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In older populations, sensitive fall risk assessment tools are important to timely intervene and prevent falls. Instrumented assessments have shown to be superior to standardized fall risk assessments such as the Timed Up and Go Test (TUG) and should capture both motor and cognitive functions. Therefore, the aim was to test novel instrumented assessments with and without a cognitive component. One hundred thirty-seven older adults aged 73.1 ± 7.3 years, 38 categorized as fallers and 99 as non-fallers, conducted five instrumented assessments on the Dividat Senso, a pressure sensitive stepping platform, and three standardized geriatric assessments (TUG, TUG-dual task, 30-s Sit-to-Stand Test (STS)). T-tests were applied to compare the test performance of fallers versus non-fallers. Furthermore, logistic regression analyses and area under the curve (AUC) analyses were performed. Statistically significant differences between fallers and non-fallers were found in the Go/No-Go test (p = .001, d = .72), the TUG (p = .014, d = .48), and the STS (p = .008, d = .51). Only the Go/No-Go test contributed significantly to all regression models. Significant AUC values were found for the Reaction Time Test (RTT) (AUC = .628, p = .023), Go/No-Go (AUC = .673, p = .002), TUG (AUC = .642, p = .012), and STS (AUC = .690, p = .001). The Go/No-Go test measuring inhibition showed the best discriminative ability suggesting added value of instrumented assessments with a cognitive component for clinical fall risk assessment in relatively healthy older adults. The study should be extended with a frailer population, in which TUG and the other instrumented assessments are possibly good predictors as well., (© 2024. The Author(s).)

Purpose: Digital fabrication, like 3D printing, is a new opportunity for rehabilitation professionals to produce customized assistive devices. It allows for empowerment and collaboration in device procurement, but practical implementations are scarcely described. We describe the workflow, discuss feasibility and propose directions for future work., Methods: We showcase a process of co-manufacturing a custom spoon handle together with two people with cerebral palsy. Our digital manufacturing process was centered around videoconferencing to remotely control the processes from design to final 3D printing. Device functionality and satisfaction were assessed using standard clinical questionnaires: the Individual Priority Problem Assessment Questionnaire (IPPA) and the Quebec User Satisfaction Assessment with Assistive Technology (QUEST 2.0)., Results: IPPA was instrumental in assessing user needs and device effectiveness. QUEST revealed where to focus future design efforts., Conclusion: Involving people with disabilities in co-creation of assistive devices opens for new opportunities for healthcare providers that should be explored in depth using the described methodology. There may also be therapeutic benefits and we envisage specific actions to take in order to make it clinically viable.

Although the 6-Minute Walk Test (6MWT) is among the recommended clinical tools to assess gait impairments in individuals with Parkinson's disease (PD), its standard clinical outcome consists only of the distance walked in 6 min. Integrating a single Inertial Measurement Unit (IMU) could provide additional quantitative and objective information about gait quality complementing standard clinical outcome. This study aims to evaluate the test-retest reliability, validity and discriminant ability of gait parameters obtained by a single IMU during the 6MWT in subjects with mild PD. Twenty-two people with mild PD and ten healthy persons performed the 6MWT wearing an IMU placed on the lower trunk. Features belonging to rhythm and pace, variability, regularity, jerkiness, intensity, dynamic instability and symmetry domains were computed. Test-retest reliability was evaluated through the Intraclass Correlation Coefficient (ICC), while concurrent validity was determined by Spearman's coefficient. Mann-Whitney U test and the Area Under the receiver operating characteristic Curve (AUC) were then applied to assess the discriminant ability of reliable and valid parameters. Results showed an overall high reliability (ICC ≥ 0.75) and multiple significant correlations with clinical scales in all domains. Several features exhibited significant alterations compared to healthy controls. Our findings suggested that the 6MWT instrumented with a single IMU can provide reliable and valid information about gait features in individuals with PD. This offers objective details about gait quality and the possibility of being integrated into clinical evaluations to better define walking rehabilitation strategies in a quick and easy way.

This paper presents the use of a parametric design platform and 3D printing to create personalized assistive devices (ADs) for individuals with cerebral palsy, specifically a fork/spoon holder. Five subjects participated in the study, each receiving a customized device to fit their dominant hand, and they tested both the 3D printed device and a commercially available one. The devices were evaluated based on functionality and satisfaction using two standard clinical questionnaires (IPPA and QUEST 2.0). The results showed that neither the 3D printed nor the commercial device provided substantial benefits, but the questionnaires provided valuable feedback on areas for improvement. The study highlights the need for highly personalized solutions in ADs, which could be addressed by 3D printing. A configurator for generating production files from a parametric model could facilitate personalization, but a large number of model versions should be available to meet individual needs. Future research could explore clinical evaluations and guide the development of efficient and effective frameworks for digital fabrication in terms of clinically feasible AD model sourcing.

