Supplemental Digital Content is available in the text People with multiple sclerosis (PwMS) experience a wide range of disabilities which negatively impact their quality of life (QOL). Several interventions have been used in PwMS such as medication, physical therapy exercises and stem cell therapy to improve their QOL. However, there is a limited evidence on the benefits of combining interventions. The purpose of this study is to explore the effect of combining physical therapy exercises (PTE) and Wharton Jelly mesenchymal stem cell (WJ-MSCs) injections on motor and non-motor symptoms versus each intervention alone in PwMS.Sixty PwMS will be allocated to either PTE, WJ-MSCs, or a combined group, followed up for 12 months and examined using a comprehensive battery of measures. Participants in the PTE group will receive 2 sessions per week of a supervised exercise program for 6 months followed by a home exercise program for another 6 months. The WJ-MSCs group will receive 3 WJ-MSCs injections in the first 6 months then they will be encouraged to follow an active life style. The third group will receive both interventions.This study will aid in a better understanding of the combined effect of physical therapy and mesenchymal stem cell therapy. The results from this proposed study may reduce disability, improve QOL in PwMS, and consequently, reduce the cost associated with the life-time care of these individuals worldwide.NCT03326505 Non-motor symptoms such as cognitive dysfunction, depression, fatigue, and sleep disturbances are also common in these individuals. These symptoms together can result in a reduction in several quality of life (QOL) indices, including physical function, psychological well-being, self-care, work ability, interpersonal relationships, and reduced ability to perform daily activities.,3,4Multiple sclerosis (MS) is a progressive inflammatory neurodegenerative disease characterized by a variety of disabling motor and non-motor symptoms. In Jordan, data from 2004 to 2005 indicated a prevalence of 39/100,000 in the capital, Amman and 38/100,000 in the northern city of Irbid, which is considered a medium to high risk similar to western countries.MS can be found all over the globe, with an estimated 2.3 million people diagnosed annually worldwide . The prevalence of MS is the highest in North America and Europe while Sub-Saharan Africa and East Asia have the lowest prevalence.–10 Balance, mobility, spasticity, fatigue, and overall QOL have been all found to improve from participating in PTE in the MS population.–10 Unfortunately, the lack of awareness about the role of physical therapy in the management of PwMS might be the reason why PwMS do not receive adequate physical therapy services in Jordan.Participation in physical therapy exercises (PTE) should start soon after the MS diagnosis, as research has shown that PTE delivers favorable outcomes in a variety of motor and non-motor symptoms in people with MS (PwMS), even in those who are not severely disabled.–13 One of the attractive stem cell therapy types is umbilical cord mesenchymal stem cells using Wharton Jelly (WJ-MSCs) due to their accessibility, high proliferation rate and their unique neuroregenerative potential as compared to bone marrow or adipose tissue derived MSCs. The WJ-MSCs was used in several studies for different aims such as cartilage repair and bone regeneration.–16 The Cell Therapy Center (CTC) at University of Jordan has demonstrated the safety and efficacy of this therapy for the past years in the setting of clinical trials, the first of which was for PwMS who had not responded to any available pharmaceutical agent.Regenerative medicine using stem cell therapy injections has also proven its efficacy in numerous preclinical and some clinical studies in halting the neurodegenerative and neuro-inflammatory aspects of MS disease. and PTE shown to be effective in PwMS, there is a limited evidence on the combined effect of WJ-MSCs and PTE on a wide range of symptoms in PwMS. Therefore, this study will be the first to assess the effect of a combined treatment intervention protocol (WJ-MSCs and PTE) that will eventually aid in a better understanding of the combined effect of 2 different treatment interventions versus when administered alone, in relation to motor and non-motor symptoms in PwMS. The findings of the study will emphasize the important role exercises have when added to regenerative medicine on managing common symptoms in PwMS. We also hope that the results of this study help guide clinicians and primary care givers on including physical therapy services soon after the diagnosis of MS to improve the QOL of these individuals.While the effect of mesenchymal stem cell therapy on PwMS has been studied before,1.1The purpose of this study is to explore the effect of PTE and WJ-MSCs injection versus PTE alone or WJ-MSCs alone on motor and non-motor symptoms in PwMS. We hypothesize that PwMS who receive the combined treatment of WJ-MSCs and PTE will demonstrate significant improvements on motor and non-motor symptoms compared to those who receive either WJ-MSCs alone or PTE alone.1.2The proposed study utilizes a randomized controlled design to examine the combined effect of a 6-month program on motor and non-motor symptoms in PwMS. This study is single-blinded where the researchers involved in the assessments are blinded to the allocation of the participants to each group. We aim to recruit 60 participants with MS (20 in each group) that will be randomly allocated to 1 of 3 groups using a computer-generated software to either a combined treatment group (PTE + WJ-MSCs), PTE alone control group or WJ-MSCs alone control group after going through a battery of comprehensive assessments , and a trained research personnel will perform the mini mental state examination.Inclusion criteria:(1)Males and females.(2)Eighteen years and older.(3)Written informed consent prior participation.(4)Independent in ambulation even with the use of an assistive device.(5)All types of MS.(6)EDSS score < 6.5.(7)mini mental state examination score ≥ 24.Exclusion criteria:(1)Uncorrected vision loss.(2)History of a nervous system disorder other than MS.(3)Severe physical, neurological, or sensory impairments that would interfere significantly with testing.(4)Developmental history of learning disability or attention-deficit/hyperactivity disorder.(5)Relapse and/or corticosteroid use within 4 weeks of assessment.(6)Acute ischemic cardiovascular event or coronary artery bypass surgery less than 3 months.(7)Uncontrolled blood pressure with medication (blood pressure (BP) > 190/110 mm Hg).2.32.3.16 cells intrathecally and 50 x106 cells intravenously. After 1 month, the second injection is administered with the same content as the first injection. The third intrathecal injection contains 8 to 10 mL of the WJ-MSCs’ conditioned media after 3 months of the first injection. The WJ-MSCs is administered by an internal medicine specialist or the neurologist himself. Prior to the intrathecal injection, the same volume of MSCs injected is withdrawn as cerebrospinal fluid (CSF) in order to maintain the CNS pressure and decrease the post-intrathecal injection headache.The stem cell treatment protocol for all participants in the WJ-MSCs only group or the combined group consists of using cryopreserved allogenic WJ-MSCs donor. The WJ-MSCs group receive 3 injections. The first one contains 100x10Prior to each treatment, patients’ vital signs are measured at the CTC “ICU equipped” transplantation room. The participants are kept under observation for an hour post injection for any immediate adverse events. Any related adverse event is noted by the CTC nurse, 24 hours, 1 week, and 1 month post treatment through direct communication with the participant.2.3.1.1 All steps are conducted according to good laboratory practice and good cell culture practice principles at the CTC clinical tissue-culture lab. A cell bank generated from a single donor expanded to a clinical grade provides sufficient number of cells to be transplanted to all patients eliminating the donor variability in interpreting treatment outcomes.The consenting umbilical cord donor is a lady in labor at the “Al-Amal Maternity Hospital” with blood group O who has been screened for infectious agents . Isolation of MSCs from the Wharton jelly is performed using the explant method.2 incubators. Cells are fed with fresh medium every 3 days until individual colonies reach 70% to 80% confluence. After the primary passage, cells are detached using the xenogenic-free10xTriple E  to reach clinical numbers at passage 3. Cells are cryopreserved and adequate number are thawed and allowed to proliferate to be ready as treatment at passage 4. The conditioned media of WJ-MSCs are stored at –800° C Freezers at the CTC to be used for the third injection.The maternal umbilical cord is rinsed with (PBS) (pH7.4) and cut into 2 cm-long pieces and plated in round tissue culture dishes. The explants are allowed to attach for about 15 minutes, then culture medium is gently added to the plates and incubated for 8 days in humidified 5% COThe expansion culture medium consists of the following: α-modified minimum essential medium  supplemented with 10% platelet lysate, 1% (w/v) Penicillin/Streptomycin (P/S) and 2 mM L-glutamine . The culture medium is changed twice a week. The quality of WJ-MSCs is examined throughout the expansion steps visually and microscopically for any fungal or bacterial contamination and using Q-PCR for any mycoplasma contaminant prior to patient administration.2.3.1.2 Cells are observed microscopically for the spindle shape and attachment to tissue culture flasks. Flow cytometry is performed to confirm the expression of CD73, CD90, and CD105 surface molecules at a percentage of at least 95% and the absence of CD34, CD45, CD14, and CD3 surface markers at no more than 5%. In addition, the differentiation assessment into adipogenic, osteogenic, and chondrogenic lineages is performed according to the differentiation media manufacturing recommendations; StemPro differentiation media .Characterization of the patients’ expanded MSCs is in accordance with the International Society for Cellular Therapy (ISCT) recommendations.2.3.2,21 Following the physical activity guidelines for adults with MS, we will further add 30 minutes of aerobic exercise to the program. Additionally, we will also follow the guidelines of having a minimum 2 sessions per week of physical activity for PwMS. The PTE program consists of a mixed program including the following types of exercises: balance, resistance, flexibility, and aerobic exercises performed 2 times per week for a total of 6 months. The intensity of the exercise will be progressed throughout the 6 months’ period and consists of 3 stages of progression for the resistance/flexibility and balance programs, and 2 stages of progression for the aerobic exercise program. Participants will be progressed to each stage depending on their tolerance and performance level of the exercises. Each session will take 60 to 80 minutes to finish, and will be supervised by a trained physical therapist (PT). Exercise will be performed in a well-equipped lab space at the CTC at University of Jordan. Following the 6 months supervised program, participants