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In this review, we give a brief outline of robot-mediated gait training for stroke patients, as an important emerging field in rehabilitation. Technological innovations are allowing rehabilitation to move toward more integrated processes, with improved efficiency and less long-term impairments. In particular, robot-mediated neurorehabilitation is a rapidly advancing field, which uses robotic systems to define new methods for treating neurological injuries, especially stroke. The use of robots in gait training can enhance rehabilitation, but it needs to be used according to well-defined neuroscientific principles. The field of robot-mediated neurorehabilitation brings challenges to both bioengineering and clinical practice. This article reviews the state of the art (including commercially available systems) and perspectives of robotics in poststroke rehabilitation for walking recovery. A critical revision, including the problems at stake regarding robotic clinical use, is also presented., Video abstract

Stefano Tamburin,1 Stefano Paolucci,2 Nicola Smania,1,3 Giorgio Sandrini4,51Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, 2Santa Lucia Foundation, IRCCS, Rome, 3Neuromotor and Cognitive Rehabilitation Research Centre, University of Verona, Verona, 4C. Mondino National Institute of Neurology Foundation, IRCCS, 5Department of Brain and Behavioural Sciences, University of Pavia, Pavia, ItalyOn behalf of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN)Pain is one of the most common reasons for seeking medical attention. When chronic, it diminishes self-perceived health status, interferes with everyday activities, lowers productivity, and affects personal relationships.

Background: Robotic training is commonly used to assist walking training in patients affected by multiple sclerosis (MS) with non-conclusive results. Objective: To compare the effect of robot-assisted gait training (RAGT) with that of conventional walking training (CWT) on gait competencies, global ability, fatigue and spasticity in a group of severely affected patients with MS. Methods: A pilot, single-blind randomized controlled trial was conducted in 43 severe (Expanded Disability Status Scale (EDSS) score of 6–7.5) and non-autonomous ambulant in-patients with MS. Experimental group performed 12 sessions of RAGT, whereas control group performed the same amount of CWT. Primary outcome measures were gait ability assessed by 2 minutes walking test and Functional Ambulatory Category; secondary outcomes were global ability (modified Barthel Index), global mobility (Rivermead Mobility Index), severity of disease (EDSS) and subjectively perceived fatigue (Fatigue Severity Scale). Results: The number of subjects who achieved a clinical significant improvement was significantly higher in RAGT than in CWT ( p Conclusions: RAGT improved the walking competencies in non-autonomous ambulant patients with MS, with benefits in terms of perceived fatigue.

There is an increasing interest about upper body accelerations during locomotion and how they are altered by physical impairments. Recent studies have demonstrated that cognitive impairments affect gait stability in the elderly (i.e., their capacity for smoothing upper body accelerations during walking) but little attention has been paid to young adults with intellectual disabilities. The purpose of this study was to examine upright stability in young adults with intellectual disabilities during walking, running, and dual-task running (playing soccer). To this aim a wearable trunk-mounted device that permits on-field assessment was used to quantify trunk acceleration of 18 male teenagers with intellectual disabilities (IDG) and 7 mental-age-matched healthy children (HCG) who participated in the same soccer program. We did not find any significant difference during walking in terms of speed, whereas speed differences were found during running (p=.001). Upper body accelerations were altered in a pathology-specific manner during the dual task: the performance of subjects with autistic disorders was compromised while running and controlling the ball with the feet. Differences in upright locomotor patterns between IDG and HCG emerged during more demanding motor tasks in terms of a loss in the capacity of smoothing accelerations at the trunk level.

Falls are common in patients who have had a stroke who return home after neurorehabilitation. Some studies have found that walking speed inversely correlates with the risk of falls.This study examined whether comparison between comfortable self-selected walking speed and maximum maintainable speed is informative with regard to the risk of falls in patients with stroke.A prospective cohort study was performed with 75 ambulant stroke patients. At discharge, the Barthel Index score and performance at the 10-m and 6-min walking tests were assessed. Number of falls was recorded by telephone interview every two months for one year. Regression analysis was performed to identify factors that were related to the risk of falls.Using forward multiple linear regression, only the ratio between walking speeds on the 6-min and 10-m tests was linked to the number of falls in the year after discharge (R=-0.451, p0.001, OR=0.046). Patients who chose a walking speed for short distances that was not maintainable long term fell more frequently.A discrepancy between short and long-term walking speed can help in identifying subjects in the subacute stage after stroke with an increased risk of suffering a fall.

Analysis of upper-body accelerations is a promising and simple technique for quantitatively assessing some general features of gait such as stability, harmony, and symmetry. Despite the growing literature on elderly healthy populations and neurological patients, few studies have used accelerometry to investigate these features in subjects with lower-limb amputation. We enrolled four groups of subjects: subjects with transfemoral amputation who walked with a locked knee prosthesis, subjects with transfemoral amputation who walked with an unlocked knee prosthesis, subjects with transtibial amputation, and age-matched nondisabled subjects. We found statistically significant differences for stability (p < 0.001), harmony (p < 0.001), and symmetry (p < 0.001) of walking, with general trends following the noted order of subjects, but with the lowest laterolateral harmony in subjects with transtibial amputation. This study is the first to investigate upper-body acceleration of subjects with unilateral lower-limb amputation during walking who were evaluated upon dismissal from a rehabilitation hospital; it is also the first study to differentiate the sample in terms of level of amputation and type of prosthesis used.

Objectives Many studies have examined how children with cerebral palsy (CP) manage to walk, but few have investigated running, yielding controversial results. The aim of this study was to quantitatively assess gait ability and its stability in children with hemiplegic CP while running and walking. Methods A group of 20 children with spastic hemiplegia due to CP (CPG, 5.1 ± 2.3 years old), and a group of 20 children with typical development (TDG, 5.9 ± 2.6 years old) underwent a 10-m walking/running test with a wearable triaxial accelerometer fixed to their lower trunk. Spatiotemporal gait parameters, root mean squares of upper body acceleration, and related harmonic and symmetry ratios were computed. Results Differences in gait speed were significantly higher during running ( – 19% for CPG with respect of TDG) than during walking ( – 14%, p = 0.028). Conversely, no significant changes were observed in terms of gait stability, and the differences in terms of gait harmony along anteroposterior axis recorded during walking ( – 43%, p Conclusions During running, children with CP are slower than children with TD, but their gait was not less stable, and the harmony of their anteroposterior movements was even more similar to TDG than during walking.