Background: Subjects with Charcot-Marie-Tooth (CMT) disease show hands impairment which is a relevant problem affecting the quality of life. This symptom is related to muscle weakness and reduced motor coordination of the upper limb. However, most studies focus on lower limb impairment, therefore the investigation of upper limb disability is necessary to identify biomarkers able to monitor disease-specific features and to tailor rehabilitation., Objective: This study aimed at characterizing upper limb muscle co-contraction using the co-contraction index (CCI) in CMT population., Methods: Upper limb kinematic and electromyography (EMG) data were collected from fourteen CMT subjects (6-CMT1A and 8-CMT1X) during motor tasks typical of daily living activities. Rudolph's CCI was used to quantify muscle co-contraction of four muscle pairs acting on shoulder, elbow and wrist. All CMT subjects underwent clinical examination. Thirteen healthy subjects served as the normative reference (HC)., Results: CMT1X and CMT1A showed a significant reduction in CCI for distal and proximal muscle pairs compared to HC. Furthermore, CMT1A showed greater values of CCI compared to CMT1X mainly for the axial and axial-to-proximal muscle pairs. Movement speed and smoothness were not altered compared to HC. In addition, EMG metrics showed moderate-to-strong significant correlations with clinical outcomes., Conclusions: CCI was able to quantify disease-specific deficits with respect to the normative reference, highlighting motor control alterations even before motor output impairment. CCI was also sensitive in detecting CMT subtypes-based differences and adopted compensatory strategies. Our findings suggest that CCI can be an outcome measure for CMT disease monitoring and interventional studies.

Background: Telerehabilitation has gained significance as a tool to deliver and supervise therapy and training as effective as traditional rehabilitation methods yet more accessible and affordable. An exergame-based telerehabilitation system has recently been developed within the scope of the international Continuum-of-Care (COCARE) project. The system comprises training devices for use in clinics (Dividat Senso) and at home (Dividat Senso Flex), an assessment system, and a rehabilitation cockpit, and its focus lies on home-based motor-cognitive training, which is remotely managed by health care professionals (HPs)., Objective: This study aims to analyze the usability, acceptance, and enjoyment of the COCARE system from the perspective of primary (older adults [OAs]) and secondary (HPs) end users., Methods: At 3 trial sites (located in Switzerland, Italy, and Cyprus), participants engaged in a single-session trial of the COCARE system, including testing of exergames and assessments. Mixed methods encompassing qualitative approaches (eg, think aloud) and quantitative measures (eg, Exergame Enjoyment Questionnaire [EEQ], System Usability Scale [SUS], and Unified Theory of Acceptance and Use of Technology [UTAUT] questionnaire) were used to analyze participants' perceptions of the system and identify potential barriers to its implementation in a home setting. In addition, the associations of performance during gameplay and assessments, demographics, and training motivation (Behavioral Regulation in Exercise Questionnaire-3 [BREQ-3]) with usability, acceptance, and enjoyment were explored., Results: A total of 45 OAs and 15 HPs participated in this study. The COCARE system achieved good acceptance ratings (OAs: 83%, range 36%-100% and HPs: 81%, range 63.8%-93.3% of the maximum score), and OAs indicated high enjoyment (mean 73.3, SD 12.7 out of 100 points in the EEQ) during the exergame session. The system's usability, assessed with the SUS, received scores of 68.1 (SD 18.8; OAs) and 70.7 (SD 12.3; HPs) out of 100 points, with substantial differences observed between the trial sites. Several requirements for improvement were identified. Commonly mentioned barriers to adoption included the movement-recognition sensitivity of the Senso Flex, its limited markings, and difficulties in understanding certain instructions for assessments and games. Performance in games and assessments showed the highest significant correlations with the SUS (Spearman ρ=0.35, P=.02 to ρ=0.52, P<.001). The BREQ-3 had significant correlations with all usability measures, thereby even large significant correlations with enjoyment (Spearman ρ=0.58; P<.001). Age had moderately significant correlations with the SUS (Spearman ρ=-0.35; P=.02) and the UTAUT total score (ρ=-0.35; P=.02) but no significant correlation with the EEQ. Concerning sex and years of education, no significant correlations were found., Conclusions: The study's findings will inform the further development of the COCARE system toward a user-friendly and widely accepted version, enhancing cognitive and physical functions in OAs. Future randomized controlled trials should evaluate the system's feasibility and effectiveness., (©Julia Seinsche, Eling D de Bruin, Enrico Saibene, Francesco Rizzo, Ilaria Carpinella, Maurizio Ferrarin, Sotiria Moza, Tanja Ritter, Eleftheria Giannouli. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 07.12.2023.)

Background: Exergame-based motor-cognitive training in older adults has been associated with improvements in physical, cognitive, and psychological functioning. The novel Cocare system (Dividat GmbH), developed through a user-centered design process, allows motor-cognitive training in a telerehabilitation setting. It includes (1) a stationary stepping platform for supervised exergame training (Dividat Senso; Dividat GmbH), (2) a home-based version (Dividat Senso Flex, which is a rollable pressure-sensitive mat; Dividat GmbH), (3) an assessment system (including motor-cognitive tests), and (4) a rehabilitation cockpit for remote training supervision and management., Objective: The aim of this study is to test the feasibility and effectiveness of this novel training system., Methods: A total of 180 older adults from Switzerland, Italy, and Cyprus aged ≥60 years with a prescription for rehabilitation are randomly allocated to an intervention group or a control group. Both groups continue with their usual care, whereas participants in the intervention group additionally perform a 2-week supervised exergame training program at rehabilitation centers, followed by a 10-week home training program under remote supervision. The assessment system is used to indicate the start level of each participant, and, in both intervention periods, standardized progression rules are applied. The measures of feasibility include adherence, attrition, exergame enjoyment, willingness to perform such a training program, and the number and types of help requests. Effectiveness is assessed in terms of cognitive and physical functioning, balance confidence, and quality of life., Results: Data collection started in February 2023 and is ongoing. Final measurements are expected to be performed in January 2024., Conclusions: Owing to the user-centered design approach, the Cocare system is expected to be user-friendly and offers several novel features to cover the whole continuum of care. This pragmatic trial will provide valuable information regarding final necessary adaptations and subsequent implementation efforts., Trial Registration: ClinicalTrials.gov NCT05751551; https://www.clinicaltrials.gov/study/NCT05751551., International Registered Report Identifier (irrid): DERR1-10.2196/49377., (©Julia Seinsche, Eling D de Bruin, Enrico Saibene, Francesco Rizzo, Ilaria Carpinella, Maurizio Ferrarin, Sarina Ifanger, Sotiria Moza, Eleftheria Giannouli. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 09.11.2023.)

