The discussions were not planned but rather unfolded as a forum in which all members of the group could share their suggestions and desires. While it did not matter at all what the dancers wore in the end, it became very important to take the suggestions seriously and to work toward an agreed cohesion, while still enabling every individual to dress in the way they wanted to. We arrived at a framework which included the following: woodland theme with a particular color scheme; Christmas; Harry Potter; magic; colored socks. In retrospect, it seems very chaotic but the extensive discussion that underpinned the development of the theme included serious social interactions in which all members of the group took part, and every contribution was equally valued. Individuals could suggest and agree (or not) what costumes should be worn through discussion and interaction. Crucial to the development and success of the program was the participation of “buddies” who were older and had an existing level of dance experience. The buddies ranged from 14 to 25 in age and had varying associations with dance such as vocational aspirations or plans to be teachers of dance. Far from merely being present to help dancers “learn” or adapt steps, buddies became mentors, creative collaborators, and friends to their dancing partners.Freedom to Move (2003) which charts their extensive work with people with disability in the Dance Movement Therapy paradigm, recount different situations working with “assistants,” volunteers, and undertaking team teaching. An assistant, whose role is to support the leader of the workshop, can help keep the “magic” through minimizing distractions and is integral to running a successful program . The assistant can also provide “emotional support” as well as sharing in the joys of special moments (p. 195). With support from the leader, the assistant works toward leadership roles. Co-operating with professionals from other disciplines can offer opportunities for knowledge sharing, but it is important to be aware of a potential lack of alignment in intention, particularly in the real time situation of the class. Kim Dunphy and Jenny Scott, authors of Buddies recruited for the AllPlay dance projects met particular criteria. The buddies for the CP program, as mentioned above, participated in a Master Class with Artistic Director of Queensland Ballet, Li Cunxin. Queensland Ballet set the criteria for those buddies, which included usual participation in at least 7h of ballet training per week and an aspiration to become a professional classical dancer. The CP buddies had great skills as dancers, and many of them were also capable improvisors and experienced in composing dances. The emphasis of the autism program was not strictly on ballet, and the buddy population was much more diverse. The criteria for joining the program included aspirations to become a dancer or dance teacher and to be undertaking at least 7h of training each week. Buddies in the autism program included some of the CP buddies who wanted to be involved again, dancers from the undergraduate dance program at Deakin University, students working toward becoming dance teachers and some psychology and occupational therapy students with significant dance training.In both programs, we aimed to keep the pairing consistent for all sessions. In some cases, this was not possible, particularly because some children missed a session or two. There was also some attrition of participants. In the CP project, the buddies outnumbered the participants with CP. Some dancers had three buddies, although others only had one. Although the difference in numbers was not planned, it turned out to be fortunate in the CP program because the dancers worked in small groups and created sequences with lifts and complicated configurations with those with wheelchairs or walkers.The range of ages in the buddies meant that their approach to their work and their way of relating to their partners varied. Some buddies seemed to see their role as a teacher or mentor, some related to their partners as peers or friends. Their work involved encouraging confidence at times and at others working as collaborators in the making of dances. Upon arrival, some participants were shy, or reluctant to participate, others were incredibly excited. Some buddies practiced the dances over and over again with their partners, others listened, while their partners chatted about their ideas for the dances or about everyday happenings. Some participants wanted to hold their buddies’ hands, and others wanted help with handstands or other tricky moves. One participant performed an amazing knee slide that his buddy, though she tried, just could not emulate. All participants and buddies worked together to create and perform their dances.For most of the children, for varying reasons, their buddy was their means to participation in the program. It is easy to imagine that a child with CP in a wheelchair has very different barriers to participation in a dance program than a child with autism. For that reason, there was no one “way,” in either of the projects, that a buddy should work, or interact with their partner. Instead they figured out, through social interactions over time, the best ways to work. Without exception, the buddies were generous and approachable, and the participants responded to that generosity.Dancer Caroline Bowditch states that inequality for people with disability is a result of a lack of prioritizing of access and inclusion. She also states that responsibility for addressing the problem of inequality should not lie with people with disability alone, “We all have a responsibility and a role to play” , p. 53. One of our approaches to inclusivity was to enable all participants to have agency in the kind of movement they were doing. In almost every aspect of the class, the dancers could choose (to varying extents) what dance moves they did or at least how they did them. As described above, participants were also supported to generate their own movement material through naming and recreating movements with prompts based within the framework of Laban’s movement analysis (1950).In the function of an author, according to A Casting Exploration. The film explores Bowditch’s experience of being re-cast in a role in dance work, Love Games by Sarah The situations in which dancers had agency in their dancing varied