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BACKGROUND In the last few years, new noninvasive strategies have emerged as rehabilitative treatments for patients with stroke. Action observation treatment (AOT) is a rehabilitation approach based on the properties of the mirror neuron system with a positive impact on modifying cortical activation patterns and improving the upper limb kinematics. AOT involves the dynamic process of observing purposeful actions with the intention of imitating and then practicing those actions. In recent years, several clinical studies suggested the effectiveness of AOT in patients with stroke to improve motor recovery and autonomy in activities of daily living. However, a deeper knowledge of the behavior of the sensorimotor cortex during AOT seems to be essential. OBJECTIVE The aim of this clinical trial, conducted in 2 neurorehabilitation centers and in patients’ homes, is to investigate the effectiveness of AOT in patients with stroke, confirming the translational power of a tailored treatment. Particular emphasis will be placed on the predictive value of neurophysiological biomarkers. In addition, the feasibility and impact of a home-based AOT program will be investigated. METHODS A 3-arm, assessor-blinded, randomized controlled trial will be performed by enrolling patients with stroke in the chronic stage. A total of 60 participants will be randomly allocated to receive 15 sessions of AOT with different protocols (AOT at the hospital, AOT at home, and sham AOT), 3 sessions per week. The primary outcome will be assessed using the Fugl-Meyer Assessment-Upper Extremity scores. Secondary outcomes will be clinical, biomechanical, and neurophysiological assessment. RESULTS The study protocol is part of a project (project code GR-2016–02361678) approved and funded by the Italian Ministry of Health. The study began with the recruitment phase in January 2022, and enrollment was expected to end in October 2022. Recruitment is now closed (December 2022). The results of this study are expected to be published in spring 2023. Upon completion of the analyses, we will examine the preliminary effectiveness of the intervention and neurophysiological outcomes. CONCLUSIONS This study will be used to evaluate the effectiveness of 2 different AOT scenarios (ie, AOT at the hospital and AOT at home) in patients with chronic stroke and to assess the predictive value of neurophysiological biomarkers. Specifically, we will attempt to induce the functional modification of the cortical components by exploiting the features of the mirror neuron system, demonstrating relevant clinical, kinematic, and neurophysiological changes after AOT. With our study, we also want to provide, for the first time in Italy, the AOT home-based program while assessing its feasibility and impact. CLINICALTRIAL ClinicalTrials.gov NCT04047134; https://clinicaltrials.gov/ct2/show/NCT04047134 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/42094

Background The Action Observation Therapy (AOT) is a well-established post-stroke rehabilitation treatment based on the theoretical framework of the Mirror Neuron System (MNS) activation. However, AOT protocols are still heterogeneous in terms of video contents of observed actions. Objective The aim of this study was to analyze electroencephalographic (EEG) recordings in stroke patients during the observation of different videos of task-specific upper limb movements, and to define which category of actions can elicit a stronger cortical activation in the observer’s brain. Methods Signals were analyzed from 19 chronic stroke subjects observing customized videos that represented 3 different categories of upper limb actions: Finalized Actions, Non-Finalized Actions, and Control Videos. The Event-Related Desynchronization in the µ and β bands was chosen to identify the involvement of the cerebral cortex: the area of the normalized power spectral density was calculated for each category and, deepening, for the reaching and completion sub-phases of Finalized Actions. For descriptive purposes, the time course of averaged signal power was described. The Kruskal–Wallis test ( P Results The analysis showed a greater desynchronization when subjects observed Finalized Actions with respect to Non-Finalized in all recorded areas; Control videos provoked a synchronization in the same areas and frequency bands. The reaching phase of feeding and self-care actions evoked a greater suppression both in µ and β bands. Conclusions The observation of finalized arm movements seems to elicit the strongest activation of the MNS in chronic stroke patients. This finding may help the clinicians to design future AOT-based stroke rehabilitation protocols. Clinical Trial Registration: Clinical Trial Registration—URL: http://www.clinicaltrials.gov . Unique identifier: NCT04047134.