Persons post-stroke experience excessive muscle co-contraction, and consequently the arm functions are compromised during the activities of daily living. Therefore, identifying instrumental outcome measures able to detect the motor strategy adopted after a stroke is a primary clinical goal. Accordingly, this study aims at verifying whether the surface electromyography (sEMG)-based co-contraction index ( CCI ) could be a new clinically feasible approach for assessing and monitoring patients' motor performance. Thirty-four persons post-stroke underwent clinical assessment and upper extremity kinematic analysis, including sEMG recordings. The participants were randomized into two treatment groups (robot and usual care groups). Ten healthy subjects provided a normative reference (NR). Frost's CCI was used to quantify the muscle co-contraction of three different agonist/antagonist muscle pairs during an object-placing task. Persons post-stroke showed excessive muscle co-contraction (mean (95% CI): anterior/posterior deltoid CCI : 0.38 (0.34-0.41) p = 0.03; triceps/biceps CCI : 0.46 (0.41-0.50) p = 0.01) compared to NR (anterior/posterior deltoid CCI : 0.29 (0.21-0.36); triceps/biceps CCI : 0.34 (0.30-0.39)). After robot therapy, persons post-stroke exhibited a greater improvement (i.e., reduced CCI ) in proximal motor control (anterior/posterior deltoid change score of CCI : -0.02 (-0.07-0.02) p = 0.05) compared to usual care therapy (0.04 (0.00-0.09)). Finally, the findings of the present study indicate that the sEMG-based CCI could be a valuable tool in clinical practice.

Poor dynamic balance and impaired gait adaptation to different contexts are hallmarks of people with neurological disorders (PwND), leading to difficulties in daily life and increased fall risk. Frequent assessment of dynamic balance and gait adaptability is therefore essential for monitoring the evolution of these impairments and/or the long-term effects of rehabilitation. The modified dynamic gait index (mDGI) is a validated clinical test specifically devoted to evaluating gait facets in clinical settings under a physiotherapist's supervision. The need of a clinical environment, consequently, limits the number of assessments. Wearable sensors are increasingly used to measure balance and locomotion in real-world contexts and may permit an increase in monitoring frequency. This study aims to provide a preliminary test of this opportunity by using nested cross-validated machine learning regressors to predict the mDGI scores of 95 PwND via inertial signals collected from short steady-state walking bouts derived from the 6-minute walk test. Four different models were compared, one for each pathology (multiple sclerosis, Parkinson's disease, and stroke) and one for the pooled multipathological cohort. Model explanations were computed on the best-performing solution; the model trained on the multipathological cohort yielded a median (interquartile range) absolute test error of 3.58 (5.38) points. In total, 76% of the predictions were within the mDGI's minimal detectable change of 5 points. These results confirm that steady-state walking measurements provide information about dynamic balance and gait adaptability and can help clinicians identify important features to improve upon during rehabilitation. Future developments will include training of the method using short steady-state walking bouts in real-world settings, analysing the feasibility of this solution to intensify performance monitoring, providing prompt detection of worsening/improvements, and complementing clinical assessments., (© 2023. The Author(s).)

Background: Cognitive-motor dual-task (CMDT) is defined as the parallel processing of motor (eg, gait) and cognitive (eg, executive functions) activities and is an essential ability in daily life. Older adults living with frailty, chronic conditions (eg, neurodegenerative diseases), or multimorbidity pay high costs during CMDT. This can have serious consequences on the health and safety of older adults with chronic age-related conditions. However, CMDT rehabilitation can provide useful and effective therapies for these patients, particularly if delivered through technological devices., Objective: This review aims to describe the current technological applications, CMDT rehabilitative procedures, target populations, condition assessment, and efficacy and effectiveness of technology-assisted CMDT rehabilitation in chronic age-related conditions., Methods: We performed this systematic review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, on 3 databases (Web of Science, Embase, and PubMed). Original articles that were published in English; involved older adults (>65 years) with ≥1 chronic condition and/or frailty; and tested, with a clinical trial, a technology-assisted CMDT rehabilitation against a control condition were included. Risk of bias (Cochrane tool) and the RITES (Rating of Included Trials on the Efficacy-Effectiveness Spectrum) tool were used to evaluate the included studies., Results: A total of 1097 papers were screened, and 8 (0.73%) studies met the predefined inclusion criteria for this review. The target conditions for technology-assisted CMDT rehabilitation included Parkinson disease and dementia. However, little information regarding multimorbidity, chronicity, or frailty status is available. The primary outcomes included falls, balance, gait parameters, dual-task performance, and executive functions and attention. CMDT technology mainly consists of a motion-tracking system combined with virtual reality. CMDT rehabilitation involves different types of tasks (eg, obstacle negotiation and CMDT exercises). Compared with control conditions, CMDT training was found to be pleasant, safe, and effective particularly for dual-task performances, falls, gait, and cognition, and the effects were maintained at midterm follow-up., Conclusions: Despite further research being mandatory, technology-assisted CMDT rehabilitation is a promising method to enhance motor-cognitive functions in older adults with chronic conditions., (©Cosimo Tuena, Francesca Borghesi, Francesca Bruni, Silvia Cavedoni, Sara Maestri, Giuseppe Riva, Mauro Tettamanti, Rosa Liperoti, Lorena Rossi, Maurizio Ferrarin, Marco Stramba-Badiale. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.05.2023.)