will continue the remaining 6 months of the study period performing a home exercise program (HEP).The PTE program utilized in this study is partly based on 2 previous published exercise programs that were found to be effective in improving balance and mobility in PwMS.The PTE session is divided as the following: pre-exercise vital signs measured using a digital HR/BP monitor, 5-minute warm-up exercises, 10 to 15 minutes of strength and flexibility exercises, 10 to 15 minutes of postural balance exercises, 40 minutes of aerobic exercise on a recumbent stepper machine and a 5-minute cool-down. Vital signs will be taken again post-exercise. Resting periods will be given to each participant before progressing to other forms of exercises and as necessary to decrease levels of fatigue. Participants will be allowed to choose the appropriate days/times to do the sessions upon their convenience but will be encouraged to choose the session every other day to allow a day rest in between. Vital signs, comments, and progress of each session will be documented for every participant using weekly exercise logs.The warm up/cool down exercises that will be performed before and after the PTE will each take around 5 minutes; all exercises are to be done for 3 to 5 repetitions. The PT will demonstrate and supervises the exercises for the participants. The warm up/cool down exercises include chin tucks, arm circles, shoulder shrugs, marching in place, hamstring stretch, heel cord stretch/calf stretch, knee to chest, heel raises/toe raises, and mini-squats . The remaining supervised exercises will be performed in the following order:2.3.2.1The following guidelines are followed across the 3 stages: A list of 10 different exercises is given to the participant. The participants are allowed to choose 5 exercises out of the 10 exercises each session with the help of the PT. In case the participant was not able to perform 1 of the exercises, the PT chooses another 1 from the remaining 5 and so on. The participant perform the other 5 exercises the next session and alternate every session accordingly. For the exercises that requires resistance, if the participant cannot perform any of the exercises against resistance using cuff weights, Thera band, etc. The participant is allowed to perform the exercise without resistance until he/she feels comfortable with it and can perform it successfully pain free. The PT will add resistance when participant perform the exercise successfully and pain free. If the participant cannot perform the required number of repetitions, the PT decreases the frequency to the participants’ ability and increase accordingly until reaching the desired outcome. The PT records the exercises/intensity/frequency performed by the participant on the weekly exercise log every session. The resistance and flexibility exercises through the 3 stages are listed in detail in Supplemental Digital Content (Appendix 1).2.3.2.2The following guidelines should be followed across the 3 stages: a list of 10 different exercises is given to the participant. The participants are allowed to choose 5 exercises out of the 10 exercises each session with the help of the PT. In case the participant was not able to perform 1 of the exercises, the PT chooses another 1 from the remaining 5 and so on. The participants perform the other 5 exercises the next session and alternate every session accordingly. For the exercises that requires challenges, if the participant cannot perform challenging exercises using: balance board, Swiss ball, dual tasking…etc. The PT will allow the participant to perform the exercise without the challenge until comfortable with exercise, and then add the challenge when participant perform the exercise successfully and safely. The PT will add resistance when participant perform the exercise successfully and pain free. If the participant cannot perform the required number of repetitions, the PT decreases the frequency to the participants’ ability and increase accordingly until reaching the desired outcome. The PT records the exercises/intensity/frequency performed by the participant on the weekly exercise log every session. The balance exercises through the 3 stages are listed in detail in Supplemental Digital Content (Appendix 2).2.3.2.3 Intensity is adjusted according to physiologic response but not to exceed the target heart rate range during the 30 minutes’ period. Rate of perceived exertion is monitored before and after the aerobic training period using the Borg scale. During the 30 minutes of exercise, each participant is instructed to keep their stepping pace at 100 steps/min that would be visible for them on the machine monitor. However, each participant is allowed ± 5 steps (95–105 steps/min) during the exercise. The intensity used, vital signs, rate of perceived exertion, and any comments or changes during the session is recorded on a weekly exercise log. After the cool down, participants are allowed ample time to rest before they leave.The following guidelines are followed across the 2 stages: exercise intensity in stage I is 50% to 59% of heart rate reserve for 3 months; increased to stage II 60% to 69% of heart rate reserve for remaining 3 months. Exercise session total time is 40 minutes on the recumbent stepper supervised by the PT including 5 minutes warm up, 30 minutes aerobic training, and 5 minutes’ cool down. Aerobic exercise is performed on the same recumbent stepper used for the submaximal testing during the baseline assessment (Model SCIFIT-StepOne). The handles and seat is adjusted according to the participant's arm and leg length prior to the exercise session . Pre and post exercise vital signs (HR and BP) are taken. Heart rate is monitored during the exercise using polar heart rate monitors. Five minutes’ warm-up and cool down on the recumbent stepper is set at 25 watts load at a comfortable pace. Exercise intensity during the 30 minutes’ period is increased to the prescribed target heart rate range that is initially calculated using the Karvonen formula.2.3.2.4,26 In brief, this DVD focuses on the main components of fitness introduced by an acting lady and a gentleman in 5 main sections. The first section is focused on warm up and flexibility activities; the second, third, and fourth sections focus on strength, flexibility, balance and endurance exercises, and training on performing functional tasks of sit to stand, stepping up onto stairs, and getting on and off the floor; and the fifth section focuses on relaxation, stretching, and breathing techniques. In addition to these main 3 sections, the DVD includes a list of precautions, equipment required, and postural instructions.The HEP focuses mainly on the home use of an exercise DVD that was specifically developed for people with movement disorders and available in the Arabic language. Details of the exercise DVD and its content are published elsewhere.During the HEP, participants are instructed to perform the exercises 2 times a week using the exercise DVD. After the end of the first 6 months of the intervention, the participants will receive 1 instructional session in the CTC from a trained PT. In this session participants are introduced to all exercises in the exercise DVD; the therapist observe the participant while performing the exercises and provide feedback whenever is needed. There is a total of 29 different exercises in the DVD, the participants are encouraged to perform all of them. However, the participant is allowed to choose which exercises to perform if any of the exercise were found difficult to execute or if it was not feasible to perform at their home. Participants should perform at least half of the exercises in the DVD. Each participant will be provided with the DVD along with a hardcopy manual of the exercises. In addition, potential benefits and risks of performing the exercises are discussed. During the instructional session, participants are also instructed on how to progress their exercises by gradually increasing the number of repetitions while decreasing the number and length of rest breaks and increasing the level of exercise progression. In addition, participants will be contacted by the PT every month via phone calls to assess their compliance to the program and document any barriers to exercise of they have any. A predetermined protocol for these instructional sessions is provided in Supplemental Digital Content (Appendix 3). For the remaining period of the program, participants are asked to perform the 2 exercise sessions per week independently at home. Participants are asked to keep an exercise diary for their HEP exercises to assess their compliance to the HEP program. Participants will return the exercise diary at their 1-year post assessment appointment. Supplemental Digital Content (Appendix 4).2.3.3In this group, a combined interventions of both the PTE and WJ-MSCs will be administered.2.4On the day of the assessment, each participant performs the measures in the following order: cognitive function assessment, surveys/questionnaires, physical function assessment, biological assessment, and (MRI).2.4.12.4.1.1. Aerobic fitness is assessed using the submaximal testing. In this test a seated recumbent stepper (Model SCIFIT-StepOne) will be used, which provides simultaneous movement of the upper and lower extremities in a continuous stepping motion. During the submaximal exercise test, the participants are asked to move their arms and legs in an alternating pattern at a constant speed of 100 steps per minute and resistance (Watts) will be increased every 3 minutes according to the total body recumbent stepper submaximal exercise test until 85% of age-predicted heart rate max is met or participant can no longer continue due to fatigue (test termination endpoint). During the test, heart rate is monitored using polar heart rate monitors. Ten seconds prior to the end of every stage, heart rate is taken and recorded. Once the test is finished, the participant will continue to step at a comfortable self-selected speed with minimal resistance for 2 minutes or until heart rate returns to near baseline levels. The outcome measure is predicted VO2 max calculated by a formula using the participant age, sex, weight, watts used, and HR.2.4.1.2. Balance and mobility are assessed using the following assessment tools:1. This test needs a hallway with 2 cones 15 meter apart to be performed. The participant walks between the 2 cones for 6 minutes. Distance is measured by number of laps to be completed.6-minute walk test will be used to assess physical endurance capacity.2.. The dynamic gait index has been translated to several languages including the Arabic language.The Arabic version of the dynamic gait index will be used to examine gait performance and the likelihood of falling 3. It consists of 14 common functional activities that occur in everyday life.The Arabic version of the Berg balance scale will be used to assess static balance.4. The participant is instructed to rise from a chair, walks 3 meters at a comfortable and safe pace, turns, walks back to the chair, and sits down. The time between the start of the test until the participant sits back on the chair is recorded and used as the outcome measure.Timed-Up and go test is a test for assessing balance and walking ability.5. This scale was found to be both reliable and valid for the assessment of balance in PwMS.,35The Arabic version of the activities-specific balance confidence scale will be used to detect balance confidence.6.. The BI is considered as a measure of disability that had good reliability and validity ,37. The BI has been used with individuals with neurological disorders.Barthel index is a self-reported questionnaire that evaluates the ability of individuals to perform activities of daily living and mobility activities Upper extremity motor function (UEMF) is assessed using the following tests:2.4.1.3. 