Background The timed up and go (TUG) test is widely used for assessing treatments effectiveness on elderly mobility. Although the TUG test consists of different tasks (e.g. walking and turning), the total TUG duration (TTD) is usually the only outcome measure, with TTD shortening indicating the patient’s improvement. Research question Does TTD shortening reflect the improvement of each TUG tasks or does it reflect the improvement of only some of them? Methods This retrospective study recruited 120 elderly patients (mean, SD: 76.9, 6.6 years) admitted to inpatient rehabilitation because of an acute or chronic neurological disease (acute patients, AP; chronic patients, CP). TTD and TUG tasks duration was measured on admission and discharge (five trials/session) by means of the instrumental TUG test (ITUG). Likelihood ratios (LRs) were used for inferring TUG tasks improvement from TTD improvement. TTD and TUG tasks have improved if at least four measurements on discharge were shorter than the shortest measurement on admission. Results TTD improvement per se is not enough to claim that all the TUG tasks have improved (LR+AP = 1.32; LR+CP = 1.85). Conversely, if TTD has not improved, not even a single TUG task has improved (LR−AP = 0.13; LR−CP = 0.19). If TTD has improved, there is at least one TUG task that actually improved (LR+AP = 3.17; LR+CP = 9.54). The improvement of all TUG tasks can be only inferred in the (unusual) event of a large TTD shortening (AP: >39%, LR+AP = 6.26; CP: >30%, LR+CP = 9.0). Significance In most cases, TTD improvement is not associated with the improvement of all TUG tasks. Moreover, when TTD has improved there is at least a TUG task that has improved, but that remains unknown. To actually understand how treatments ameliorate patients’ mobility, ITUG with TUG task duration measurement should be preferred to TTD.

Home-based rehabilitation after an acute episode or following an exacerbation of a chronic disease is often problematic with a clear lack of continuity of care between hospital and home care. Secondary prevention is an essential element of long-term rehabilitation where strategies oriented toward risk reduction, treatment adherence, and optimization of quality of life need to be applied. Frail and sometimes isolated, the patient fails to adhere to the proposed post-discharge clinical pathway due to lack of appropriate clinical, emotional, and informational support. Providing a suitable rehabilitation after an acute episode or a chronic disease is a major issue, as it helps people to live independently and enhance their quality of life. However, as the rehabilitation period usually lasts some months, the continuity of care is often interrupted in the transition from hospital to home. Virtual coaches could help these patients to engage in a personalized rehabilitation program that complies with age-related conditions. These coaches could be a key technology for empowering patients toward increasing their adherence to the care plan and to improve their secondary prevention measures. In this paper, we are presenting a novel virtual coaching system that will address these challenges by combining recent technological advances with clinical pathways, based on joint research and validation activities from researchers from the medical and information and communication technology (ICT) domains.

Elderly people with peripheral neuropathy of the lower limbs (PNLL) demonstrate a typical balance and gait impairment because of sensory ataxia. There is evidence that rehabilitation produces important gains on balance and gait. However, responsiveness to rehabilitation of balance and gait measures is unknown in PNLL. Aim of the current work is to evaluate the responsiveness to rehabilitation of balance, gait and sensory ataxia measures in elderly with PNLL. Twenty-five elderly with PNLL attending physiotherapy and occupational therapy during inpatient rehabilitation were recruited. Balance and gait measures (including static posturography, TUG test and the 10 m walking test) were administered on admission and discharge. An accelerometer secured to the trunk was used for TUG recording and static balance assessment. Static balance was tested with open and closed eyes, so as to assess sensory ataxia. Following rehabilitation, patients improved gait [admission vs discharge, mean(SD): 0.86(0.33) vs 0.98(0.32) m/s], TUG [18.7(7.8) vs 15.1(5.2) s] and turning [46.2(15.3) vs 53.3(15.3) °/s]. However, none of 12 static balance parameters derived from trunk acceleration significantly changed. Principal component analysis showed that before training, eyes closed and eyes open balance correlated with orthogonal components (one and two vs. three and four). After training, eyes open and eyes closed balance were more similar to each other being both correlated with component one. Responsiveness to rehabilitation is larger for gait than static balance measured by trunk acceleration. However, exercise can also have a beneficial effect on sensory ataxia by making eyes closed balance more similar to eyes open balance.

Falls in the elderly are a known problem, leading to hospitalization, impaired life quality, and social costs. Falls are associated to multiple risk factors, related to the subject’s health, lifestyle, and living environment. Living alone makes it difficult to detect a patient’s decline, which increases the fall risk. In this paper, we present NONCADO, a project funded by the Lombardy Region (Italy), aimed at developing a system for preventing falls in the elderly living alone, by integrating data from a network of sensors (both wearable and environmental). The collected data are analyzed by a decision support system (DSS) that exploits advanced temporal data analysis techniques to detect behaviors known to increase the individual risk (e.g. moving within the house with inadequate lighting, or performing not enough physical activity). A daily report listing the detected risky behaviors is produced and delivered through a mobile app. Since we address long-term monitoring, it’s important to detect as well the changes in a subject’s habits that may increase fall risk. Such changes are summarized in a weekly report. A preliminary feasibility evaluation of the system was performed during a 2-weeks pilot study involving 16 patients treated at the Casa di Cura Privata del Policlinico hospital, in Milan, Italy. Patients were asked to perform 5 activities, and the system’s ability to correctly detect them was assessed. The study results were encouraging, as the system reached an overall accuracy of 90%.