Actigraphy is a tool used to describe limb motor activity. Some actigraphic parameters, namely Motor Activity (MA) and Asymmetry Index (AR), correlate with stroke severity. However, a long-lasting actigraphic monitoring was never performed previously. We hypothesized that MA and AR can describe different clinical conditions during the evolution of the acute phase of stroke. We conducted a multicenter study and enrolled 69 stroke patients. NIHSS was assessed every hour and upper limbs' motor activity was continuously recorded. We calculated MA and AR in the first hour after admission, after a significant clinical change (NIHSS ± 4) or at discharge. In a control group of 17 subjects, we calculated MA and AR normative values. We defined the best model to predict clinical status with multiple linear regression and identified actigraphic cut-off values to discriminate minor from major stroke (NIHSS ≥ 5) and NIHSS 5-9 from NIHSS ≥ 10. The AR cut-off value to discriminate between minor and major stroke (namely NIHSS ≥ 5) is 27% (sensitivity = 83%, specificity = 76% (AUC 0.86 p < 0.001), PPV = 89%, NPV = 42%). However, the combination of AR and MA of the non-paretic arm is the best model to predict NIHSS score (R 2 : 0.482, F: 54.13), discriminating minor from major stroke (sensitivity = 89%, specificity = 82%, PPV = 92%, NPV = 75%). The AR cut-off value of 53% identifies very severe stroke patients (NIHSS ≥ 10) (sensitivity = 82%, specificity = 74% (AUC 0.86 p < 0.001), PPV = 73%, NPV = 82%). Actigraphic parameters can reliably describe the overall severity of stroke patients with motor symptoms, supporting the addition of a wearable actigraphic system to the multi-parametric monitoring in stroke units.

Dynamic balance disorders are common impairments in People with Multiple Sclerosis (PwMS) leading to gait disorders and a higher risk of falling. However, the assessment of dynamic balance is still challenging and instrumented indexes provide objective and quantitative data of CoM movement and Base of Support, which are considered that are two key factors describing dynamic balance. This study aims at validating recent instrumented indexes based on the inverted pendulum model and characterizing dynamic balance disorders in PwMS. We clinically assessed 20 PwMS and we collected instrumented gait data through an optoelectronic system. Data from 20 Healthy Subjects (HS) were also considered as normative reference. Margin of Stability by HoF (MoS&#95;Hof) and by Terry (MoS&#95;Terry) at midstance, and Foot Placement Estimator (D FPE ) at heel strike were calculated in mediolateral (ML) and anteroposterior (AP) directions, for both less affected and most affected sides for PwMS and for dominant and non-dominant side for HS. MoS&#95;HOF well discriminated between PwMS and HS, followed by MoS&#95;TERRY in ML direction (Mos&#95;HOF: PwMS = 130.0 ± 27.2 mm, HS = 106.5 ± 18.6 mm, p  < 0.001, MoS&#95;TERRY: PwMS = 75.1 ± 24.3 mm, HS = 56.5 ± 23.4 mm, p  < 0.02). MoS&#95;HOF and MoS&#95;TERRY discriminated between sides in both directions in PwMS. D FPE did not discriminate between groups and sides. Moderate correlations were found between all three indexes and clinical balance scales (from r  = 0.02 to r  = 0.66), energy recovery (from r  = -0.77 to r  = -0.11), single stance time (from r  = -0.11 to r  = 0.80) and step length (from r  = -0.83 to r  = -0.20). MoS&#95;HOF resulted in the best index to describe dynamic balance disorders in PwMS: they keep CoM position far from the lateral and as close as possible to the anterior boundary of the Base of Support as preventive strategies to control balance perturbations. Furthermore, PwMS seem to use different preventive strategies in accordance with the specific lower limb impairments. This alters the physiological gait mechanisms increasing the energy expenditure and decreasing gait quality and dynamic balance.

(1) Background: A noticeable association between the motor activity (MA) profiles of persons living together has been found in previous studies. Social actigraphy methods have shown that this association, in marital dyads composed of healthy individuals, is greater than that of a single person compared to itself. This study aims at verifying the association of MA profiles in dyads where one component is affected by Parkinson's disease (PD). (2) Methods: Using a wearable sensor-based social actigraphy approach, we continuously monitored, for 7 days, the activities of 27 marital dyads including one component with PD. (3) Results: The association of motor activity profiles within a marital dyad (cross-correlation coefficient 0.344) is comparable to the association of any participant with themselves (0.325). However, when considering the disease severity quantified by the UPDRS III score, it turns out that the less severe the symptoms, the more associated are the MA profiles. (4) Conclusions: Our findings suggest that PD treatment could be improved by leveraging the MA of the healthy spouse, thus promoting lifestyles also beneficial for the component affected by PD. The actigraphy approach provided valuable information on habitual functions and motor fluctuations, and could be useful in investigating the response to treatment., Competing Interests: The authors declare no conflict of interest.