Patients with chronic low back pain have a worse posture, probably related to poor control of the back muscles and altered perception of the trunk midline. The aim of this study was to evaluate the efficacy of a perceptive rehabilitation in terms of stability and pain relief in patients with chronic nonspecific low back pain. Thirty patients were enrolled and randomized into two groups: 15 patients received rehabilitation, on the basis of a specific tool to perform perceptive exercises [perceptive group (PG)], and 15 patients received a back school programme [back school group (BG)]. Both groups were assessed using stabilometry and the McGill Pain Questionnaire before and at the end of treatment. For the reference values of stabilometric parameters, 15 healthy individuals were enrolled. Significant reductions in sway length (P=0.019) and laterolateral sway velocity (P=0.038) were observed in the PG. The anteroposterior sway velocity was reduced in both the groups, but significantly only for BG (P=0.048). The percentage of sway length reduction was inversely and significantly correlated with the initial sway length value for PG (R=-0.708, P=0.003), but not for BG (R=-0.321, P=0.243). In the PG, the sagittal arrows and bi-acromial and bi-spinoiliac lines' angles were all significantly reduced. General pain relief was reported after treatment, without a significant difference (P=0.436). Our results suggest that a perceptive rehabilitation can improve the postural stability for the realignment of the trunk, controlling the back pain. The use of cognitive exercises may strengthen the usual rehabilitation of low back pain, avoiding the recurrence of symptoms.

To define diagnostic and prognostic markers of parvovirus B19 (B19V) fetal infection, two groups were investigated: 1) pregnant women with specific symptoms or contacts with symptomatic households (n=37); 2) mothers with pathological ultrasound findings and the relevant fetus at the time of prenatal diagnosis (n=16). In the first group, diagnosis of B19V infection was achieved using IgM detection in 29/37 (78.3%) of patients, while B19V DNA was detected in 36/37 (97.3%) of infected women. In the second group, intrauterine infection was investigated by amniocentesis (n=5), cordocentesis (n=3) or both (n=5). Median B19V DNA load in amniotic fluid was 8.2x107 copies/ml and in fetal blood was 2x109 copies/ml. Maternal blood was positive for B19V DNA (median 3.8x104 copies/ml) in 14/16 (87.5%) women examined. At time of fetal US investigation, all mothers were B19V IgG positive and B19V IgM were detected in 10/16 (62.5%), while fetal B19V IgG and IgM were detected in 1/8 (12.5%) and 5/8 (62.5%), respectively. Phylogenetic analysis revealed that all B19V maternal and fetal strains belonged to genotype 1A. Diagnosis of maternal, fetal and neonatal B19V infection should be based on both IgM and DNA detection. Prognostic markers of congenital B19V infection need to be defined.

Dual task paradigm is a common mechanism of daily life, and it is often used for investigating the effect on cognitive processing of motor behavior.In the present study we investigate the dual task interference during walking on upright gait stability.Cross-sectional study.Inpatient neurorehabilitation unit and children neurorehabilitation unit.Eighty-five subjects were enrolled, divided into five groups: healthy young, healthy elderly, children with typical development, children with cerebral palsy and adults with stroke in subacute phase.All subjects had to walk through a pathway during which they had to hear a sound, turn the head to watch a number and verbalize it. Subjects wore an accelerometer on their lumbar spine to measure upright gait stability have been assessed by means of the Root Mean Square (RMS) of the trunk acceleration.All subjects showed a reduced speed when performing a dual task with respect to single task. This reduction was significantly different among groups (F(4,81)=12.253, P0.001, effect size 0.377). The RMS appeared to be increased along the latero-lateral axis, and reduced along the anterio-posterior and the cranio-caudal axes during the dual task walking.These accelerations were significantly related to the changes in speed that were managed in a different way in subjects affected by cerebral palsy and stroke.The information obtained in this study may be used to support specific rehabilitation techniques in subjects with poor balance ability.

Stefano Tamburin,1 Stefano Paolucci,2 Francesca Magrinelli,1 Massimo Musicco,2,3 Giorgio Sandrini4,5 On behalf of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) 1Department of Neurological, Biomedical and Movement Sciences, University of Verona, Verona, 2Santa Lucia Foundation, IRCCS, Rome, 3Institute of Biomedical Technologies (IBT) National Research Council of Italy (CNR), Segrate, Milan, 4C. Mondino National Institute of Neurology Foundation, IRCCS, 5Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy Abstract: Pain is very common in the neurorehabilitation setting, where it may not only represent a target for treatment but can also negatively influence rehabilitation procedures directly or through the side effects of painkillers. To date, there are neither guidelines nor consensus on how to assess and treat pain in neurorehabilitation. Because of the very scanty pieces of evidence on this topic, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) was promoted under the auspices of different scientific societies. This article illustrates the rationale, methodology, and topics of the ICCPN. The recommendations of the ICCPN will offer some information on how to deal with pain in neurorehabilitation and may represent the starting point for further studies.Keywords: assessment, consensus conference, neurology, pain, rehabilitation, treatment

Background To date etiology of adolescent idiopathic scoliosis appears complex and still remains unclear. A distorted body schema has been proposed to be a part of a sequence of pathological events in the development of adolescent idiopathic scoliosis. Objective To investigate the awareness of trunk misalignment in adolescents with idiopathic scoliosis. Methods Information about 44 adolescents with idiopathic scoliosis was collected as follows: age; sex; handedness; family history of scoliosis; back pain; sport practice; shoulder and waist line symmetry; leg length; dorsal kyphosis; back hump; rehabilitation; scoliotic curve; Risser sign. We evaluated awareness of trunk misalignment with a graphic table displaying pictures of progressively increasing scoliotic curves. Patients were asked to indicate which picture corresponded to their perceived own spinal alignment. Results Patients with thoracolumbar scoliosis overestimated their actual thoracic spine curve. Patients with thoracic-thoracolumbar scoliosis underestimated their actual thoracolumbar spine curve and overestimated their actual lumbar spine curve. Scoliotic curve > 15°, double curve, younger age, back pain, family history of scoliosis and lower Risser score related with a misperception of trunk alignment. Conclusions Our results support the hypothesis that adolescents with idiopathic scoliosis have an altered corporeal awareness of their trunk alignment.