Background Balance impairment is a hallmark of Parkinson's disease with dramatic effects for patients (e.g. falls). Its assessment is thus of paramount importance. The aim of this work is to assess which measures from the instrumented Timed Up and Go test (recorded with inertial sensors) are valid balance measures in Parkinson's disease and evaluate their responsiveness to rehabilitation. Methods The Mini-BESTest (a criterion-standard balance measure) and the instrumented Timed Up and Go test (with inertial sensors secured to the trunk) were administered to 20 Parkinson's disease patients before and after inpatient rehabilitation (median [IQR]; 76.5 [8.25] years; 5 females; Hoehn and Yahr stage: 2.5 [0.5]). 81 parameters from the instrumented Timed Up and Go test were evaluated. Multiple factor analysis (a variant of principal component analysis for repeated measurements) and effect sizes were used to assess validity and responsiveness, respectively. Findings Only the first component of the multiple factor analysis correlated with the Mini-BESTest, and 21 measures from the instrumented Timed Up and Go test had large loadings on this component. However, only three of these 21 measures also directly correlated with the Mini-BESTest (trunk angular velocities from sit-to-walk and turning; r = 0.46 to 0.50, P = 0.021 to 0.038). Sit-to-walk angular velocity showed greater responsiveness than the Mini-BESTest, while turning showed slightly less. Interpretation Angular velocities from the turning and sit-to-walk phases of the Timed Up and Go test are valid balance measures in Parkinson's disease and are also responsive to rehabilitation.

Background and Objective: We illustrate a low-cost platform easing the estimation of spatio-temporal parameters (GA-STP) ready for large-scale deployment in fall prevention. Methods: We used a commercial sensorized carpet with a limited cost and a very coarse resolution. An instrument validation test was accomplished: the Wilcoxon test for paired samples and the correlation test with Spearman method were used to compare the values computed by the platform with reference ones. Hierarchical clustering using Ward’s method and ROC curves have been used to assess the performance in a pilot study enrolling patients. Results: Validation shows no significant difference between computed and reference values of gait speed (ρ-value:0.99; p-value:2.2E-16), step number (ρ-value:0.91; p-value:5.8E-16) and stride-length (ρ-value:0.92; p-value:7.5E-9). The clinical pilot study confirms that the platform may also be used to track the improvements occurring during a rehabilitation program. Conclusions: We believe that the use of a commercial carpet makes the solution proposed ready to be deployed on a large scale for effectively bringing GA into the clinical practice.

BACKGROUND In the last few years, several studies have focused on describing and understanding how virtual coaches (ie, coaching program or smart device aiming to provide coaching support through a variety of application contexts) could be key drivers for health promotion in home care settings. As there has been enormous technological progress in the field of artificial intelligence and data processing in the past decade, the use of virtual coaches gains an augmented attention in the considerations of medical innovations. OBJECTIVE This scoping review aimed at providing an overview of the applications of a virtual coach in the clinical field. In particular, the review focused on the papers that provide tangible information for coaching activities with an active implication for engaging and guiding patients who have an ongoing plan of care. METHODS We aimed to investigate the use of the term virtual coach in the clinical field performing a methodical review of the relevant literature indexed on PubMed, Scopus, and Embase databases to find virtual coach papers focused on specific activities dealing with clinical or medical contexts, excluding those aimed at surgical settings or electronic learning purposes. RESULTS After a careful revision of the inclusion and exclusion criteria, 46 records were selected for the full-text review. Most of the identified articles directly or indirectly addressed the topic of physical activity. Some papers were focused on the use of virtual coaching (VC) to manage overweight or nutritional issues. Other papers dealt with technological interfaces to facilitate interactions with patients suffering from different chronic clinical conditions such as heart failure, chronic obstructive pulmonary disease, depression, and chronic pain. CONCLUSIONS Although physical activity is a healthy practice that is most encouraged by a virtual coach system, in the current scenario, rehabilitation is the great absentee. This paper gives an overview of the tangible applications of this tool in the medical field and may inspire new ideas for future research on VC.