Introduction: Telerehabilitation in older adults using information and communication technologies (ICTs) provides therapy, which is potentially equally effective as traditional rehabilitation, yet more accessible. This study aimed to analyze the needs and requirements of older adults (OA) and healthcare-professionals (HP) toward ICTs and telerehabilitation in general as well as toward a specific novel exergame-based telerehabilitation system (COCARE system, Dividat)., Materials and Methods: The COCARE telerehabilitation system enables individual training based on exergames, as well as an assessment system and a digital centralized case management. Six focus groups with in total 34 participants were conducted. A mixed-methods approach was used comprising questionnaires and semi-structured interviews., Results: Both OA and HP would engage to an exergame-based telerehabilitation program. Major motivating factors are the relevance of such a training for health and the entertainment component of exergames. Main requirements are simplification of the system, variety, a personalized training, a constantly available contact person, and comprehensive instructions for use. Besides, HP praised the system's motivational effect, but remained concerned about risk of falls and social isolation., Conclusion: ICTs for telerehabilitation are accepted by OA and HP but should be adapted hardware- and software-wise to address OA' age-stemming vulnerabilities (e.g., risk of falls) and low ICT literacy., Competing Interests: EB was a co-founder of Dividat, the spin-off company that created and developed the COCARE-system used in this study. However, no revenue was paid (or promised to be paid) directly to EB or his institution. SM was employed by company Materia Group. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Seinsche, de Bruin, Carpinella, Ferrarin, Moza, Rizzo, Salatino and Giannouli.)

The balance of people with multiple sclerosis (PwMS) is commonly assessed during neurological examinations through clinical Romberg and tandem gait tests that are often not sensitive enough to unravel subtle deficits in early-stage PwMS. Inertial sensors (IMUs) could overcome this drawback. Nevertheless, IMUs are not yet fully integrated into clinical practice due to issues including the difficulty to understand/interpret the big number of parameters provided and the lack of cut-off values to identify possible abnormalities. In an attempt to overcome these limitations, an instrumented modified Romberg test (ImRomberg: standing on foam with eyes closed while wearing an IMU on the trunk) was administered to 81 early-stage PwMS and 38 healthy subjects (HS). To facilitate clinical interpretation, 21 IMU-based parameters were computed and reduced through principal component analysis into two components, sway complexity and sway intensity, descriptive of independent aspects of balance, presenting a clear clinical meaning and significant correlations with at least one clinical scale. Compared to HS, early-stage PwMS showed a 228% reduction in sway complexity and a 63% increase in sway intensity, indicating, respectively, a less automatic (more conscious) balance control and larger and faster trunk movements during upright posture. Cut-off values were derived to identify the presence of balance abnormalities and if these abnormalities are clinically meaningful. By applying these thresholds and integrating the ImRomberg test with the clinical tandem gait test, balance impairments were identified in 58% of PwMS versus the 17% detected by traditional Romberg and tandem gait tests. The higher sensitivity of the proposed approach would allow for the direct identification of early-stage PwMS who could benefit from preventive rehabilitation interventions aimed at slowing MS-related functional decline during neurological examinations and with minimal modifications to the tests commonly performed.

Introduction: Difficulties faced while walking are common symptoms after stroke, significantly reducing the quality of life. Walking recovery is therefore one of the main priorities of rehabilitation. Wearable powered exoskeletons have been developed to provide lower limb assistance and enable training for persons with gait impairments by using typical physiological movement patterns. Exoskeletons were originally designed for individuals without any walking capacities, such as subjects with complete spinal cord injuries. Recent systematic reviews suggested that lower limb exoskeletons could be valid tools to restore independent walking in subjects with residual motor function, such as persons post-stroke. To ensure that devices meet end-user needs, it is important to understand and incorporate their perspectives. However, only a limited number of studies have followed such an approach in the post-stroke population., Methods: The aim of the study was to identify the end-users needs and to develop a user-centered-based control system for the TWIN lower limb exoskeleton to provide post-stroke rehabilitation. We thus describe the development and validation, by clinical experts, of TWIN-Acta: a novel control suite for TWIN, specifically designed for persons post-stroke. We detailed the conceived control strategy and developmental phases, and reported evaluation sessions performed on healthy clinical experts and people post-stroke to evaluate TWIN-Acta usability, acceptability, and barriers to usage. At each developmental stage, the clinical experts received a one-day training on the TWIN exoskeleton equipped with the TWIN-Acta control suite. Data on usability, acceptability, and limitations to system usage were collected through questionnaires and semi-structured interviews., Results: The system received overall good usability and acceptability ratings and resulted in a well-conceived and safe approach. All experts gave excellent ratings regarding the possibility of modulating the assistance provided by the exoskeleton during the movement execution and concluded that the TWIN-Acta would be useful in gait rehabilitation for persons post-stroke. The main limit was the low level of system learnability, attributable to the short-time of usage. This issue can be minimized with prolonged training and must be taken into consideration when planning rehabilitation., Discussion: This study showed the potential of the novel control suite TWIN-Acta for gait rehabilitation and efficacy studies are the next step in its evaluation process., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Semprini, Lencioni, Hinterlang, Vassallo, Scarpetta, Maludrottu, Iandolo, Carè, Laffranchi, Chiappalone, Ferrarin, De Michieli and Jonsdottir.)