1. Each participant will be instructed to squeeze the handle with maximum strength first on the dominant hand and then on the non-dominant hand. Three trials on each hand will be performed. The average maximum force exerted from the 3 trials will be used as a primary outcome measure.Grip strength of the participants will be assessed using a hand held dynamometer (Model Jamar hydraulic hand dynamometer).2. The participant is asked take pegs from a container, one by one and put them into holes. Then take the pegs back from the hole, one by one an out them into the container as quickly as possible. The time taken to finish the task will be recorded and used as an outcome measure. The test will be performed first on the dominant hand then on the non-dominant hand.9-hole peg test is a specific test for finger dexterity.2.4.1.4. Fall assessment: the Arabic version of the falls efficacy scale-international will be used to assess fall. The FES-I is a self-report questionnaire that evaluates fear of falling.2.4.22.4.2.1. Depreesion is assessed using the Arabic version of the Beck depression inventory-II. The Beck depression inventory-II measures how depression is manifested in behavior. It not only identifies varying levels of depression but is also able to indicate changes in intensity of depression over a period of time. Ratings are summed to provide a total score ranging from 0 to 63.2.4.2.2. Fatigue is assessed using the Arabic version of the modified fatigue impact scale (A-MFIS). The MFIS is a 21 item self-administered questionnaire that offers multidimensional assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning. The MFIS was translated into the Arabic language and was found valid and reliable tool to assess fatigue in people with MS.2.4.2.3. Sleep quality is assessed using the following tests:1. Pittsburgh sleep quality index is a well-validated and reliable measure of global sleep quality which consists of 19 self-rated questions. These 19 questions form 7 component scores, each of which is rated on a scale of 0 to 3 with 0 indicating no sleep difficulty and 3 indicating severe sleep difficulties. The 7 component scores are then summed to form a single global score ranging from of 0 to 21. A global score of 5 or more reflects poor sleep quality for all age groups.The Arabic version of Pittsburgh sleep quality index will be used to assess sleep quality.2. It consists of 8 items where the participant uses a 4-point Likert scale to rate how likely they would be to fall asleep in 8 different scenarios of daily activities.The Arabic version of Epworth sleepiness scale (ESS) will be used to assess the daytime sleepiness.2.4.2.4. Cognitive assessment will be examined using the following measures:1.. A validated Arabic version will be used in this study.The Stroop test is a tool performed as a measure of executive functioning that requires participants to inhibit the natural response (reading a word) and replace it with another response (saying a color) 2.. The total correct responses in 90 seconds will be used as the outcome measure.The symbol digit modalities test, oral form, is a measure of information processing speed that asks participants to quickly say the number that matches a corresponding symbol 2.4.2.5. Pain is assessed using the pain rating scale that was translated into the Arabic by the British pain society and recommended for use in populations where pain is a major issue.2.4.2.6. Quality of life (QOL) is assessed using the short form SF-36 (SF-36 version-1). The SF36 is a health-related quality of life measure. An Arabic version of the SF-36 has been validated.2.4.32.4.3.1. Clinical disability assessment is examined using the EDSS. The EDSS is the MS golden standard that assesses the degree of disability. The EDSS is performed by a trained internal medicine specialist under the supervision of the lead neurologist from Jordan University Hospital. It is a scale from 0  to 10 (Death due to MS) with an increment of 0.5. An EDSS change of 0.5 or 1.0 point or more in either direction is considered as a significant change.2.4.3.1Bio-specimens including blood and cerebrospinal fluid are collected from participants by a trained nurse. Inflammatory markers in the blood are examined using Multiplex ELISA technology. Neural regeneration markers will be measured in the CSF and blood collected. Tests will be performed by CTC biotechnologists. Moreover, the percentage of T, B and NK cells in the blood of participants will be calculated at the CTC flow cytometry lab by a dedicated biotechnologist. Additionally, the IgG levels in the CSF will be measured in a referral CAP accredited lab (MEDLAB).The difference in concentrations compared to baseline measurements of biomarkers in the blood and CSF of patients in pg/mL enables the evaluation of the inflammatory and neural regeneration/degeneration status in response to interventions. While a change in the percentages of the different immune cells in participant's blood is an indication of immune-modulation outcome.2.4.3.2Visual evoked potential that measures the electrical conductivity is performed by a technologist at the CTC and supervised by the leading neurologist at the Jordan University Hospital.Optical coherence tomography is conducted by technologist and supervised by an ophthalmologist at the Jordan University Hospital. A measurement of the retinal nerve fiber layer in um and comparison to the baseline measurements in both the poor eye and less affected eye would indicate the outcome of the Optical coherence tomography examination. While the increase or decrease in the speed of electrical conduction in milliseconds of the nerve fiber would be evaluated as the target heart rate range outcomes.2.4.3.3 Fuzzy connections algorithm in JIM software is used to calculate lesion volume measurements.T2-weighted FLAIR and T1-weighted MPRAGE images are generated for all patients. The detailed imaging sequences protocol of the brain and those of the cervical and thoracic spine have been previously described.2.4.3.5. MRI scanning is performed at Farah hospital using a 3 Tesla (3T) imaging device to measure lesion load. Scheduling the MRI scanning will be on a separate occasion within 7 days from the day of the baseline assessment and prior to receiving the treatment.2.5Eligible participants will be scheduled for their baseline assessments. They will undergo a comprehensive battery of measures including motor, non-motor, and medical assessments, which will take around 2 to 3 hours to complete. Part of the baseline assessment that include MRI imaging will be performed on another day within a week from the baseline assessment on a time convenient to the participant. Participants will repeat these measures at 3, 6, and 12 months post the baseline assessment  and their electronic data is stored in university network drives and data collection occurs on an encrypted password-protected laptop computer. Data is available and accessed only by the study research personnel.2.9Statistical Package for the Social Sciences (SPSS) 23.0  will be used to perform all statistical analysis and alpha is set at 0.05. Correlations will be utilized to assess the relationship between the outcome measures of interest. Changes in outcomes at the follow-up scores for within-group and between-group differences will be computed using analysis of variance. Effect sizes of all outcomes will be also computed based on the difference in the change score from base line to follow up.2.10This trial has been approved by the Ethics Review Committee at University of Jordan. Prior to participation in the study, written informed consent will be obtained from each participant. The research personnel involved in the study will carefully explain the consent form to each participant including potential risks and benefits of study participation. Any changes to the study protocol will require approval from University of Jordan Ethics Review Board.The results of current trial will be published in peer-reviewed journals and presented in national and international scientific meetings and conferences to promote dissemination.2.11This trial is funded by the Deanship of Academic Research at University of Jordan. The authors declare that they have no competing interests.3In this study we will investigate the combined effect of stem cell therapy and physical therapy exercises in a wide range of MS symptoms. Moreover, we will compare the effect of a combined therapy to the separate effect of each therapeutic intervention alone. This will help health care professionals dealing with PwMS to have a better understanding of the combined versus separate effects of each therapeutic intervention. The outcomes from this study may help in reducing the cost associated with the life-time care of these individuals worldwide. More importantly, this study may help improving patients’ QOL and reducing their disability. For rehabilitation specialists, neurologists, and regenerative medicine specialists, the outcomes of this trial would clarify the added value of the regenerative interventions with the physical therapy exercise on different symptoms that PwMS suffer from. This will allow them to have a better understanding of this combination to answer PwMS questions that they usually have. Moreover, the combination between biological interventions and having the patients physically active through regular and progressive exercises would emphasize the benefits that the patients may get from both techniques. The expected benefits from both interventions could lead to a medical breakthrough in the treatment of PwMS. This would have positive socio-economic impact, including reducing the treatment cost related to the chronic nature of the disease and getting this active segment of the society back to the work market.Authors would like to thank the CTC personnel, research assistants, and patients for their commitment to this trial.Alia Alghwiri and Fatima Jamali have equal contribution and both of them deserve to be first author.Conceptualization: Alia Alghwiri, Fatima Jamali.Data curation: Alia Alghwiri, Fatima Jamali, Mayis Aldughmi.Funding acquisition: Alia Alghwiri, Fatima Jamali, Abdalla Awidi.Investigation: Alia Alghwiri, Fatima Jamali, Mayis Aldughmi, Dana Alhattab, Ali Al-Radaideh, Abdalla Awidi.Methodology: Alia Alghwiri, Fatima Jamali, Mayis Aldughmi, Hanan Khalil, Alham Al-Sharman, Dana Alhattab, Ali Al-Radaideh, Abdalla Awidi.Project administration: Fatima Jamali, Abdalla Awidi.Supervision: Abdalla Awidi.Writing – original draft: Alia Alghwiri, Fatima Jamali, Mayis Aldughmi, Hanan Khalil, Alham Al-Sharman.Writing – review & editing: Alia Alghwiri, Fatima Jamali, Abdalla Awidi.