Background Patients affected by mild stroke benefit more from physiological overground walking training than walking-like training performed in place using specific devices. The aim of the study was to evaluate the effects of overground robotic walking training performed with the servo-assistive robotic rollator (i-Walker) on walking, balance, gait stability and falls in a community setting in patients with mild subacute stroke. Methods Forty-four patients were randomly assigned to two different groups that received the same therapy in two daily 40-min sessions 5 days a week for 4 weeks. Twenty sessions of standard therapy were performed by both groups. In the other 20 sessions the subjects enrolled in the i-Walker-Group (iWG) performed with the i-Walker and the Control-Group patients (CG) performed the same amount of conventional walking oriented therapy. Clinical and instrumented gait assessments were made pre- and post-treatment. The follow-up observation consisted of recording the number of fallers in the community setting after 6 months. Results Treatment effectiveness was higher in the iWG group in terms of balance improvement (Tinetti: 68.4 ± 27.6 % vs. 48.1 ± 33.9 %, p = 0.033) and 10-m and 6-min timed walking tests (significant interaction between group and time: F(1,40) = 14.252, p = 0.001; and F(1,40) = 7.883, p = 0.008, respectively). When measured, latero-lateral upper body accelerations were reduced in iWG (F = 4.727, p = 0.036), suggesting increased gait stability, which was supported by a reduced number of falls at home. Conclusions A robotic servo-assisted i-Walker improved walking performance and balance in patients affected by mild/moderate stroke, leading to increased gait stability and reduced falls in the community. Trial registration This study was registered on anzctr.org.au (July 1, 2015; ACTRN12615000681550).

Objective Recently, an intrinsic fractal harmonic structure was found underlying the rhythm of physiological walking, but it has not yet been investigated in subjects with a neurological disease. The aim of this study was to determine if and how this harmonic structure is altered in patients with Parkinson’s Disease. Methods Gait analysis of 70 patients with Parkinson’s Disease in pharmacological phase on was performed, the findings of which we compared with reference data of age-matched healthy subjects. Fifteen patients were retested after a washout period of 12 h. Results Alterations in all spatio-temporal gait parameters and gait indices with regard to symmetry, coordination, and harmony were noted, but after correction for multicollinearity bias, only the latter correlated significantly with Unified Parkinson’s Disease Rating Scale motor score (p = 0.001). The fractal gait structure underwent even more extensive alterations in pharmacological off phase (p Conclusions The intrinsic gait harmony was altered in patients with Parkinson’s Disease and significantly correlated to motor severity. It could be partially recovered by assumption of L-dopa. Significance Loss of harmony is a quantitatively assessable gait benchmark in Parkinson’s Disease. It seems to be dependent on dopaminergic but also on non-dopaminergic networks.

The use of exergame for balance competencies was recently explored in women affected by balance ability reduction with non-conclusive results. The aim of the study was to evaluate the efficacy of a supervised exergame performed with the Wii Fit® compared to conventional exercises on balance function, quality of life, fear of fall and well-being in women with bone loss. Thirty-eight female participants aged over 65 years, with a bone loss condition, were enrolled and random allocated in the Wii group or control group. Subject enrolled in Wii group performed a balance training with a Wii Fit supervised by a physiotherapist (1 h, 2 days per week, during 8 weeks) while in control subjects performed the same amount of conventional balance exercises. Subject enrolled in experimental group showed significantly higher scores in terms of Berg Balance Scale (p = 0.027). In SF-36 scores, a significant difference was reported for physical activity score after treatment (p = 0.031). Fear of falling and the psychological scales were not significantly different between the two groups. In women with bone loss condition, a supervised Wii Fit training has shown better efficacy in improving balance performance with respect to conventional balance exercises.

Malnutrition in hospitalised patients is often underestimated. The present study aimed to evaluate the validity of a questionnaire for the semi-quantitative evaluation of food intake compared to weighed records in patients who were hospitalised for the rehabilitation of neurological disorders.Food intake at breakfast, lunch and dinner was evaluated in 319 in-patients, by weighing the meals and the residuals, and using a semi-quantitative questionnaire, during five consecutive days. The questionnaire represented, for each offered food, the pictures of the nonconsumed quantities. The consumption of each food was determined by weighing foods that were served and the residuals after the meal. As a measure of validity of the questionnaire, the agreement over chance (kappa statistic) between the questionnaire and the weight was calculated. Considering the weight as the gold standard, the sensitivity and specificity of the questionnaire in detecting patients who consumed50% or 75% of the meals was calculated.The agreement between the two measures was satisfactory (κ ≥ 0.70) or almost satisfactory (0.60κ0.70) for most of the foods, with the exception of fruit and the first course at dinner. The sensitivity and specificity of the questionnaire in detecting consumers of50% or 75% of the offered foods were always80%, except for bread and first course, as well as fruit at dinner.The present study shows that this semi-quantitative questionnaire on food consumption reproduces with sufficient precision the measures obtained by weighing. The questionnaire appears also to be a valid and suitable instrument for the identification of patients with poor food intake in a neurorehabilitation hospital.

The aim of this study was to quantitatively assess the stability and harmony of gait in children with cerebral palsy. Seventeen children with spastic hemiplegia due to cerebral palsy (5.0±2.3 years old) who were able to walk autonomously and seventeen age-matched children with typical development (5.7±2.5 years old, p=0.391) performed a 10-m walking test with a wearable device fixed to their lower trunk and included a triaxial accelerometer and three gyroscopes. Three parameters related to gait stability and three related to gait harmony were computed; all of these yielded significant differences between children with cerebral palsy and those with typical development (p0.020 for all the computed parameters). In the latter group of children, trunk accelerations were found to be negatively correlated with age (partial correlation controlled for walking speed: R(p)-0.58, p0.020). Conversely, in children with cerebral palsy, the upper body accelerations were proportionally correlated with their gait speed (R=0.548, p=0.023 in the antero-posterior direction) but not with their age (p0.05). This finding can be related both to difficulties in managing the higher upper body accelerations involved in rapid walking and to compensation strategies.

The present paper provides practical guidance on the management of adult spasticity with OnabotulinumtoxinA. Advisory Board members reviewed the available evidence and discussed their personal experiences in order to address the unmet needs in the management of spasticity with botulinum toxin type A identified by the recent Italian Real-Life Post-Stroke Spasticity Survey. Stroke patients should be referred to spasticity services that have adequate facilities and multidisciplinary teams with the necessary training, competence and expertise. The current literature shows a strong correlation between the development of post-stroke spasticity and the degree of central sensorimotor system destruction/disorganization. Use of tools such as the Poststroke Checklist may help clinicians in the long-term follow-up of stroke patients. The maximum dose of onabotulinumtoxinA - according to the current literature this ranges from 300U to 400U for upper limb and from 500U to 600U for lower limb aggregate postures - should be re-considered. In addition, there is a need for future consensus (also based on pharmacoeconomic considerations) on consistent clinical care models for the management of patients with post-stroke spasticity.