(1) Background: Actigraphic methods allow prolonged monitoring of human physical activity (PA) by wearable sensors in a real-life unsupervised context. They generally do not characterize the social context, and nearby persons can have a modulating effect on the performed PA. The present study aims to apply an existing method for bimanual actigraphy to both components of a marital dyad to verify the level of association between the two PA profiles. Other dyad comparisons complete the overall figure. (2) Methods: Seven-day actigraphic recordings collected from both components of 20 married couples of retired, cohabiting, healthy subjects (age ranging from 58 to 87 years) were considered. (3) Results: PA profiles of a marital dyad are significantly more correlated (coefficient: 0.444) than unrelated couples (0.278). Interestingly, participants' profiles compared with their own recording shifted by 24 h, evidencing an intermediate level of association (0.335). Data from the literature, the high association (0.875) of individual right and left wrist profiles, enforce the analysis. (4) Conclusions: The proposed method, called "social actigraphy", confirmed that the partner has a relevant effect on one's PA profile, thus suggesting involving the partner in programs concerning lifestyle changes and patient rehabilitation.

The continuous monitoring of an individual's breathing can be an instrument for the assessment and enhancement of human wellness. Specific respiratory features are unique markers of the deterioration of a health condition, the onset of a disease, fatigue and stressful circumstances. The early and reliable prediction of high-risk situations can result in the implementation of appropriate intervention strategies that might be lifesaving. Hence, smart wearables for the monitoring of continuous breathing have recently been attracting the interest of many researchers and companies. However, most of the existing approaches do not provide comprehensive respiratory information. For this reason, a meta-learning algorithm based on LSTM neural networks for inferring the respiratory flow from a wearable system embedding FBG sensors and inertial units is herein proposed. Different conventional machine learning approaches were implemented as well to ultimately compare the results. The meta-learning algorithm turned out to be the most accurate in predicting respiratory flow when new subjects are considered. Furthermore, the LSTM model memory capability has been proven to be advantageous for capturing relevant aspects of the breathing pattern. The algorithms were tested under different conditions, both static and dynamic, and with more unobtrusive device configurations. The meta-learning results demonstrated that a short one-time calibration may provide subject-specific models which predict the respiratory flow with high accuracy, even when the number of sensors is reduced. Flow RMS errors on the test set ranged from 22.03 L/min, when the minimum number of sensors was considered, to 9.97 L/min for the complete setting (target flow range: 69.231 ± 21.477 L/min). The correlation coefficient r between the target and the predicted flow changed accordingly, being higher (r = 0.9) for the most comprehensive and heterogeneous wearable device configuration. Similar results were achieved even with simpler settings which included the thoracic sensors (r ranging from 0.84 to 0.88; test flow RMSE = 10.99 L/min, when exclusively using the thoracic FBGs). The further estimation of respiratory parameters, i.e., rate and volume, with low errors across different breathing behaviors and postures proved the potential of such approach. These findings lay the foundation for the implementation of reliable custom solutions and more sophisticated artificial intelligence-based algorithms for daily life health-related applications., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Out-of-the-lab instrumented gait testing focuses on steady-state gait and usually does not include gait initiation (GI) measures. GI involves Anticipatory Postural Adjustments (APAs), which propel the center of mass (COM) forward and laterally before the first step. These movements are impaired in persons with Parkinson’s disease (PD), contributing to their pathological gait. The use of a simple GI testing system, outside the lab, would allow improving gait rehabilitation of PD patients. Here, we evaluated the metrological quality of using a single inertial measurement unit for APA detection as compared with the use of a gold-standard system, i.e., the force platforms. Twenty-five PD and eight elderly subjects (ELD) were asked to initiate gait in response to auditory stimuli while wearing an IMU on the trunk. Temporal parameters (APA-Onset, Time-to-Toe-Off, Time-to-Heel-Strike, APA-Duration, Swing-Duration) extracted from the accelerometric data and force platforms were significantly correlated (mean(SD), r: 0.99(0.01), slope: 0.97(0.02)) showing a good level of agreement (LOA [s]: 0.04(0.01), CV [%]: 2.9(1.7)). PD showed longer APA-Duration compared to ELD ([s] 0.81(0.17) vs. 0.59(0.09) p < 0.01). APA parameters showed moderate correlation with the MDS-UPDRS Rigidity, Characterizing-FOG questionnaire and FAB-2 planning. The single IMU-based reconstruction algorithm was effective in measuring APAs timings in PD. The current work sets the stage for future developments of tele-rehabilitation and home-based exercises.

Smoothness (i.e. non-intermittency) of movement is a clinically important property of the voluntary movement with accuracy and proper speed. Resting head position and head voluntary movements are impaired in cervical dystonia. The current work aims to evaluate if the smoothness of voluntary head rotations is reduced in this disease. Twenty-six cervical dystonia patients and 26 controls completed rightward and leftward head rotations. Patients' movements were differentiated into "towards-dystonia" (rotation accentuated the torticollis) and "away-dystonia". Smoothness was quantified by the angular jerk and arc length of the spectrum of angular speed (i.e. SPARC, arbitrary units). Movement amplitude (mean, 95% CI) on the horizontal plane was larger in controls (63.8°, 58.3°-69.2°) than patients when moving towards-dystonia (52.8°, 46.3°-59.4°; P = 0.006). Controls' movements (49.4°/s, 41.9-56.9°/s) were faster than movements towards-dystonia (31.6°/s, 25.2-37.9°/s; P < 0.001) and away-dystonia (29.2°/s, 22.9-35.5°/s; P < 0.001). After taking into account the different amplitude and speed, SPARC-derived (but not jerk-derived) indices showed reduced smoothness in patients rotating away-dystonia (1.48, 1.35-1.61) compared to controls (1.88, 1.72-2.03; P < 0.001). Poor smoothness is a motor disturbance independent of movement amplitude and speed in cervical dystonia. Therefore, it should be assessed when evaluating this disease, its progression, and treatments., (© 2022. The Author(s).)