Photovoltaic technology using perovskite solar cells has emerged as a potential solution in the photovoltaic makings for cost-effective manufacturing solutions deposition/coating solar cells. The hybrid perovskite-based materials possess a unique blend from low bulk snare concentrations, ambipolar, broad optical absorption properties, extended charge carrier diffusion, and charge transport/collection properties, making them favourable for solar cell applications. However, perovskite solar cells devices suffer from the effects of natural instability, leading to their rapid degradation while bared to water, oxygen, as well as ultraviolet rays, are irradiated and in case of high temperatures. It is essential to shield the perovskite film from damage, extend lifetime, and make it suitable for device fabrications. This paper focuses on various device strategies and computational attempts to address perovskite-based solar cells' environmental stability issues. Stability; Efficiency; Perovskite-Chalcogenide; Density function theory One of the promising technologies is solar cell technology, which is considered efficient for clean energy at low cost and minimal pollution Despite the research efforts, a tiny portion of PSCs' gross research has reported power conversion efficiency greater than 25%. The reason is partly the instability of the perovskite medium and problems related to the devices remanufacturing 2PSC are A is an organic CH3NH3, NH2CHNH2, B is metal , X is halide, makes this material important for more applications ETM) and Hole Transport Materials (HTM). In fundamental, one of the electrodes should be a transparent conductive oxide, such as a nitride containing indium PSC compositions. Therefore, the PSC charge transport channel is often discussed based on the kind of the device structure The comprehensive chemical structures of 2, which forms an interlocking network between the two-phase interfaces. Therefore, light-induced electrons can be transported to the cathode through the TiO2 channel, and the pores are transported to the anode via the perovskite channel The perovskite layers have a mesoporous structure and are formed by a layer of porous semiconductor metal oxide such as titanium oxide TiO3PSC have explained that light excitation in a perovskite medium will immediately generate electron-hole excitons in less than 2-picoseconds at electric field caused by the difference of function between anode and cathode and then splits it into delocalized charge carriers 1.Photons absorption and excitons formation2.Excitons diffusion and splitting3.Charge transmission4.Charge collectionOver the past a few years, several studies on charge transport kinetics in Once sunlight drop on the perovskite layer, it absorbs photons excitons. Owing to the difference in the excites' binding energies in the perovskite material, the exons can form electrons and holes when the excitons are separated. Exciton separation happens at the interface between the hole transport layer and the charge transport layer. Electrons are separated from the holes and injected into the electron transport layer, typically migrating to the Fluorine-doped Tin Oxide (FTO) anode, at the same moment, holes are mainlined into the holes transport layer and then transferred to the cathode, usually a metal as displayed in 43NH3PbBr3 just as the solar sensitive material and obtained a solar cell with an efficiency of 2.2% 3NH3PbBr3, CH3NH3PbI3 as sensitizers in the cell. The measurement of PCE approximately 3.81% into the CH3NH3PbBr3 as well as 3.13% into an CH3NH3PbI3-based cells, respectively, but with improved fabrication conditions. However, they found limitations produced by the nanocrystals' decomposition in the iodide fluid that led to quick device degradation. The device lasted only about 10 min 3 perovskite as quantum dots, resulting in enhanced productivity to 6.5% through TiO2 surface treatment. By mid-2012, Park et al. HTM and absorber (CH3NH3PbI3) into avoid an effect of electrolytes manufacture with a significantly increased the PCE of 9.7%. Demonstrates that a solid-state as HTM highly increased the device's stability compared with liquid electrolytes. Nevertheless, instability challenge remained the major limitation impeding manufacturing and photovoltaic marketing of HTM and Al2O3 as supports. The efficiency of the device was 10.9%. In their report, they showed that the use of mixed halides (CH3NH3PbIx) can improve performance because of its higher charge carrying capacity. They also showed that perovskite has bipolar charge transport electrons and hole transport. In March 2013, Seok et al. 2 infiltrated by mixed-halides PSC through optimization the halides in 3NH3PbIx and poly-triarylamine HTM of 16.2% and 17.9%, respectively. Subsequently, Saliba et al. 2)2CH3NH3 to prepared solar cells with surface defects. Sahil et al. PSC.There has been the development of perovskites to achieved high the ideal efficiency for solar cells devices. Miyasaka et al. 52 just outside the atmosphere 2, using the energy equation of a photon Eq. λ is the wavelength. That half the photons have a wavelength less than 1000 nm, which is between 1.24 to 1.5 eV D) perovskite calculations that can handle electronics. The absorbed photons are photons with higher energy than the band gap of the material. Bandgap has an essential effect on the material's optical properties, in a systematic study Shockley and co. Workers found that most favourable bandgap should be near to the Shockley-Queisser limit 1.34 3 has been widely used as a light absorber for PSCs with ideal bandgap. The long-term stability has currently been attributed to several studies, which will replace Methylammonium iodide (MA) MAPbI3. Although the best energy gap of a single-junction cell is between 1.1 and 1.4 eV, it has been reported that the bandgap of MAPbI3 is between 1.50 and 1.61 eV, further reducing PSC's solar power collection efficiency may be used MAPbI33 is 1.59 eV, and the bandgap of FAPbI3 is PL peak makes it should be used in solar cells advantageous +, Cs+ and Rb+ on the properties of FAPbI3 perovskite has been investigated through density function theory calculations. It was established that these additives might increase the energy gap of FAPbI33, they found a band gap of Rb doped MAPbI3, between 3, Rb-doped systems, the band gap is 1.49 eV. Furthermore, it has been shown that Rb-doping will reduce the structural stability of MAPbI3, which can be attributed to the near band gap of it, which means if the bandgap <1 eV of a perovskites-type solar absorber is too small, the device may collect additional current from infrared emission, but the open-circuit voltage will be much smaller. Also, when the energy bandgap is more than 2 eV, a tiny amount from the sun's light can be harvested. Therefore, the materials with a bandgap of between The design of solar cell technology strongly depends on the knowledge of the energy from the sun. The sun releases a considerable amount of energy ≈174 PW, roughly 6000 times worldwide energy usage 5.1PSC devices produce an exciton electrical bound pair. This exciton has to dissociate into electron and hole. Thus, the quantity of exciton binding energy has direct influences on PCE of the PSC device's performance. If the bending energy is weak, excitons are miss bound; then dissociation is favoured. While if band energy is elevation, excitons are tightly bound. Thus, recombination may be favoured PES and DFT as displayed in 3 is determined should be It has already been mentioned that upon absorption of photons, Another property that enhances charge dissociation is the degree of the modification in dipole moment from a ground state to the excited state 6DFT calculation and experimentally synthesized the reported performance is summarized based on the configurations displayed in 3 compound investigated based on DFT method. The results of their calculations indicate that a small Zr substation PCE of Perovskite-based on transition metal chalcogenides have emerged as a modern category of flexible semiconductors, with large chemical, as well as structural tenability that translates to a tenable bandgap visible to the infrared the electromagnetic spectrum 7Designing better perovskite electronic materials requires a comprehensive understanding of these materials electronic structure and the factors affecting it. By systematically studying a series of materials, valuable information can be generated regarding the materials properties. There are two distinct methods used to study the properties of materials, experimental and computational. Here we give a summary of both the experimental and computational approaches.7.11.vacuum deposition2.solution processing Although the first method has positive benefits, the second method is cost-effective and compatible with large-scale devices manufacturing. Researchers used different methods to design perovskite cells with different properties and reported power conversion efficiency Two main techniques are used to generate Typical methods commonly used in vacuum deposition are one-step precursor deposition, sequential vapour deposition, and dual-source vacuum deposition (TSVD). Among the solution deposition methods, so deposition method Ab initio calculations are one of the most promising computational approaches to obtain detailed structural information of such perovskite structure.Various experimental techniques such as X-ray diffraction 7.2ab initio, and semi-empirical approaches. A widespread disadvantage of the above methods is that they depend on external parameters or experimental results. For example, as long as a constant force field of interaction parameters is provided between atoms, molecular dynamics simulations can predict molecules' structural evolution under temperature and kinetic properties MD calculations strongly depend on ab initio calculation results, which assist into the improved force field and parameters necessary. Nowadays, MD successfully applied to the halide perovskites. Belugas et al. MD simulation analysis show that the methylammonium lead iodide spectrum has a large temperature development, has the transformation of orthorhombic crystal to tetragonal crystal to cubic crystal, and strongly depends on the restriction and order of molecules. Taufique et al. MD simulation to study the accumulation of ETL on the surface of various perovskite crystals in the presence of solvents. There have been several reviews of the theoretical research into halide perovskites: reviews on optoelectronic properties MD simulations Ab initio quantum mechanical calculation, which does