Rehabilitation robots have built-in technology and sensors that allow accurate measurement of movement kinematics and kinetics, which can be used to derive measures related to upper limb performance and highlight changes in motor behavior due to rehabilitation. This study aimed to assess the test-retest reliability of some robot-measured parameters by analyzing their intra-session and inter-session (day-by-day) variability. The study was carried out in two groups: 31 patients after stroke and 15 healthy subjects. Both groups practiced two different motor tasks consisting of point-to-point reaching movements in the shape of two geometrical figures that were selected for the assessment of global and directional (eight directions of the workspace) test-retest reliability. The reliability of six parameters measuring movement velocity, accuracy, efficiency and smoothness was assessed intra-session and inter-session by the ICC, SEM, and CV. Healthy subjects exhibited very high ICC values ( > 0.85) and low SEM for all parameters. Patients had high ICC values and low SEM but their global reliability was generally lower compared to healthy subjects. In addition, their inter-session reliability showed very high ICC values ( > 0.91) and low SEM for all parameters. Direction analysis showed that in some parameters the reliability was generally high but not homogeneous in all directions. In addition, some directions showed systematic error. This study demonstrates that robot-measured parameters are reliable and can be considered ideal candidates for use in combination with impairment and functional clinical scales to evaluate motor improvement during robot-assisted neurorehabilitation.

The aims of this study were to develop and evaluate reliability of a quantitative assessment tool for upper limb sense of position on the horizontal plane. We evaluated 15 healthy individuals (controls) and 9 stroke patients. A robotic device passively moved one arm of the blindfolded participant who had to actively move his/her opposite hand to the mirror location in the workspace. Upper-limb's position was evaluated by a digital camera. The position of the passive hand was compared with the active hand's ‘mirror’ position. Performance metrics were then computed to measure the mean absolute errors, error variability, spatial contraction/expansion, and systematic shifts. No significant differences were observed between dominant and non-dominant active arms of controls. All performance parameters of the post-stroke group differed significantly from those of controls. This tool can provide a quantitative measure of upper limb sense of position, therefore allowing detection of changes due to rehabilitation.

The purpose of this study was to determine whether a conventional robot-assisted therapy of the upper limb was able to improve proprioception and motor recovery of an individual after stroke who exhibited proprioceptive deficits. After robotic sensorimotor training, significant changes were observed in kinematic performance variables. Two quantitative parameters evaluating position sense improved after training. Range of motion during shoulder and wrist flexion improved, but only wrist flexion remained improved at 3-month follow-up. These preliminary results suggest that intensive robot-aided rehabilitation may play an important role in the recovery of sensory function. However, further studies are required to confirm these data.

Rehabilitation robots have built-in technology and sensors that allow accurate measurement of movement kinematics and kinetics, which can be used to derive measures related to upper limb performance and highlight changes in motor behavior due to rehabilitation. This study aimed to assess the test-retest reliability of some robot-measured parameters by analyzing their inter-session (day-by-day) variability. The study was carried out using the MEMOS device, in a group of 14 patients after stroke who practiced two different motor tasks consisting of point-to-point reaching movements in the shape of two geometrical figures specifically selected for the assessment of global and directional (8 directions of the workspace) test-retest reliability. The reliability of 4 parameters measuring movement velocity, accuracy, efficiency and smoothness was assessed by the Intra-class Correlation Coefficient, Standard Error of Measurements and Coefficient of Variation. Patients enrolled in the study had high reproducibility values. Directional analysis showed that in some parameters the reliability was generally high but not homogeneous in all directions. In addition, some directions showed systematic error. This study demonstrates that robot-measured parameters are reliable and can be considered ideal candidates for use in combination with clinical scales assessing functional impairment to evaluate motor improvement during robot-assisted neurorehabilitation.

Spasticity is a common motor impairment in patients with neurological disorders that can prevent functional recovery after rehabilitation. In the clinical setting, its assessment is carried out using standardized clinical scales. The aim of this study was to verify the applicability of inertial sensors for an objective measurement of quadriceps spasticity and evaluate its test-retest and inter-rater reliability during the implementation of the Wartenberg pendulum test. Ten healthy subjects and 11 patients in vegetative state with severe brain damage were enrolled in this study. Subjects were evaluated three times on three consecutive days. The test-retest reliability of measurement was assessed in the first two days. The third day was devoted to inter-rater reliability assessment. In addition, the lower limb muscle tone was bilaterally evaluated at the knee joint by the modified Ashworth scale. The factorial ANOVA analysis showed that the implemented method allowed us to discriminate between healthy and pathological conditions. The fairly low SEM and high ICC values obtained for the pendulum parameters indicated a good test-retest and inter-rater reliability of measurement. This study shows that an inertial sensor can be reliably used to characterize leg kinematics during the Wartenberg pendulum test and provide quantitative evaluation of quadriceps spasticity.