Background: Turning the head while walking (an action often required during daily living) is particularly challenging to maintain balance. It can therefore potentially reveal subtle impairments in early-stage people with multiple sclerosis who still show normal locomotion (NW-PwMS). This would help in identifying those subjects who can benefit from early preventive exercise aimed at slowing the MS-related functional decline., Objectives: To analyze if the assessment of walking with horizontal head turns (WHHT) through inertial sensors can discriminate between healthy subjects (HS) and NW-PwMS and between NW-PwMS subgroups. To assess if the discriminant ability of the instrumented WHHT is higher compared to clinical scores. To assess the concurrent validity of the sensor-based metrics., Methods: In this multicenter study, 40 HS and 59 NW-PwMS [Expanded Disability Status Scale (EDSS) ≤ 2.5, disease duration ≤ 5 years] were tested. Participants executed Item-6 of the Fullerton Advanced Balance scale-short (FAB-s) wearing three inertial sensors on the trunk and ankles. The item required to horizontally turn the head at a beat of the metronome (100 bpm) while walking. Signals of the sensors were processed to compute spatiotemporal, regularity, symmetry, dynamic stability, and trunk sway metrics descriptive of WHHT., Results: Mediolateral regularity, anteroposterior symmetry, and mediolateral stability were reduced in NW-PwMS vs. HS ( p ≤ 0.001), and showed moderate discriminant ability (area under the receiver operator characteristic curve [AUC]: 0.71-0.73). AP symmetry and ML stability were reduced ( p ≤ 0.026) in EDSS: 2-2.5 vs. EDSS: 0-1.5 subgroup (AUC: 0.69-0.70). The number of NW-PwMS showing at least one abnormal instrumented metric (68%) was larger ( p ≤ 0.002) than the number of participants showing abnormal FAB-s-Item6 (32%) and FAB-s clinical scores (39%). EDSS: 2-2.5 subgroup included more individuals showing abnormal instrumented metrics (86%) compared to EDSS: 0-1.5 subgroup (57%). The instrumented metrics significantly correlated with FAB-s-Item6 and FAB-s scores (|Spearman's r s | ≥ 0.37, p < 0.001), thus demonstrating their concurrent validity., Conclusion: The instrumented assessment of WHHT provided valid objective metrics that discriminated, with higher sensitivity than clinical scores, between HS and NW-PwMS and between EDSS subgroups. The method is a promising tool to complement clinical evaluation, and reveal subclinical impairments in persons who can benefit from early preventive rehabilitative interventions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Carpinella, Gervasoni, Anastasi, Di Giovanni, Tacchino, Brichetto, Confalonieri, Solaro, Rovaris, Ferrarin and Cattaneo.)

Background: Postural transitions have been identified as presenting challenging situations for the elderly., Research Question: This study hypothesizes a relationship between age-related factors and postural stabilization performance after a transition movement. In particular, the controlled factors in the experiment are: 1) assistance in living (independent living for community-dwelling subjects vs. assisted living for institutionalized subjects in nursing homes); 2) age of institutionalized individuals, by comparing groups with different age ranges., Methods: Sixty-three institutionalized individuals in nursing homes were recruited (17 in the age range 64-79; 46, including 6 drop-outs, in the age range 80-95). Moreover, seventeen (one drop out) community dwelling subjects (64-79 years) were enlisted. The study focuses on the postural stabilization phase after a "step forward" task., Results: When comparing age-matched subjects from the two groups, the residents in nursing homes were characterised by a worse stabilization performance: the stabilization time more than doubled, Instability increased by 39 %, and Promptness decreased by 77 %, although there was no significant difference in the quiet erect posture between the groups. No difference was observed when comparing the two age groups of residents in the nursing homes, however a potential confounding effect has been identified in the unequal mortality rates between the two groups., Significance: It is hypothesized that an individual identification of abnormal values of Instability and/or Promptness may inform different rehabilitation approaches., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: Emotional states have been shown to influence cognitive processes including visual-spatial learning. Parkinson's Disease (PD), besides manifesting with the cardinal motor symptoms, presents cognitive and affective disturbances. Here we aimed at investigating whether manipulation of the emotional state by means of music was able to influence the performance of a visual-spatial learning task in a group of PD participants., Methods: Ten PD patients and 11 healthy elderly (ELD) were asked to perform a visual-spatial learning task while listening two musical pieces evoking a neutral emotion or fear. Targets were presented on a screen in a preset order over four blocks and subjects were asked to learn the sequence order by attending to the display. At the end of each block, participants were asked to verbally recall the sequence and a score was assigned (Verbal Score, VS)., Results: Analysis of variance-type statistic test on the VS disclosed a significant effect of Music and sequence Blocks (p = 0.01 and p < 0.001, respectively) and a significant interaction between Group and sequence Blocks. Sequence learning occurred across the training period in both groups, but PD patients were slower than ELD and at the end of the training period learning performance was worse in PD with respect to ELD. In PD patients, like in ELD, fear-inducing music has a detrimental effect on visual-spatial learning performances, which are slower and decreased., Conclusion: These findings confirm an impairment in visual-spatial learning in PD and indicates that the emotional state influences this learning ability similarly to healthy controls., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Soft tissue artefacts (STAs) undermine the validity of skin-mounted approaches to measure skeletal kinematics. Magneto-inertial measurement units (MIMU) gained popularity due to their low cost and ease of use. Although the reliability of different protocols for marker-based joint kinematics estimation has been widely reported, there are still no indications on where to place MIMU to minimize STA. This study aims to find the most stable positions for MIMU placement, among four positions on the thigh, four on the shank, and three on the foot. Stability was investigated by measuring MIMU movements against an anatomical reference frame, defined according to a standard marker-based approach. To this aim, markers were attached both on the case of each MIMU (technical frame) and on bony landmarks (anatomical frame). For each MIMU, the nine angles between each versor of the technical frame with each versor of the corresponding anatomical frame were computed. The maximum standard deviation of these angles was assumed as the instability index of MIMU-body coupling. Six healthy subjects were asked to perform barefoot gait, step negotiation, and sit-to-stand. Results showed that (1) in the thigh, the frontal position was the most stable in all tasks, especially in gait; (2) in the shank, the proximal position is the least stable, (3) lateral or medial calcaneus and foot dorsum positions showed equivalent stability performances. Further studies should be done before generalizing these conclusions to different motor tasks and MIMU-body fixation methods. The above results are of interest for both MIMU-based gait analysis and rehabilitation approaches using wearable sensors-based biofeedback., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Scalera, Ferrarin, Marzegan and Rabuffetti.)