not depend on external parameters, is of great help since it can predict the structure, energy levels, and optical transition strength of compounds before synthesis The computational approach is further divided into several disciplines, including molecular dynamics, chemical dynamics, molecular approaches, 7.2.1DFT) began in 1926 with the appearing of the Thomas-Fermi theory Since was introduced the Schrödinger equation DFT using the HK theorem XC is approximate, and the result is only as good as the estimated value. The XC was first approximated using a theory called local density approximation (LDA), given by Eq. GGA) represented by Eq. density DFT functionals were so well developed until the 1990s, they still could not treat Van der Walls interactions or provide accurate long-range dispenser forces ab-initio approaches, re-parameterization of creating functions, and practical terms. Recently, the second method has attracted the interest of the people. Several attempts have reported that the term two-way affinity is used in molecular complexes and extended systems as Though 8UV light PSC. Various experimental and computational studies were carried out to determine possible solutions to improve stability. Solving the instability of perovskite materials is a key strategy to increase long-term stability. The geometric factors limit the formation of stable 3-dimensional the perovskite structures. Stability structure of perovskite can be defined by Goldsmidt's called tolerance coefficient, as shown in Eq. 3 is considered ideal stable perovskite which has a tolerance factor slightly higher than 0.9 D+ and Sn2+ while maintaining high performance is the main challenge for the research community The primary challenge in realization perovskite solar cells today is the instability of the devices in a surrounding environment. Over the past few years, have made considerable effort to improve perovskite-type solar cell devices, stability by adopting various device architectures, compositions, and manufacturing technologies. Stability and efficiency are essential parameters for commercial applications of perovskite solar cells. Perovskite devices have achieved high efficiency so far. However, the stability of the devices is still one of the problems facing the research community. Perovskite compounds with manufacturing processes can contain traps into the degradation of perovskites 8.13 undergo humidity degradation process, in which the methylamine group is gone because of sublimation, PbI2 being further degraded, CH3, NH2 and HI3 hydrate phase is a complete part of the degradation mechanism 3 was added to the periscope precursor solution. As a result, nanosheets were slow down. The crystallization rate is reduced, forming larger particles and spheres on the perovskite's surface, effectively protecting the perovskite film from humidity, light, and thermal degradation Instability of perovskite by moisture arises, from the effect the hygroscopic nature on amine salt 3 (001) with different terminations. Their results showed the interaction between Pb atoms and water molecules accelerate the release of I atoms. The surface of the MAI end is easy to dissolve. It was also found that, due to the stronger PbI bonds on these surfaces, the PbI−2 terminated surface is less sensitive to interfacial water, they also suggested that the incorporation of water molecules to the PbI2 exposed surface may be to the first step in the formation of an intermediate hydrated phase. Zhang et al. ab initio molecular dynamics and DFT simulations of MAPbI3 perovskite, calculations results shown the light absorption attenuation caused by water is closely related to the formation of hydrated species, and the electronic excuses exposed to water. The adsorbed MAPbI3 nanoparticles tend to weaken the PbI bond in the excited state. Water molecules participate in electronic excitation, and binding mode is reduced into 20% due to light excitation, which is similar to that of perovskite. Denotes quickened of perovskite decomposition in the existence of sunlight and humidity. Long et al. ab initio molecular dynamics from scratch. Found that the tetragonal MAPbI3 can destroy the perovskite surface with a small amount of adsorbed water on the surface of the MAI tip (001), bringing the photoelectrons closer to the surface. More importantly, by preventing overlapping, the electron holes are reduced by avoiding deep electron traps overlap and increasing the induced state's life span. Some of a theoretic studies efforts have focused on the effect of water molecules on the stability of different perovskite materials, such as MAGel3, MAPbI33, water readily diffuses to perovskite structure destructions, the formation of hydrated intermediates, and the humidity-related reduction in optical absorption observed in MAPbI3. Calculations based on DFT are used to study water degradation mechanisms in perovskite solar cells and propose strategies to improve water stability. Dong et al. 3 and determined the stability of hydrogen bond interactions among the inorganic PbI3 and the organic CH3NH3 unit plays a vital role to determine the stability of MAPbI3. A computational investigation shows that due to the height polarity of water, the perovskite structure will, as a consequence, change in a humid environment. Depends on these theoretical insights, they deposited an ultra-thin Al2O3 film on the hole transport layer to improve the medium's stability without reducing efficiency. First-principles DFT calculations performed by Zhang and his colleagues on 2 end (001) surface of MAPbI3 is more stable than the MAI-terminated PbI2 defect surface in a humid environment 3 (001) is greatly affected by the orientation of CH3NH3 (MA) cations close to surface. Water is positively adsorbed at all positions on the surface of PbI2 and MAI. Water can be actively adsorbed and supports the existence of the hydrated state observed in the experiment. This may be the first step in the corrosion process. The calculations (including the underlying release mode) indicate that higher water concentrations may promote degradation by increasing lattice deformation. Heben et al. Mosconi et al. η) of the device depends to a large extent on the formula Eq. T and η are the temperatures, respectively, and PCE and PV. It should be noted that these relationships reported for standard solar cell modules and that performance loss due to degradation of device components have not been considered. Makuleha et al. AZO as the front contact, Au and Ag as the back contact, and the temperature reached 45.3 °C Thermal instability of Fumani et al. 8.2PSC, such as many another solar cell technologies, becomes cause degradation of PSC which attributed to using TiO2 as a photosensitizer in PSC, UV light can help the TiO2 could interact with Exposure to ultraviolet light is one of the main challenges that affect the stability of h for devices with packages and without packages and UV filters under one sun MM 1.5 G lighting conditions goes. The results show that the encapsulated device decreases faster than the unencapsulated device, indicating that degradation begins not only from the active layer but also from titanium dioxide TiO2, as depicted in UV 1-sun solar bicycling light test results and possible mechanisms. Ito et al. 2S3 layer in the interface among the mesoporous TiO2 and a perovskite layer increased stability due to the iodide pair's interruption at this interface. Unfortunately, UV filters can increase production costs due to additional material costs. It has also reported that the presence of oxygen prevents the ultraviolet activation degradation at the TiO2 interface, which eliminates the surface state and passivates the grave trapping sites at the interface, which is the titanium dioxide n-type semiconductor 2O3 scaffold is a more stable alternative to TiO2PSC devices. Several groups have demonstrated the stability of about 1000 hours under a light with little or no degradation in performance Leijtens et al. 9The hysteresis mechanism in perovskite devices is still unknown; several hypotheses were established. One of these hypotheses was ferroelectric polarization, widely discussed The presence of ion migration depends on measuring the temperature-dependent conductivity of the perovskite film in the lateral electrode structure and the current-voltage 102 suffers from UV-induced instability, contributing to the short lifetimes of PSC. Suggested alternatives, such as SnO2 and ZnO, have shown massive potential in the PSC community, with low-temperature fabrication. Moreover, replacing Pb with non-toxic ingredients will also prove beneficial in the future. We also introduce the perovskite-chalcogenide with narrow band gap, which provides more light absorption, one of the promising aspects of In this article, we have reviewed the developments and fundamental structure the perovskite-based solar cells. We also explained in detail the several computational and experimental attempts to address and understanding certain vital factors such as the optical properties, band-gap energy, as well as the stability of the perovskites materials limiting development. The commonly used Pb element is highly toxic, and TiOCurrently, the theoretical approaches to understanding the microscopic physical mechanism of perovskite solar cells are considered a viable means. It will be easier to provide ideas for improvement and develop materials and structures that are simpler and more efficient if researchers can develop a theoretical device to verify the complex composition of the perovskite.PSC are also still been debated, and more research is needed to full comprehension since this is a significant underlying problem of perovskite photovoltaic technology. Many strategies are being developed to improve the stability of PSC and a large number of publications, an investigation of newly designed strategies for improving the stability issues has taken a step forward in commercialization. Furthermore, more efforts should be made for the internal and basic mechanisms of the degradation operation. The significant operators influencing the degradation of perovskite in the environmental atmosphere should be elucidated to give more scientific orientation to improve stability.The instability issues of All authors listed have significantly contributed to the development and the writing of this article.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data included in article/supplementary material/referenced in article.The authors declare no conflict of interest.No additional information is available for this paper.