Background: To test whether supplementary antioxidants and n–3 fatty acids, alone or in combination, could improve functional status in stroke survivors. Methods: We performed a randomized, double-blind, placebo-controlled clinical trial in 72 stroke patients (47 males; age 65.3 ± 12.9 years) admitted to a rehabilitation hospital for sequelae of first-ever ischemic stroke, and divided them into 4 subgroups. Group 1 patients received daily oral antioxidants, group 2 received n–3 polyunsaturated fatty acids, group 3 both supplements, and group 4 placebo, all for 12 months. No difference at baseline was observed among groups in neurological severity or in disability. All measures were repeated after 6 and 12 months of treatment. All major clinical events were recorded. Results: At baseline, 25% of the patients had a low plasma vitamin status, and 48.5% was at risk of undernutrition. At the 1-year follow-up, we observed a trend for lower mortality (p = 0.060) in subgroups treated with n–3 fatty acids, but without significant differences in rehabilitation result status among groups. Conclusions: Malnutrition is widely observed in patients admitted to a rehabilitative hospital for stroke rehabilitation, and dietary supplementation, even if not able to improve rehabilitation results, is likely to reduce mortality at the 1-year follow-up.

Background: This study was designed to quantify the probability of recovery of mobility in admission nonwalking stroke survivors. Methods: We evaluated 437 of 500 consecutive patients admitted for sequelae of first ischemic stroke within the first month. We performed several logistic regressions using mobility status at discharge (independence in stair climbing; walking outside and inside, without aid or supervision; walking with cane or other aid, or need for wheelchair) as dependent variable, and several independent variables, including stratification of patients according to their Barthel Index (BI) score into 6 classes (≤10; 11–20; 21–30; 31–40; 41–50; 51–60). Results: At discharge, 4.58% of patients were independent in stair climbing, 8.70% were able to walk outside, 14.41% to walk inside, and 27.46% to walk with cane or other aid, while 44.85% remained in wheelchair. Very low BI scores at admission were associated with a high risk of need for wheelchair, whereas patients with BI score 51–60 showed a high probability to reach independence in stair climbing (OR = 5.60). Age, severity of neurological impairment, global aphasia, unilateral spatial neglect, male gender and vocational status also played a prognostic role. Conclusions: The probability of potential mobility recovery can be quantified at admission with better accuracy for independence in stair climbing and walking outside without any aid (percentages correctly predicted 95.4 and 91.8%, respectively). Stratification of BI score may be useful to better quantify the risk for each patient.

In nature, many systems have a harmonic organization due to their fractal structure related to an irrational number called golden ratio. That is a constant proportion found in phases of human gait cycle, and is also found in the lengths of human body segments. In this study we tested if artificial alterations in anthropometric proportions may alter gait proportions. Twenty healthy subjects (29.15±5.66years) were enrolled in this study and asked to walk normally and with special shoes altering their anthropometric proportions. Further, to test if the relationship between gait phases and anthropometry could be due to the pendular mechanism of walking, subjects were also asked to walk with extra masses located on their shanks. Results showed that the artificial alteration of body segment proportions affected the gait ratio based on the proportion of time between stance and swing (p=0.015). Conversely, no changes occurred during walking in weighted condition (p=0.394). These results confirm the connection between anthropometric proportions and gait ratio, and suggest the idea that humans may have evolved into the actual anthropometric proportions for favoring a walking having a golden ratio based harmony, but research is required to verify this hypothesis.

Stroke affects many gait features, such as gait stability, symmetry, and harmony. However, it is still unclear which of these features are directly altered by primary damage, and which are affected by the reduced walking speed. The aim of this study was to analyze the above gait features in patients with subacute stroke with respect to the values observed in age- and speed-matched healthy subjects. A wearable triaxial accelerometer and an optoelectronic device were used for assessing the upright gait stability, symmetry of trunk movements, and harmonic structure of gait phases by means of the root-mean-square (RMS) acceleration of the trunk, harmonic ratio (HR), and gait ratios (GRs), respectively. For healthy subjects, results showed that RMS acceleration increased with speed, HR peaked at a comfortable speed, and GRs tended towards the theoretical value of the golden ratio for speeds >1 m/s. At matched speed conditions, patients showed higher instabilities in the latero-lateral axis (p = 0.001) and reduced symmetry of trunk movements (p = 0.002). Different from healthy subjects, antero-posterior and latero-lateral acceleration harmonics were coupled in patients (R = 0.507, p = 0.023). Conversely, GRs were not more altered in patients than in slow-walking healthy subjects. In conclusion, patients with stroke showed some characteristics similar to those of the elderly when the latter subjects walk slowly, and some altered characteristics, such as increased latero-lateral instabilities coupled with movements performed along the antero-posterior axis.

[Purpose] Recently, there has been growing interest in the somatosensory system, but little data exist on the interaction between dynamic postural control and the somatosensory system. The purpose of this study was to determine whether a training program, based on tactile and proprioceptive sensory stimulation of the trunk with the use of perceptual surfaces, improved the estimation of walking distance by healthy subjects, the ability to walk toward a memorized distance without vision, and whether it increases upright gait stability. [Subjects and Methods] Ten healthy subjects with a mean age of 31.9 ± 2.5 years were enrolled and participated in 10 daily sessions of perceptive training using perceptual surfaces, for 45 minutes each session. An experimental indoor test measured the subjects' ability to perceive walking distances to a memorized target in an indoor environment. [Results] After treatment, the distances that were traversed were closer to the target than before treatment. Trunk acceleration did not differ significantly between pre- and post-training and did not increase significantly after training. [Conclusion] Treatment with perceptual surfaces stimulating the trunk midline improves the estimation of walking distance and modifies proprioceptive gait patterns, allowing various corrective strategies to be implemented during ambulation.

The leap motion controller (LMC) is a new optoelectronic system for capturing motion of both hands and controlling a virtual environment. Differently from previous devices, it optoelectronically tracks the fine movements of fingers neither using glows nor markers.This pilot study explored the feasibility of adapting the LMC, developed for videogames, to neurorehabilitation of elderly with subacute stroke.Four elderly patients (71.50 ± 4.51 years old) affected by stroke in subacute phase were enrolled and tested in a cross-over pilot trial in which six sessions of 30 minutes of LMC videogame-based therapy were added on conventional therapy. Measurements involved participation to the sessions, evaluated by means of the Pittsburgh Rehabilitation Participation Scale, hand ability and grasp force evaluated respectively by means of the Abilhand Scale and by means of the dynamometer.Neither adverse effects nor spasticity increments were observed during LMC training. Participation to the sessions was excellent in three patients and very good in one patient during the LMC trial. In this period, patients showed a significantly higher improvement in hand abilities (P = 0.028) and grasp force (P = 0.006).This feasibility pilot study was the first one using leap motion controller for conducting a videogame-based therapy. This study provided a proof of concept that LMC can be a suitable tool even for elderly patients with subacute stroke. LMC training was in fact performed with a high level of active participation, without adverse effects, and contributed to increase the recovery of hand abilities.