in each class and throughout the projects. In improvising, dancers could choose whatever movement they wanted to do, although their dancing bodies were certainly structured by the environment in which they were dancing. In adjusting phrases that had been learned, the dancers could make versions or movements that suited their bodies and their desires. Some dancers added a slide to the floor whenever they could, others made versions of movement that were percussive or had jumping in them. When the small groups made set dances using words or scores, some groups used complex timing arrangements, some included lifts or balances, and some developed material with repetition or in which all members of the group danced the same movement. The buddies played a vital role in enabling each participant to make choices about their dance. They encouraged and supported their partners through making suggestions or helping them to try out ideas. As the participants became more confident, the role of some of the buddies was to help their partners realize their “visions” by stepping back or by becoming the executor of created movements.As suggested by dance scholar Susanne Ravn, it is the dance situation itself which determines how one can have agency. The two projects were only possible because of the collaborative approach to the research, that is, the coming together of two discipline-specific research practices and working methods. We employed the dance studies methodology of the taking into account of the occurrence of dance activities and their effects while concurrently gathering objective and subjective data from children and parents both prior to and following the dance program to measure its benefits. Performing Arts scholar As mentioned above, not all aspects of our projects ran smoothly. Some children left the projects after a couple of weeks. Others stayed although the classes were not exactly what they were hoping for. There were participants who had difficulty consistently participating, despite our and their parents’ best effort to find a “way in” for them. One parent was disappointed that their child had not been taught to dance “well” as they perceived it, instead in the performance they seemed to be dancing individually, and not in sync with the group. There was a suggestion that there was not enough social time, that too much of the time was spent dancing with little time left to make friends.One short coming which we feel most keenly is that an eight-week program is too short. It is too short for there to be real development of physical and creative skills. Even more concerning is the fact that for several children, this was the first time they had been able to participate in a dance program, having been excluded from community programs because of a lack of confidence or training on the part of the teachers, or because the way the programs run are simply unsuitable. To offer a series of classes which children felt happy and confident in, and in which they had agency in their own participation, only for the classes to be over after such a short time, felt inadequate and disappointing for us; the real implications for the children are possibly akin to perpetuating their struggle to be included.We continue our work, aiming to address the challenges and to continue to develop our program in varying ways. In 2021, we take on two new projects: one to develop and deliver a series of online dance classes for children with autism, the other to consult with community dance teachers to develop professional development so they are supported to include children with disability in their classes.This paper discusses the development of two projects that preference the experiential understandings gained through a dance studies approach. Other than to reap the therapeutic benefits, is there value in encouraging children to dance, particularly if there is a chance of them not living up to an expectation of what a dancer is? While working to develop a program that is inclusive and transferable, could we also challenge the notion that dancers “overcome” their disability in order to “become” a dancer? Instead these young dancers could, in Cooper Albright’s words, “radically re-figure the very category of dancer itself” . By removing the authority of what dancing should be from a single individual and diffusing it among all participating members of a group, there is the possibility to define the dancer as one who considers themself to be dancing. Caroline Bowditch writes: “[w]e need to move away from seeing access as a drain on resources, time and quality toward seeing it as the most creative opportunity we have available” . Rather than aiming to “intervene,” in AllPlay Dance, we aim to continue working with children in a collaborative way, enabling them agency in their own dancing and therefore in their social and developmental goals.olivia@deakin.edu.au.The data sets presented in this article are not readily available because the data used in this article include the development of an original dance program for children with disabilities and qualitative responses to survey questions. Requests to access the datasets should be directed to OM, The studies involving human participants were reviewed and approved by Deakin University Human Research Ethics Committee. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.OM, EL, NR, and JM participated in the conception and design of the study. OM, EL, and NP were involved in recruitment and data collection. OM and EL conceived and designed the dance program and OM facilitated and taught workshops. OM analyzed the program, formulated the framework for paper discussion, and led the paper. All authors contributed to the article and approved the submitted version.allplaydance.org.au) and systematic review. Moose Toys funds the AllPlay program . The funders were not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.AllPlay Dance is funded by National Disability Insurance Scheme, Moose Toys, MECCA Brands, Grace and Emilio Foundation, and the Wenig Family. Donations and philanthropic support from MECCA Brands, Grace and Emillio Foundation funded research staff and the Wenig Family funded PhD scholarship. NDIS supported initial AllPlay Dance program development including online resources (see 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. 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