Elderly patients with impaired vision, cognitive decline or motor/sensory disturbances of their fingers suffering from chronic-obstructive pulmonary disease (COPD) encounter difficulties in handling inhaler devices used as the cornerstones of treatment of pulmonary obstruction. Many elderly patients make severe mistakes which impede adequate drug delivery to the bronchioles. This multimodal training program was designed to reduce the number of handling mistakes of inhaler devices.> 65 years (median age 79 years) with previously diagnosed COPD. The effect of an 8-day intervention comprising daily counselling and video demonstration according to the recommendations of the German Airway League on the frequency of mistakes during handling of inhaler devices, the forced expiratory volume in 1 s (FEV1), the forced vital capacity (FVC) and the perception of symptoms  were studied. Measurements on days 1 and 8 were compared by Wilcoxon signed rank test.From October 1, 2016 to September 30, 2017, a prospective intervention study was conducted in 38 in-patients p < 0.0001)]. The CAT Score decreased from 19.5 (14/24) to 14.5 (10.75/21) [median  indicating a substantial reduction of clinical symptoms. Conversely, FEV1 and FVC only slightly increased . At study entry, the number of handling mistakes was inversely correlated with the Mini Mental Status Test (MMST) score (p = 0.01). The reduction of the number of handling mistakes during the intervention was not correlated with the MMST.The number of handling mistakes per patient decreased as a consequence of the intervention from 3.0 (0–7) to 0.5 (0–6) [median .German Clinical Trials Registry  Worldwide, the prevalence of stage II or more severe chronic-obstructive pulmonary disease (COPD) is 10.1% with a greater prevalence of 11.8% for men compared to 8.5% for women . AccordiInhaling long-acting anticholinergic and β-adrenergic drugs  represent the cornerstones of treatment of pulmonary obstruction caused by COPD. Many elderly patients make severe mistakes which impede adequate drug delivery to the bronchioles. Most drugs for the treatment of COPD are inhaled either via metered dose inhalers (MDI) with the drug as a gas, soft mist inhalers  or dry powder inhalers (DPI). Elderly patients suffering from COPD, particularly those with impaired vision, cognitive decline or motor/sensory disturbances of their fingers, encounter difficulties in handling inhaler devices used as the cornerstones of treatment of pulmonary obstruction.Adherence to the prescribed treatment plan is low in COPD patients. In studies the reason was either forgetfulness or deliberate omission of one or more doses. Patient compliance decreased with the number of drugs prescribed –7. IntenThe present study was driven by the observation on our clinical rounds that the frequency of treatment protocol violations and of inhaler device handling mistakes was extremely high among the patients treated in our geriatric department. This inspired us to set up an 8 day systematic training aiming at improving the adherence to the prescribed treatment protocols and reducing the number and severity of inhaler handling mistakes.From October 1, 2016 to September 30, 2017, we conducted a single-center, non-randomized, open prospective intervention study in the Dept. of Geriatrics, Protestant Hospital Göttingen-Weende. We included patients ≥65 years with previously diagnosed stable COPD, who used at least one inhaler device regularly and independently and had been using this device prior to hospital admission, were able to communicate in German without problems and gave their written informed consent to participate. We did not include patients with an acute exacerbation of their COPD or with another diagnosis potentially causing dyspnea . COPD exacerbations are heterogeneous events associated with increased airways and systemic inflammation. We excluded them, since during exacerbations lung physiology parameters and CAT scores change rapidly precluding an assessment of the effect of the intervention. Furthermore, we did not include patients considering themselves as non-compliant.https://www.atemwegsliga.de/atemwegsliga.html). To reliably score the inhaler devices of different companies, for each inhaler 10 steps of the inhaling procedure were defined and scored either as correct or wrong. For the quantification of the patient’s symptom load the COPD Assessment Test (CAT Score) (https://www.atemwegsliga.de/copd-assessment-test.html) was used consisting of 8 individual questions on COPD symptoms, which the patient had to quantify on a scale from 0 to 5 , the difference, however, was not statistically significant (p = 0.28). Subgroup analyses according to sex and type of inhaler device used showed comparable reductions of the numbers of mistakes and of the CAT Scores in each subgroup, and the FEV1 did not change significantly in all subgroups.The separate analysis of the patients with a FEV1/FVC < 70% . The CAT Score improved significantly in patients classified GOLD grade II (p = 0.004), whereas in the other groups there was a tendency towards the relieve of symptoms . The FEV1 did not change substantially in all GOLD grades studied.According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria, 9 patients were classified grade I, 17 patients grade II, 12 patients grade III, and no patient grade IV. The number of mistakes was reduced in GOLD grades I – III , i.e. patients suffering from cognitive decline upon entry into this study made more mistakes than patients with normal cognition. Conversely, the reduction of mistakes did not depend on the MMST Score , i.e., patients with normal and abnormal cognition equally benefitted from the training program. Only one patient with a MMST Score of 14 was not able to reduce the number of mistakes during inhaling suggesting that patients with severe cognitive deficits may not have a benefit from this exercise program. The greatest reduction of inhaling mistakes (reduction by 4 mistakes) was seen in two patients with mild cognitive decline (MMST Score 25 and 26) suggesting that this group of patients definitely showed a benefit from training. Age did not significantly correlate with the number of mistakes on day 1 and with the reduction of the number of mistakes from day 1 to day 8 .The number of handling mistakes on day 1 was inversely correlated with the MMST Score  irrespective of the inhaler device used. This corresponded with a strong reduction of the severity of perceived symptoms as measured by the difference of the CAT Score at entry and after completion of this study. A reduction of the CAT Score by 2 points has been considered the minimal clinically important difference (MCID) in previous studies , i.e., tAlthough the patients had used the inhaler device already at home, in the first assessment, 36 of 38 patients made at least one mistake in the use of this device (94.7%). Other studies came to similar results: in a study on 52 patients with COPD or bronchial asthma, only 6% used their inhaler correctly . SimilarThe 8 day-intervention led to a strong improvement of the handling of the inhaler devices (in median 0.5 versus 3 mistakes), irrespective whether the patients used MDIs or DPIs or a Respimat™. Several studies investigated the effectiveness of different training programs. Generally, a multimedia intervention accompanied by verbal comments was more effective than an exclusive written or verbal explanation , 19, 23.This study has several limitations, in particular its design as a single-center, non-randomized, unblinded intervention study without a control group. We did not assess the effect of training on the resolution of symptoms during an acute exacerbation, and we excluded patients considering themselves as non-compliant. Moreover, the number of participants was relatively low: although the reduction of the number of mistakes was comparable with all inhaler devices used, the low number of patients using individual inhalers precluded the analysis of subgroups of patients using individual inhalers. We did not conduct a follow-up of the patients. For this reason, it is unclear, for which interval this training program was effective. Studies in younger patients had shown that the effect of training lasted up to 3 months , 25. It Since the physicians in charge of the patients had to judge the potential participant of this study as capable of giving informed consent before study entry, in this study many patients with mild cognitive decline and no patient with a MMST Score below 14 were included. Therefore, we cannot answer the important question whether training in the present form is effective in patients with severe dementia. Here, a tailored teach-to-goal placebo device training, which allows many repetitions, may be more effective. This question probably will also not be answered by the Portuguese study, since it also requires written informed consent from each participant at entry into the study and thereby excludes patients who are unable to give their informed consent .The main strengths of this study were the inclusion of patients ≥65 years only, the high age of the participants, the exclusion of patients with bronchial asthma and the intensity of the training program leading to a strong reduction of the numbers of mistakes independent of age and cognitive status. Furthermore, the intense training led to a strong reduction of the patients` perceived symptom load as measured by CAT Score. The FEV1 and the FVC increased slightly, the difference failed to reach statistical significance. Patients with a severe decline of their lung function may in fact have some potential benefit from small increases of the FEV1 and FVC. The sample size of the present study resulted in a low statistical power to detect such small differences. The failure to strongly improve the FEV1 and FVC by correct application of the inhalers for 1 week was not unexpected. COPD is a chronic pulmonary degenerative disease usually associated with mild inflammation, and the full effect on pulmonary obstruction usually is seen after several weeks of therapy , 28.In COPD, intensive multimodal training including daily short video movies, demonstration and counselling for 8 days improved the handling of inhaler devices and reduced clinical symptoms. No significant reduction of airway obstruction was noted in a group of true geriatric patients. Patients with cognitive abnormalities also had a benefit from the intervention. It remains to be studied, how long the training effect will last and whether also patients with severe cognitive abnormalities will benefit from such program.