Objective To evaluate the feasibility of brain-computer interface (BCI)-assisted motor imagery training to support hand/arm motor rehabilitation after stroke during hospitalization. Design Proof-of-principle study. Setting Neurorehabilitation hospital. Participants Convenience sample of patients (N=8) with new-onset arm plegia or paresis caused by unilateral stroke. Interventions The BCI-based intervention was administered as an "add-on" to usual care and lasted 4 weeks. Under the supervision of a therapist, patients were asked to practice motor imagery of their affected hand and received as a discrete feedback the movements of a "virtual" hand superimposed on their own. Such a BCI-based device was installed in a rehabilitation hospital ward. Main Outcome Measures Following a user-centered design, we assessed system usability in terms of motivation, satisfaction (by means of visual analog scales), and workload (National Aeronautics and Space Administration–Task Load Index). The usability of the BCI-based system was also evaluated by 15 therapists who participated in a focus group. Results All patients successfully accomplished the BCI training. Significant positive correlations were found between satisfaction and motivation ( P =.001, r=.393). BCI performance correlated with interest ( P =.027, r=.257) and motivation ( P =.012, r=.289). During the focus group, professionals positively acknowledged the opportunity offered by BCI-assisted training to measure patients' adherence to rehabilitation. Conclusions An ecological BCI-based device to assist motor imagery practice was found to be feasible as an add-on intervention and tolerable by patients who were exposed to the system in the rehabilitation environment.

Patients with peripheral and central nervous system diseases may suffer from different types of pain, namely nociceptive, neuropathic and mixed pain. Although in some cases, the distinction between these types of pain is clinically evident, yet in some patients an accurate differential diagnosis requires dedicated clinical examination, screening questionnaires and diagnostic techniques some of which are available only in specialized pain centres. This review briefly addresses the currently agreed definitions of the different types of pain and shows how clinical examination, pain questionnaires and diagnostic tests can help the clinicians in identifying neuropathic pain.

Background and Purpose— We sought to assess the specific influence of sex on rehabilitation results. Methods— A case-control study in 440 consecutive patients with sequelae of first ischemic stroke were enrolled in 2 subgroups (males and females) and matched for severity of stroke (evaluated by means of the Canadian Neurological Scale), age (within 1 year), and onset-admission interval (within 3 days). Functional data, evaluated by means of the Barthel Index and the Rivermead Mobility Index, were compared between subgroups. Logistic regressions were used to clarify the role of sex in affecting global autonomy and mobility. Results— After rehabilitation treatment, a sex-related difference was observed essentially in the higher levels of response. Indeed, more men than women reached independence in both stair climbing and activities of daily living (ADL), with a higher response and effectiveness on mobility. In multivariate analyses, male patients had a 3 times higher probability than female patients of good autonomy in both stair climbing and ADL (odds ratio [OR]=3.22; 95% CI, 1.67 to 6.18 and OR=2.92; 95% CI, 1.63 to 5.42, respectively). Conversely, female patients had a higher risk of walking with a cane (OR=1.69; 95%, CI 1.04 to 2.76) or of partial autonomy with respect to ADL (OR=1.90; 95% CI, 1.25 to 2.91). No significant difference was found for the other functional parameters. Conclusions— Female sex is a mildly unfavorable prognostic factor in rehabilitation results after stroke.

Brunelli S, Averna T, Porcacchia P, Paolucci S, Di Meo F, Traballesi M. Functional status and factors influencing the rehabilitation outcome of people affected by above-knee amputation and hemiparesis. Objectives To evaluate the functional status of people with transfemoral amputation and hemiparesis and to identify the factors that influence rehabilitation outcome after inpatient treatment. Design Retrospective study. Setting Rehabilitation hospital. Participants Forty-five patients (30 men, 15 women; mean age, 69±9y) with intact mental status affected by unilateral transfemoral amputation for vascular disease and mild or moderate hemiparesis. Interventions Not applicable. Main Outcome Measures Barthel Index, Barthel Index effectiveness, and Locomotor Capabilities Index (LCI) scores were measured. The following factors were studied: side and cause of amputation, side and severity of hemiparesis, sequence and laterality of dual impairment, time interval between impairments, and hospital length of stay. Results At discharge, mean Barthel Index and LCI scores ±1 standard deviation were 79±12 and 15±5.6, respectively; Barthel Index effectiveness was 55±23.8. Only 2 patients ambulated without walking aids. Barthel Index effectiveness was better in patients with mild hemiparesis than in patients with more severe impairment. Ipsilateral localization of dual impairment increased the probability of higher LCI scores. Conclusions Selected patients with dual impairment can recover the ability to walk. Severity of hemiparesis and laterality were the 2 clinical factors that had the greatest influence on functional measures.

Background and Purpose— The goal of this study was to assess the specific influence of stroke etiology on rehabilitation results. Methods— This was a case-control study of 270 inpatients with sequelae of first stroke who were enrolled in homogeneous subgroups and matched for stroke severity, basal disability, age (within 1 year), sex, and onset admission interval (within 3 days) who were different only in terms of stroke origin, infarction versus hemorrhage. We compared the groups’ length of stay, efficiency and effectiveness of treatment, and percentage of low and high responder patients. Odds ratios of dropouts and of low and high therapeutic response were also quantified. Results— Compared with ischemic patients, hemorrhagic patients had significantly higher Canadian Neurological Scale and Rivermead Mobility Index scores at discharge; higher effectiveness and efficiency on the Canadian Neurological Scale, Barthel Index, and Rivermead Mobility Index; and a higher percentage of high responders on the Barthel Index. Hemorrhagic patients showed a probability of a high therapeutic response on the Barthel Index that was ≈2.5 times greater than that of ischemic patients (odds ratio, 2.48; 95% confidence interval, 1.19 to 5.20; accuracy on prediction, 87.06%). Conclusions— The results of this study provide further evidence of better functional prognosis in stroke survivors with hemorrhagic stroke.

The aim of this study was to assess the specific influence of age on basal functional status and rehabilitation results. We conducted a case-comparison study on 150 stroke inpatients. They were enrolled in homogeneous subgroups, matched for severity of stroke (measured by Canadian Neurological Scale – CNS) and onset admission interval (within 3 days) and divided into five subgroups according toage: ≤50; 51–64; 65–74; 75–84; and ≧85 years. Even when severity of stroke was the same, increasing age was associated with greater disability in activities of daily living (ADL) and mobility, minor results of rehabilitation treatment and shorter length of stay. Patients ≧85 years were nearly ten times as likely to show a low response in ADL (OR = 9.28, 95% CI = 2.89–29.76) and nearly six times in mobility (OR = 6.13, 95% CI = 2.18–17.25) than younger patients. However, rehabilitation treatment was efficacious also in patients ≧85 years, with effectiveness of treatment 27.96% on ADL and 18.64% on mobility. On one hand our results confirm the unfavorable influence of age on functional outcome and on the other that inpatient rehabilitation is substantially effective also for very old patients, although less than for younger ones.