BACKGROUND Robotic neurorehabilitation, thanks to high dosage/intensity training protocols, has the potential for a greater impact on impairment. OBJECTIVE We aimed to analyze how time since the acute event may influence the motor recovery process during robot-assisted rehabilitation of the upper limb. METHODS A total of 41 patients after stroke were enrolled: 20 in subacute phase, i.e. ≤ 6 months elapsed since their unilateral cerebrovascular accident (CVA), and 21 at chronic stage, i.e. > 6 months since CVA. All subjects underwent 30 minutes of robot-aided rehabilitation twice a day, 5 days a week for at least three weeks of training. Patients were evaluated at the start and end of treatment using the Fugl-Meyer and Modified Ashworth clinical scales and by a set of robot measured kinematic parameters. The time interval from stroke was considered as a grouping factor to analyze its impact on time course of recovery. RESULTS After training both groups significantly improved their impairment (F = 44.25, p < 0.001) but sub-acute patients showed a greater improvement on the Fugl-Meyer scale than chronic patients. The time course of recovery of the kinematic variables showed higher time constants of motor improvement in the sub-acute than chronic group, but they were one order lower than spontaneous recovery time constants. CONCLUSIONS Spontaneous recovery seems to have a limited impact on the improvement of sub-acute patients, most of their changes being likely due to re-learning during rehabilitation. In addition, a longer recovery time was required to maximize outcome in sub-acute than in chronic patients.

The high number of patients involved every year in stroke rehabilitation interventions calls for urgent understanding of the neural mechanisms underlying both spontaneous and rehabilitation-induced recovery. The aim of this study was to analyze how the time since the acute event of patients may influence the motor recovery processes during robot-assisted rehabilitation of the upper limb. The study was conducted in two groups of patients after stroke in Sub-acute (n=10) and Chronic (n=10) phase who underwent robot-assisted rehabilitation of the upper limb. After training, both groups improved their level of impairment and quality of movement thus indicating effectiveness of the rehabilitation intervention. The preliminary analysis of the time course of recovery evidenced a specific pattern of recovery in the two groups of patients.

Spasticity is a common motor impairment in patients with neurological disorders. The aim of this study was to investigate the test-retest reliability of the Wartenberg pendulum test using an inertial sensor. The analysis was conducted in six healthy subjects and six patients in vegetative state with severe brain damage secondary to traumatic brain injury (n=3) or cerebrovascular disease (n=3). The reliability analysis showed high intraclass correlation coefficients (ICC = 0.77 to 0.89) and low SEM for all measured parameters. The instrumentation here described can provide a reliable measurement of spasticity and be easily applied in the clinical environment.

Many exercise protocols for robot therapy are designed to adjust their degree of difficulty in order to maintain a constant challenge level. A simple way to do this is to design exercises that consist of a variable number of sub-movements in different directions — task difficulty is determined by the number of sub-movements. But, how does recovery proceed in these tasks, and how to regulate the magnitude of the assistance provided by the robot in this case? Here we focus on a simple task in which subjects had to complete a square figure. At every trial, an adaptive regulator selects the appropriate degree of robot assistance needed to complete the entire figure. We tested this protocol with four severely impaired stroke survivors during a multisession study. Robotic training succeeded — the controller gradually reduced the degree of assistance while performance remained constant, suggesting that in fact recovery took place. We used a dynamic model of the recovery process to further analyze the effects of the assistive force and the temporal evolution of the subjects' voluntary control. The model provided an excellent fitting of the subjects' performance and revealed that magnitude and modalities of recovery are very different in the different sub-movements. These results suggest that in order to maximize the recovery the modulation of assistance should occur at the level of each sub-movement.