Due to the high electric conductivity and large surface area of nanographites, such as graphene and graphite nanoplatlets, these materials have gained a large interest for use in energy storage devices. However, due to the thin flake geometry, the viscosity of aqueous suspensions containing these materials is high even at low solids contents. This together with the use of high viscosity bio-based binders makes it challenging to coat in a roll-to-roll process with sufficient coating thickness. Electrode materials for commercial energy storage devices are often suspended by organic solvents at high solids contents and coated onto metal foils used as current-collectors. Another interesting approach is to coat the electrode onto the separator, to enable large-scale production of flat cell stacks. Here, we demonstrate an alternative, water-based approach that utilize slot-die coating to coat aqueous nanographite suspension with nanocellulose binder onto the paper separator, and onto the current collector as reference, in aqueous metal-free supercapacitors. The results show that the difference in device equivalent series resistance (ESR) due to interfacial resistance between electrode and current collector was much lower than expected and thus similar or lower compared to other studies with a aqueous supercapacitors. This indicates that electrode coated paper separator substrates could be a promising approach and a possible route for manufacturing of low-cost, environmentally friendly and metal-free energy storage devices. Nanographites can be produced by a large variety och routes, but for large-scale production liquid exfoliation techniques seem to be the most promising methods9. To promote low-cost, sustainable and environmentally friendly devices, water-based solvents is preferred in the process10 together with bio-based binders, such as cellulose, instead of polytetrafluoroethylene (PTFE) and polyvinyl alcohol (PVA)14. However, due to the thin flake geometry of nanographites the viscosity and yield stress of the suspension is high even at solids contents of a few percent. These suspension also exhibits a very low water retention which in combination with the low solids content is challenging to coat in a roll-to-roll process with sufficient coating thickness for conductive layers or energy storage electrodes. One possible route for large-scale coating of nanographite electrodes is with slot-die coating. High shear rates can be achieved in a pressure driven flow when the suspension is passed through a narrow slot, causing a reduction in its apparent viscosity (for shear-thinning suspensions). The suspension with reduced viscosity can exit the slot and be transferred immediately to the substrate and form a uniform film.16.Due to the high electric conductivity and large surface area of nanographites, such as graphene and graphite nanoplatlets, these materials have gained a large interest for use in energy storage devices and printed electronics18. Except for the well-known corrosion-resistant materials such as titanium, stainless steel, nickel and platinum, modified aluminum foil and graphite foil have shown promising results in previous studies for aqueous Li-ion batteries (LIBs) and supercapacitors (SCs)17. Electrode materials for commercial energy storage devices are often suspended by organic solvents into pastes which are coated onto metal foils used as current-collectors, followed by heat treatment and calendering to minimize the electrical resistance between electrode and current collector. Two electrode-coated current-collectors are then put together with a separator in between forming a battery or SC cell19. Another interesting approach, for large-scale electrode fabrication, is to coat directly on the separator, preferably on both sides, and then attach the current-collectors in the stage of cell assembly. This approach would also enable large-scale production of flat cell stack modules were bipolar plates are used instead of traditional current collectors20.An important aspect in aqueous energy storage is the choice of material for the current-collector. Commercial energy storage often use aluminum and copper foil which provide excellent conductivity and simple cell assembly together with organic electrolytes. To utilize the favorable cost and environmental aspects of energy storage with aqueous electrolytes the current collectors needs to be corrosion resistant due to the aggressive nature of the aqueous environmentIn this work we address these challenges and study the difference in electrode and device properties for electrodes coated onto the paper separator versus the contact in aqueous SCs. We utilized slot-die coating to coat nanographite suspension with nanocellulose binder onto substrates of paper and graphite foil to investigate the difference in electrode and device properties. The results shows that the electrode thickness and porosity differs between the substrates coated with identical material and with the same wet coating thickness. We could also see that the difference in device equivalent series resistance (ESR) due to interfacial resistance between electrode and current collector was much lower than expected. Compared to other studies with a aqueous SCs the ESR was similar or low for both coated substrates, indicating that electrode coated paper separator substrates could be a promising approach for use with bipolar plates for direct cell stacking of flat SC modules. The achieved results are an important step towards increased understanding on large-scale electrode fabrication from nanographite/nanocellulose composite suspensions and a possible route for manufacturing of low-cost, environmentally friendly and metal-free energy storage devices.sp) and ESR, samples with two different substrates were prepared; graphite foil (current collector) and kraft paper (separator). To avoid clogging in the applicator and achieve a coatable suspension with a viscosity close to standard coating colors, the solids content was adjusted to 3.5%. The suspension viscosity is compared with standard coating color in the methods section. The substrates were coated with nanographite-nanocellulose suspension in a continuous roll-to-roll coater with slot-die applicator. One and two layers was applied on each substrate with 300 μm wet coating thickness for each layer. All samples showed good adhesion to the substrate and resulted in fairly smooth electrodes; see Fig. To investigate the influence of substrate in roll-to-roll coated nanographite electrodes for metal-free supercapacitors, in terms of electrode sheet resistance, SC device specific capacitance  KP300 and (d) KP600 are the kraft paper samples with one and two layers of 300 μm wet coating respectively. It can be seen that the coated kraft paper has some wrinkles, which is not present for the graphite foil, and this is due to swelling and shrinking of the substrate during coating and drying. One of the challenges with coating of nanographite-nanocellulose suspensions is the low solids content and low water retention, generating insufficient coat weight with traditional blade or film coating. With a slot-die applicator the wet coating thickness can be much higher but this leads to a large amount of water in the coatings and a rapid wetting of the substrate, resulting in longer drying period and a higher probability of substrate and coating wrinkles if the substrate changes dimensions.Figure μm in width. Figure μm, and Fig. μm wide view field.Figure μm for GF300, 60 μm for KP300, 70 μm for GF600 and 110 μm for KP600, which fits well with the thicknesses measured with the digital indicator. Measured electrode thickness with deviation is shown in Table From SEM cross-sections it can clearly be seen that there are a difference in coating thickness between the substrates, for both one and two layers of coating. All images are oriented with the substrate in the bottom (solid gray). The coating thickness varies slightly along the cross section but was approimately 50 Table −2 and 21.0 gm−2 for 300 μm and 600 μm of wet coating thickness respectively. Sheet resistance was measured on the electrode-coated substrates and ESR together with specific capacitance was measured on the SC-units. All units had a symmetrical set of electrodes , the ESR was calculated from galvanostatic charge-discharge measurements (GCD) at a current density of 1.04 mA/cm2 and the specific capacitance is calculated from GCD at a current density of 0.52 mA/cm2, which corresponds to 0.5 Ag−1 for one layer samples and 0.25 Ag−1 for two layer samples.The dry coat weight was calculated from the wet coating thickness and the solids content of the nanographite-nanocellulose suspension. The calculated dry coat weight was 10.5 gm3. GF300 stands out in this study with a noteworthy specific capacitance in relation to the low-cost and environmentally friendly materials used. This result is similar to studies on inkjet printed graphene (48–132 Fg−1)21 and carbon nanotube coated cotton fibers (70–80 Fg−1)22 but low compared to small-scale electrodes based on functionalized graphene (135 Fg−1)23 or holey graphene flakes (170–350 Fg−1)24. However, all of these studies used more complex and thus more expensive materials and processes. The ESR was similar or low compared to other studies on aqueous SCs27, but still large for high power applications.The specific capacitance for GF600 and KP300 is similar to a previous study with the same nanographite and binder, but then with an addition of 50% to 90% low-cost activated carbons with high surface area2, (b) 1.04 mA/cm2 and (c) 2.08 mA/cm2. The result indicated that the curve shapes of all units were slightly bent at low cell voltage during charging and at high cell voltage during discharge. This can be seen as a measure of charge propagation (charge transfer) in the devices, were an ideal linear curve shape corresponds to ideal charge propagation. This behaviour can be an effect of a high interfacial resistance between electrode and current collector, partly due to cavities in the interface and partly due to the fact that the devices exhibits low compression during measurements. Since GF600 and KP600 has two layers of electrode coating they are expected to have approximately twice the charge and discharge times, and thus twice the device capacitance, compared to GF300 and KP300. It can be seen from the results that GF600 has higher capacitance