Antonucci G, Aprile T, Paolucci S. Rasch analysis of the Rivermead Mobility Index: a study using mobility measures of first-stroke patients. Arch Phys Med Rehabil 2002;83:1442-9. Objective: To evaluate the validity and item unidimensionality of the Rivermead Mobility Index (RMI) by using Rasch analysis. Design: Application of Rasch analysis on the RMI partial data set. Setting: A stroke program at a rehabilitation hospital in Italy. Participants: A total of 308 consecutive patients (155 women, 153 men; avg age, 62.79±11.94y) hospitalized between 1990 and 1996. Average interval between stroke onset and admission was 52.48±36.22 days. Intervention: Medical inpatient rehabilitation. Main Outcome Measures: Patients' mobility status was assessed using the RMI administered at admission and discharge. Ratings were assigned by 4 staff members working as a team. We performed separate Rasch analyses on the RMI data, gathered from different groups of first stroke inpatients examined before and after rehabilitation treatment. Results: asch analysis showed the overall good validity of the RMI, except for item 15, which did not fit the unidimensional continuum estimated through the Rasch rating model. Conclusion: The RMI is a unidimensional scale with a hierarchy of easy-to-hard test questions. Item difficulty level was stable when processed on different groups of patients assessed on different occasions. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objectives – The aim of the present study was to determine the impact of commonly used and potentially detrimental drugs on rehabilitation results and to clarify their role as prognostic factors. Material and methods – The study included 154 patients admitted to a rehabilitation hospital for sequelae of a first stroke. Multivariate analyses were performed using effectiveness of treatment, evaluated by both the Barthel Index (BI) and the Rivermead Mobility Index (RMI) and low response on both of these indexes as dependent variables. Independent variables were medical, demographic and pharmacological factors. Results – The use of detrimental drugs was negatively associated with effectiveness on both BI and RMI. Severity of stroke (Canadian Neurological Scale score at admission) and hemineglect were the other negative prognostic factors that significantly entered the analyses. On the other hand, the presence of Broca's aphasia positively influenced the recovery, essentially due to prolonged length of stay. The presence of detrimental drugs and hemineglect were associated with a higher risk of low response on both BI and RMI. Conclusion – These findings confirm that the use of some drugs can influence rehabilitation results. Therefore, the choice of pharmacological treatment of stroke patients should be carefully evaluated by considering the potential detrimental effects of some drugs commonly used for the treatment of coincidental medical conditions.

The aim of the study was to analyse swallowing function and to identify reliable prognostic factors associated with dysphagia in a consecutive series of patients with multiple sclerosis (MS). Swallowing examination was performed by means of indirect and direct methods (fiberendoscopic evaluation) in 143 consecutive patients with primary and secondary progressive MS. Dysphagia was found in 49 patients (34.3%). A close relationship with dysphagia was found in the patients with severe brainstem impairment (OR=3.24; 95% CI 1.44-7.31) as compared to the patients without. There was also a significant correlation with pronounced severity of illness (OR=2.99; CI 1.36-6.59). Compensatory strategies were sufficient to resolve the dysphagia in 46 cases (93.8%). The potential risk of aspiration and malnutrition and the high efficacy of swallowing rehabilitation suggests that all MS patients should have a careful evaluation of deglutition functionality, especially those with brainstem impairment and a high grade of disability level.

Erratum in: Familial occurrence and heritable connective tissue disorders in cervical artery dissection. [Neurology. 2016]; International audience; In a large series of patients with cervical artery dissection (CeAD), a major cause of ischemic stroke in young and middle-aged adults, we aimed to examine frequencies and correlates of family history of CeAD and of inherited connective tissue disorders. We combined data from 2 large international multicenter cohorts of consecutive patients with CeAD in 23 neurologic departments participating in the CADISP-plus consortium, following a standardized protocol. Frequency of reported family history of CeAD and of inherited connective tissue disorders was assessed. Putative risk factors, baseline features, and 3-month outcome were compared between groups. Among 1,934 consecutive patients with CeAD, 20 patients (1.0%, 95% confidence interval: 0.6%-1.5%) from 17 families (0.9%, 0.5%-1.3%) had a family history of CeAD. Family history of CeAD was significantly more frequent in patients with carotid location of the dissection and elevated cholesterol levels. Two patients without a family history of CeAD had vascular Ehlers-Danlos syndrome with a mutation in COL3A1. This diagnosis was suspected in 2 additional patients, but COL3A1 sequencing was negative. Two patients were diagnosed with classic and hypermobile Ehlers-Danlos syndrome, one patient with Marfan syndrome, and one with osteogenesis imperfecta, based on clinical criteria only. In this largest series of patients with CeAD to date, family history of symptomatic CeAD was rare and inherited connective tissue disorders seemed exceptional. This finding supports the notion that CeAD is a multifactorial disease in the vast majority of cases.

Motor imagery and internal motor models have been deeply investigated in literature. It is well known that the development of motor imagery occurs during adolescence and it is limited in people affected by cerebral palsy. However, the roles of motor imagery and internal models in locomotion as well as their intertwine received poor attention. In this study we compared the performances of healthy adults (n=8, 28.1±5.1 years old), children with typical development (n=8, 8.1±3.8 years old) and children with cerebral palsy (n=12, 7.5±2.9 years old), measured by an optoelectronic system and a trunk-mounted wireless inertial magnetic unit, during three different tasks. Subjects were asked to achieve a target located at 2 or 3m in front of them simulating their walking by stepping in place, or actually walking blindfolded or normally walking with open eyes. Adults performed a not significantly different number of steps (p=0.761) spending not significantly different time between tasks (p=0.156). Children with typical development showed task-dependent differences both in terms of number of steps (p=0.046) and movement time (p=0.002). However, their performance in simulated and blindfolded walking were strictly correlated (R=0.871 for steps, R=0.673 for time). Further, their error in blindfolded walking was in mean only of -2.2% of distance. Also children with cerebral palsy showed significant differences in number of steps (p=0.022) and time (p

Background The aim of the study is to determine the probability of achieving independence and the related prognostic factors with regard to single activities of daily living after 3 months of rehabilitation following stroke. Methods This longitudinal observational study, conducted in a neurorehabilitation unit of a research and health care institute, involved 435 subjects who were affected by stroke (age, 68 ± 14 years, 230 men). Barthel index (BI) scores were recorded at admission and dismissal 3 months later. Results The highest improvement after rehabilitation was observed for bowel and bladder function and transfer and mobility, whereas the lowest improvement was seen in bathing, grooming, dressing, and stair climbing. Conclusions Severity of stroke, presence of unilateral neglect, age, gender, and onset-to-admission interval (OAI) were significant prognostic factors for 6 of 10 activities, as assessed by BI subscores. Feeding was influenced only by neglect and OAI, whereas OAI did not affect bowel or bladder function recovery. Practice Patients and their relatives could be informed about the specific activities in which patients will be expected to be independent after rehabilitation and the specific needs that they might have on returning home. Implication Our results might help optimize the management of the rehabilitative process.