In robot-assisted neurorehabilitation, matching the task difficulty level to the patient's needs and abilities, both initially and as the relearning process progresses, can enhance the effectiveness of training and improve patients' motivation and outcome. This study presents a Progressive Task Regulation algorithm implemented in a robot for upper limb rehabilitation. It evaluates the patient's performance during training through the computation of robot-measured parameters, and automatically changes the features of the reaching movements, adapting the difficulty level of the motor task to the patient's abilities. In particular, it can select different types of assistance (time-triggered, activity-triggered, and negative assistance) and implement varied therapy practice to promote generalization processes. The algorithm was tuned by assessing the performance data obtained in 22 chronic stroke patients who underwent robotic rehabilitation, in which the difficulty level of the task was manually adjusted by the therapist. Thus, we could verify the patient's recovery strategies and implement task transition rules to match both the patient's and therapist's behavior. In addition, the algorithm was tested in a sample of five chronic stroke patients. The findings show good agreement with the therapist decisions so indicating that it could be useful for the implementation of training protocols allowing individualized and gradual treatment of upper limb disabilities in patients after stroke. The application of this algorithm during robot-assisted therapy should allow an easier management of the different motor tasks administered during training, thereby facilitating the therapist's activity in the treatment of different pathologic conditions of the neuromuscular system.

The status of motor function in stroke survivors and the effect of any therapeutic intervention are generally measured by physiotherapists using clinical assessment scales that probe specific aspects of a subject's motor behavior. Although they are widely accepted, these measurement tools are limited by interrater and intrarater reliability and are time-consuming to apply. This paper analyzes the changes in movement kinematics and kinetics during robot-aided neurorehabilitation of subjects after stroke and verifies the possibility of estimating outcome measures by means of a set of robot measured parameters.

Traditional assessment of a stroke subject's motor ability, carried out by a therapist who observes and rates the subject's motor behavior using ordinal measurements scales, is subjective, time consuming and lacks sensitivity. Rehabilitation robots, which have been the subject of intense inquiry over the last decade, are equipped with sensors that are used to develop objective measures of motor behaviors in a semiautomated way during therapy. This article reviews the current contributions of robot-assisted motor assessment of the upper limb. It summarizes the various measures related to movement performance, the models of motor recovery in stroke subjects and the relationship of robotic measures to standard clinical measures. It analyses the possibilities offered by current robotic assessment techniques and the aspects to address to make robotic assessment a mainstream motor assessment method.

The assessment obtained by both automatic scores of patients’ performance enrolled in the robotic group shown a marked decrease of movement time (p < 0.005) and marked increase of smoothness, measured by counting the number of peaks in the velocity profile (p < 0.005). A correlation was observed between the two automatic performance indexes and the functional indexes of BAT scale (p < 0.05). The performance improvement in movement execution was analysed over different directions of space by means of the robot-based assessment. A significant improvement was observed mainly in the ipsilateral space (p < 0.05), while less significant improvement was obtained in the contralateral space. Discussion: This study confirm previous results obtained with a robotic exoskeleton providing indications that robotic treatment associated to rehabilitation of hand function might lead to significant improvement of motor function, if compared to physical therapy. Moreover it appears that the observed improvement in smoothness of movement, assessed by the robot, represents a predictive indicator of both clinical assessment and regained ability to perform activity of everyday life.

The aim of this study was to describe in detail a new method, called normalized force control parameter (nFCP), to measure changes in movement dynamics obtained during robot-aided neurorehabilitation, and to evaluate its ability to estimate the clinical scales. The study was conducted in a group of 18 subjects after chronic stroke who underwent robot therapy of the upper limb. We used two different measures of movement dynamics to assess patients' performance during each session of training: the nFCP and force directional error (FDE), both measuring the directional error of the patient-exerted force applied to the end-effector of the robot device. Both metrics exhibited significant changes over the three-week course of treatment. The comparison between nFCP and FDE slopes showed a significant and high correlation (r = 0.79; p < 0.001), indicating that the two parameters are closely correlated. The FDE informed on the direction of the force error, while the nFCP showed a better performance in predicting the clinical scale values. Assessment of the time course of recovery showed that nFCP, FDE and the movement smoothness improved quickly at first and then plateaued, while steady gains in mean velocity of movement took place over a longer time course. These data may be helpful to the therapist in developing more effective robot-based therapy protocols.

Patient motivation is an important factor in rehabilitation. The difficulty level of the motor task, the awareness of the performance obtained, and the quantity and quality of feedbacks presented to the patient can influence patient motivation and produce different ways of acting and different performances. This study presents a Progressive Task Regulation algorithm able to evaluate the patient's performance during training and automatically change the features of the reaching movement, so as to adapt automatically the difficulty level of the motor task to the patient's ability. Use of the progressive task regulation algorithm should promote patient motivation throughout the course of treatment.