than GF300 and KP600 has higher capacitance than KP300 for all current densities, but far from twice. It can also be seen that at low current density GF300 shows similar capacitance as KP600, containing twice the amount of electrode material. This can be linked to the calendering effect of the electrodes in the web tension nip. The samples with two coated layers have passed the nip once for each layer and since the porous electrodes easily can be compressed, the pores in the first layer may be partly blocked or compressed to a size not accessible for the electrolyte ions. This would result in inaccessible surface area and lower specific capacitance. The ESR is correlated to the interfacial resistance between electrode and current collector, the resistance of electrolyte and the inner resistance of ion diffusion in the electrode. ESR is used to determine the rate that the supercapacitor can be charged and discharged, and thus an important factor in high power applications. The resistive drop between charge and discharge, and thus the device ESR, is lower for GF600 and KP600 compared to the other devices and it can be seen that GF300 and GF600 has lower ESR than KP300 and KP600 when comparing devices with the same coat weight.Figure 29. This would also result in lower capacitance at higher current densities and high scan rates, which is evident in the decrease of discharge times compared to current density in GCD measurements along with the plot area during discharge in the CV measurements.Figure 2 for all units. KP300 and KP600 shows stable ESR values over 2000 cycles with a small decrease over time. GF300 and GF600 are less stable, were the ESR in GF300 decreases between 500 and 1500 cycles. Both GF300 and GF600 show a small net increase in ESR after 2000 cycles. The cyclability study indicates good ESR cycle stability, despite the use of low-cost materials, aqueous electrolyte, water-based binder solution and coating suspension along with a scalable coating technique. In previous studies9 we have showed that high shear forces are needed to produce the nanographites and also to mix the nanographite with nanocellulose. When the composite suspension is dried, the particles in composite are held together by the nano-sized cellulose fibrils in a web-like formation forming a robust composite with good mechanical stability and wet strength. This, together with the graphite foil current collectors, can be an explanation to the good ESR cycle stability. It is also highly probable that both ESR and electrode charge propagation would be improved significantly by larger compression of the devices and hence increasing the contact area between electrode particles and between the electrode and current collector. This would however require a more advanced cell encapsulation or the use of bipolar plates to directly stack flat cells into modules.Figure To conclude, we demonstrated a possible large-scale route for manufacturing of nanographite-nanocellulose electrodes. With a slot-die applicator it is possible to get electrodes with sufficient coat weight for supercapacitor applications, even at a suspension solids content of 3.5%. The result showed differences in both electrode and device properties for electrodes coated onto the paper separator versus the contact in aqueous supercapacitors. The coating thicknesses was lower and more dense for the graphite foil samples compared to the samples coated on the paper separator, probably due to an calendering effect in the coating setup at the rolls before rewind. The samples with two layers of electrode coating showed much lower specific capacitance compared to samples with one layer, indicating either that the actual coat weight was lower than calculated or that a part of the material in the electrode could not be accessed by the electrolyte ions. In terms of specific capacitance, the electrode-coated graphite foil samples was superior electrode-coated paper separator. However, the difference in ESR due to interfacial resistance between electrode and current collector was much lower than expected. Furthermore, the specific capacitance for GF300, GF600 and KP300 is noteworthy in a wider perspective. Compared to commercially available electrode material and advanced new developments the specific capacitance is low, however, considering the low-cost materials used, the potential low-cost production process and the fact that the electrodes only contains nanographite and cellulose, the performance per unit cost is high.et al.4. The nanographite was processed according to the method described by Blomquist et al.9 using thermally expanded graphite  as the initial material. The nanographite was mixed with 10%wt CNF and the solids content of the suspension was adjusted to 3.5% (35 gl−1) by removing weather with filtration. The cellulose used was a once-dried kraft pulp supplied by SCA, Sweden. The CNF preparation is based on the method described by Saito et al.30 with some modifications. A detailed description of the procedure are described by Andres et al.31. After the chemical pretreatment, the suspension with a dry content of 2% was prepared and dispersed using an Ultra Turrax T50 and a dispersing element S50N-G45F (both from IKA-Werke GmbH & CO. KG) for 30 min at 8100 rpm to obtain the nanofibrils. Two different substrates was used; untreated grease proof paper  and graphite foil . 1 M Sulfuric acid was used as electrolyte for the assembled SC devices.The electrode materials used in this study were nanographite and nanocellulose. The nanographite was used to provide good electrical conductivity and surface area. Cellulose nanofibrils (CNF) was used as a binder to improve strength and stability in the electrodes as described by Andres Rheology measurement of the suspension was carried out using a Paar Physica MCR300 rheometer (Anton Paar GmbH). A Couette geometry  was used and the measurement was done according to the standards specified in DIN 53019-1. Shear flow measurement was performed with a shear rate ramp of 0.1–1000 s-1 with 20 s per data point. The viscosity unit used was milipascal seconds (mPas) Table −1, and depending on the requirement, it can be fitted with various coating heads. It was equipped with a 5 kW infrared drying unit and two 10 kW hot-air dryers with adjustable airflows and temperatures reaching 200 °C. The suspension was fed into a custom built slot-die  from an air-pressurized feed vessel. The slot-die was installed at a 3 o’clock position relative to a backing roll and was used as both coating applicator and metering device, same setup as used by Koppolu et al.15 to coat cellulose nanocrystals on pigment coated paperboard. Figure 5The substrates were coated using a Rotary Koater (RK PrintCoat Instruments Ltd.), which is a laboratory scale roll-to-roll pilot coating machine with operating speeds between 1 and 50 mmin−1 onto the two different substrates with 300 μm wet coating thickness and in 1 and 2 layers. The graphite foil samples are called GF300 and GF600 for one and two layers of 300 μm wet coating respectively, and the kraft paper samples are called KP300 and KP600 for one and two layers of 300 μm wet coating respectively.shows the schematic of the roll-to-roll coating setup. The pressure drop in the slot was controlled by adjusting the air pressure to the feed vessel. The wet coating thickness was controlled by precisely adjusting the gap between the substrate and the slot lips, and the excess coating was metered off and collected into the tray below. Four additional infrared dryers (2 kW each) and four hot air dryers (2 kW each) were installed on the machine to help with the drying process. The suspension was coated with a coating speed of 3 mminAfter coating the sample and substrate thickness were measured with a Mahr Millitast 1083 digital indicator. The median of five measurements was calculated and the sample thickness was subtracted with the substrate thickness in order to obtain the dry thickness of the coating. The electrode porosity was measured using Hg-intrusion porosimetry. The dry coat weight was calculated from the wet coating thickness and the solids content of the nanographite-nanocellulose suspension. The electrode-coated graphite foil was cut into 50 mm-wide and 100 mm-long samples with an electrode size of 50 mm × 50 mm . The electrode-coated separator paper were cut into an equal sized electrodes but with 50 mm-wide and 100 mm-long graphite foil pieces as current collectors.To assemble SC devices from GF300 and GF600, two electrode-coated graphite foils were put together, with the electrodes facing each other and with two 60 mm × 60 mm paper separators between them. For KP300 and KP600, two electrode-coated separator papers were put together between two 50 mm-wide and 100 mm-long graphite foil current collectors, with the electrodes facing the current collectors. In this way samples from both substrates were assembled to flat SCs with identical cell structure; : graphite foil - electrode - separator - separator - electrode - graphite foil. The SC devices were soaked in electrolyte for 5 min and then placed between two thick plastic plates as support, see Fig. Furthermore, cross-section images of the electrode-coated substrates were obtained using a field emission scanning electron microscope (TESCAN MAIA3-2016) at 5 kV. SEM images was obtained to analyze structural differences in the coatings due to the choice of substrate. The cross-section samples were cut with a IM400 Ion milling system from Hitachi and then coated with 5 nm of Iridium by sputtering.28. The specific capacitance, Csp, was calculated from the discharge curve in GCD measurements using equation  in terms of ESR. The specific capacitance, Csp was calculated by using Equation (m is the mass of one electrode. The ESR was calculated by dividing the resistive voltage drop, generated between charging and discharging, with the change in current. The sheet resistance was measured using a Keithley 2611A four-point-probe system. The mean value of 10 measurements was calculated.Three different electrical measurements were performed on the SCs; sheet resistance, CV and GCD. CV was performed on all SC units with a Versastat4 and scan rates of 10 mV/s, 50 mV/s and 100 mV/s. Using the same cell configuration, GCD were performed immediately after CV using a LabVIEW-based PXI system. The collected data were analyzed according to the method described by Stoller and Ruoff