Purpose Transcranial direct current stimulation (tDCS) of the motor cortex seems to be effective in improving motor performance in patients with chronic stroke, while some recent findings have reported conflicting results for the subacute phase. We aimed to verify whether upper extremity motor rehabilitation could be enhanced by treatment with tDCS administered before a rehabilitative session. Methods Hand dexterity and force in 16 individuals with subacute stroke were assessed before (T0) and after anodal stimulation (T1) and after a successive session of motor rehabilitation (T2) in a double-blind, randomized, sham-controlled, crossover trial. To confirm the value of the device as a specific effector, behavioral tests were also administered. Results Anodal and sham stimulation plus rehabilitation significantly improved manual dexterity (repeated-measure Anova: A-tDCS: p = 0.005; S-tDCS: p = 0.042). Post hoc analysis revealed a significant stimulation effect only for A-tDCS (p = 0.013 between T0 and T1) and not for S-tDCS, whereas the rehabilitation effect (between T1 and T2) was not significant in either group. Hand force and behavioral features were unchanged. Conclusions Anodal brain stimulation improves hand dexterity but does not increase the effectiveness of the rehabilitation directly. These results suggest the presence of aftereffects, not priming effects, of A-tDCS superimposed onto motor learning phenomena.

The video game-based therapy emerged as a potential valid tool in improving balance in several neurological conditions with controversial results, whereas little information is available regarding the use of this therapy in subacute stroke patients. The aim of this study was to investigate the efficacy of balance training using video game-based intervention on functional balance and disability in individuals with hemiparesis due to stroke in subacute phase. Fifty adult stroke patients participated to the study: 25 subjects were randomly assigned to balance training with Wii Fit, and the other 25 subjects were assigned to usual balance therapy. Both groups were also treated with conventional physical therapy (40 min 2 times/day). The main outcome was functional balance (Berg Balance Scale-BBS), and secondary outcomes were disability (Barthel Index-BI), walking ability (Functional Ambulation Category), and walking speed (10-meters walking test). Wii Fit training was more effective than usual balance therapy in improving balance (BBS: 53 versus 48,P=0.004) and independency in activity of daily living (BI: 98 versus 93,P=0.021). A balance training performed with a Wii Fit as an add on to the conventional therapy was found to be more effective than conventional therapy alone in improving balance and reducing disability in patients with subacute stroke.

Stroke is the second leading cause of death and the third leading cause of disability-adjusted life-years (DALYs) worldwide [1]. In the past two decades, the absolute number of people who have a stroke every year and stroke survivors and the overall global burden of stroke have been increasing [2]. This was the consequence of an increase in life expectancy and reduced mortality in the acute phase in stroke care. The public health systems and the scientific communities should seriously take into account the “pandemia” of stroke survivors [3]. From the other side, a big amount of economic resources, needed for the rehabilitation of people after stroke, is related to the increasing prevalence of patients affected by stroke sequelae. It transforms this ethical duty in an utopistic mission. There is the need of increasing rehabilitation and, at the same time, reducing its costs. New technologies for neurorehabilitation can provide modern tools for increasing efficiency. Despite the extraordinary possibilities of these new approaches, there is a lot of work for integrating them into the routinary rehabilitation programs. These devices should be considered as tools in the hands of neurorehabilitation teams usable in the framework of a rehabilitative program and not only rehabilitative per se. In fact, they should be integrated in a complex model in which the aim and the actual patients conditions concur to tailor training with multimodal conditions integrating classical and well-known conventional therapy with the new approaches, including new technological devices [4]. This complex model includes strategies for motor recruitment control, increasing performance during a task, the enhancement of patients' motivation and engagement, and trainings to empower cognitive functions, to increase cardiorespiratory fitness, to increase quality of movement, and to improve balance and motor control. Each of these specific endpoints should be addressed and concur in a different manner to the rehabilitation user-tailored program in stroke. The efficacy of the robotic training in arm and walking neurorehabilitation after stroke has been proven in several trials; furthermore, the debate has still been open and there is no possibility at the moment to perform only machine aided training [5]. It should be noted that the machines provide the basics and the therapist's task is to implement these basics into more complex tasks; thus, no machine can replace the experienced therapists. From the other side, the high costs of such robots limit their diffusion, but the possibility that more robots can be used to treat more patients at the same time with only one physiotherapist monitoring all of them should decrease the cost of each therapy [6]. In this special issue, S. Masiero et al. analyzed the costs of the 5 years experiments on arm robotic training in hospital setting in subacute stroke, reaching this conclusion “Robotic upper limb rehabilitation after acute stroke by NeReBot: evaluation of treatment costs.” The increase of the rehabilitation offers in terms of number of therapies provided without increasing the costs is mandatory. In this line telerehabilitation is an important strategy when coupled to an early discharge. M. Agostini and colleagues showed us the feasibility and the efficacy of a home telerehabilitation protocol in poststroke anomia “Telerehabilitation in poststroke anomia.” Video game-based therapy and the virtual reality system are playing an important role in reducing costs, especially, using commercial gaming systems, and augmenting the involvement of patients' attention and participation to the exercise/game. A paper in this special issue for the first time has shown that the balance training performed using a commercial console is more effective than the conventional therapy: “The efficacy of balance training with video game-based therapy in subacute stroke patients: a randomized controlled trial.” Furthermore, the development of a patients' tailored system with specific exercises and specific augmented feedback as described in the paper of P. Kiper et al. “Reinforced feedback in virtual environment for rehabilitation of upper extremity dysfunction after stroke: preliminary data from a randomized controlled trial” provides a next step toward this aim. Quantitative assessment is also important for providing a tailored rehabilitation. The study of M. Manca et al. identified five clusters characterizing the gait dysfunction of patients with stroke “Gait patterns in hemiplegic patients with equinus foot deformity.” Similarly, I. Aprile et al. have identified an upper limb kinematic analysis for assessing alterations in reaching function, providing more chances to train each patient in a specific tailored way “Kinematic analysis of the upper limb motor strategies in stroke patients as a tool towards advanced neurorehabilitation strategies: a preliminary study.” Among the novel rehabilitation approaches, the action observation is another one of interest. The observation of actions performed by other people activates in the perceiver the same neural structures responsible for the actual execution of the same actions exploiting the neurophysiological mechanism for the recovery of motor impairment as shown in the paper of P. Sale and colleagues “Action observation therapy in the subacute phase promotes dexterity recovery in right-hemisphere stroke patients.” The complex model for treating patients with stroke, in the last years, involved also cardiovascular fitness, in chronic [7], as well as in subacute, phase [8]. The energy cost of walking assessed by a breath to breath method could be expensive involving machines with high costs and not easy to use; conversely, the physiological cost index is easy to use and of low cost. A. S. DeLussu and colleagues have proved the validity of the physiological cost index for assessing the energy cost during walking training on floor and on robotic gait training in subacute stroke “Concurrent validity of physiological cost index in walking over ground and during robotic training in subacute stroke patients.” Finally, the attention to the sleepiness problems and the correlation with the disabilities is increasing after stroke, but little is known about the sleep and daytime sleepiness of chronic stroke patients as an important factor conditioning patients' ability in activity of daily living. The paper of K. Herron et al. explored the sleep and sleepiness in a chronic stroke population with sustained physical deficits “Quantitative electroencephalography and behavioural correlates of daytime sleepiness in chronic stroke.” All the studies reported in this special issue showed the complexity of the neurorehabilitation of people who suffered from stroke and the consequent need of a complex tailored rehabilitation that is not only an economic burden but also an ethical issue. The way a nation cares for people with disabilities is an indicator of its progress. Giovanni Morone Stefano Masiero Cordula Werner Stefano Paolucci

Robotic-assisted walking training has spread in recent years with positive results regarding its efficacy. However there are few information regarding the target people for a more effective robotic rehabilitation. The present study is aimed to investigate if possible demographic factors can influence robotic-assisted walking training. The study was performed in a neurorehabilitation setting. A total of 74 patients were randomized in robotic-assisted gait training abbreviated conventional therapy (RAGT) and floor-assisted gait training abbreviated conventional therapy intervention (FAGT). Outcome measure was the walking ability measured by Functional Ambulation Classifications (FAC). Results show that in RAGT group walking recovery was more effective for female than males (p=0.0048) and for patients over 65 years (≥65 yrs, p=0.040). This combined gender/age effect was not observed in FAGT group. Among demographic factors gender and age are critical for selecting stroke patients with higher chance of gait robotic gait therapy efficacy.

Gait Trainer (GT) and the Lokomat (Loko) are two commercial robotic devices developed for assist task-oriented, intensive practice of walking in neurological patients. Despite the many studies involving these devices, there are not specific studies comparing electromyography (EMG) activity during sessions of walking training performed using these devices. This study aimed to explore the differences in the EMG patterns between these two devices and in respect over-ground walking. EMG of eight lower limb muscles were bilaterally recorded and analyzed in one healthy subject. Thigh muscles were more active during GT-session, whereas shank muscles during Loko-session. Furthermore, decreasing the guidance assistance of Loko (i.e. the percentage of force applied by the robot in respect to that needed for following the predetermined trajectory, training), all the muscles showed an increment of the EMG signal. These results showed clear differences in muscle activation patterns between the two systems and, as expected, quite different from the pattern observed in over-ground locomotion. These results are of importance for the correct use of robotic devices in gait rehabilitation and would represent the preliminary step to address their correct use in neurologically impaired subjects.

Physiological Cost Index (PCI) has been proposed to assess gait demand. The purpose of the study was to establish whether PCI is a valid indicator in subacute stroke patients of energy cost of walking in different walking conditions, that is, over ground and on the Gait Trainer (GT) with body weight support (BWS). The study tested if correlations exist between PCI and ECW, indicating validity of the measure and, by implication, validity of PCI. Six patients (patient group (PG)) with subacute stroke and 6 healthy age- and size-matched subjects as control group (CG) performed, in a random sequence in different days, walking tests overground and on the GT with 0, 30, and 50% BWS. There was a good to excellent correlation between PCI and ECW in the observed walking conditions: in PG Pearson correlation was 0.919 (p<0.001); in CG Pearson correlation was 0.852 (p<0.001). In conclusion, the high significant correlations between PCI and ECW, in all the observed walking conditions, suggest that PCI is a valid outcome measure in subacute stroke patients.

Transcranial direct current stimulation (tDCS) is a noninvasive technique that could improve the rehabilitation outcomes in stroke, eliciting neuroplastic mechanisms. At the same time conflicting results have been reported in subacute phase of stroke, when neuroplasticity is crucial. The aim of this double-blind, randomized, and sham-controlled study was to determine whether a treatment with cathodal tDCS before the rehabilitative training might augment the final outcomes (upper limb function, hand dexterity and manual force, locomotion, and activities of daily living) in respect of a traditional rehabilitation for a sample of patients affected by ischemic stroke in the subacute phase. An experimental group (cathodal tDCS plus rehabilitation) and a control group (sham tDCS plus rehabilitation) were assessed at the beginning of the protocol, after 10 days of stimulation, after 30 days from ending of stimulation, and at the end of inpatient rehabilitation. Both groups showed significant improvements for all the assessed domains during the rehabilitation, except for the manual force, while no significant differences were demonstrated between groups. These results seem to indicate that the cathodal tDCS, provided in an early phase of stroke, does not lead to a functional improvement. To depict a more comprehensive scenario, further studies are needed.

The aim of this study was to assess the effects of the arbitrary choices of threshold-values for dichotomizing not binary factors on the computation of odds ratio (OR) for the identification of prognostic factors, in particular of motor recovery after stroke. Data of a sample of 1000 patients with subacute stroke have been analysed. We considered as dependent variable the effectiveness of neurorehabilitation (i.e. the achieved level of independency in activities of daily living, measured using the Barthel Index, expressed in percentage of the maximum achievable improvement), and as independent variables age, time between stroke acute event and beginning of neurorehabilitation, gender, type of stroke (ischemic vs. haemorragic) and side of hemiparesis. We performed univariate analyses for computing OR with respect to different choices of threshold for dichotomizing age and time from stroke. In this analysis median value of effectiveness was used for dichotomizing subjects in good and poor responders. Then these analyses were repeated also varying the threshold-value of effectiveness. Finally multivariate analyses based on forward binary logistic regression were performed varying at the same time the thresholds of age and time from stroke. With respect to threshold choice, OR-values of age resulted stable, but those of time from stroke resulted more variable. Variability increased when also the threshold chosen for dichotomizing the independent variable was changed. Multivariate analyses showed that these choices could even make not statistically significant the effect of a binary prognostic factor such as gender. In conclusion, OR-values resulted affected by threshold choices. It can increase the difficulties in marking predictions of outcomes after stroke. In this study we reported a possible graphical evaluation of the variability of OR-values with respect of threshold choice, that can be helpful whenever threshold is arbitrary chosen.