Maintaining a stable gait requires a dynamic balance control, that can be altered in persons with Multiple Sclerosis (MS), Stroke (ST), and Parkinson's disease (PD). The understanding of the strategy for Center of Mass (CoM) positioning adopted by patients during walking is important to be able to program treatments aimed at improving gait control and preventing falls. Forty-four persons with a mild-to-moderate neurological disorder (20 with MS, 14 with ST, 10 with PD) underwent clinical examination and gait analysis. Ten Healthy Subjects (HS) walking at matched speed provided the normative data. Dynamic balance was assessed using the margin of stability (MoS). It was calculated as the distance between the extrapolated Center of Pressure and the extrapolated CoM at mid-stance. The MoS values for lower limbs were calculated in patients and compared with speed-matched values of HS. Persons with neurological disorder showed increased MoS in the medio-lateral direction with respect to HS. Within-group comparison analysis showed a symmetry between lower limbs in HS (Mean (95%CI) [mm], dominant vs non-dominant limb, 43.3 (31.9-54.6) vs 42.9 (28.8-56.9)) and PD (less affected vs more affected limb, 71.1 (59.8-82.5) vs 72.5 (58.5-86.6)), while a significant asymmetry was found in MS (54.4 (46.4-62.4) vs 81.1 (71.2-91.1)) and ST (52.1 (42.6-61.7) vs 74.7 (62.8-86.6)) participants. The history of falls was comparable among PD, MS, and ST groups, and the MoS in the frontal plane showed a strong correlation with these records. Objective assessment of MoS revealed pathology-specific strategies showing different impacts in MS, ST, and PD on the ability to control CoM information to manage the balance between limbs during gait. MoS evaluation will provide useful information to address a tailored rehabilitation program and to monitor disease progression.

Background and Purpose: People with multiple sclerosis (PwMS) often report walking limitations even when the gold standard Expanded Disability Status Scale (EDSS) indicates normal walking endurance/autonomy. The present multicenter study on early-stage PwMS aims at analyzing which aspects are associated with patient-reported walking limitations measured with the 12-item Multiple Sclerosis Walking Scale (MSWS-12)., Methods: Eighty-two PwMS (EDSS ≤ 2.5) were assessed using the Fullerton Advanced Balance Scale-short (FAB-s), the Fatigue Severity Scale (FSS) and the 6-min Walk Test (6MWT), the latter administered also to 21 healthy subjects. Participants performed the 6MWT wearing three inertial sensors on ankles and trunk. Instrumented metrics describing gait velocity (stride length and frequency) and quality (regularity, symmetry, instability) were computed from sensor data. Fatigue (FSS), balance (FAB-s), walking endurance (6MWT) and instrumented metrics were entered in a multiple regression model with MSWS-12 as dependent variable., Results: Gait symmetry, gait instability, fatigue and balance were significantly associated with self-rated walking ability, whilst walking endurance and velocity were not. Fatigue, balance, gait symmetry and instability were more impaired in participants reporting mild-to-moderate (MS MM-PWL , 25 ≤ MSWS-12 < 75) compared to those reporting none-to-minimal (MS nm-PWL , 0 ≤ MSWS-12 ≤ 25) perceived walking limitations. Compared to healthy subjects, gait symmetry and stability were reduced in MS nm-PWL and MS MM-PWL , even in those participants with EDSS ≤ 1.5., Conclusion: Instrumentally assessed gait quality aspects (symmetry and instability) are associated with patient-reported walking ability in early-stage PwMS and seem sensitive biomarkers to detect subtle impairments even in the earliest stages of the disease (EDSS ≤ 1.5). Future studies should assess their ability to follow walking change due to MS progression or pharmacological/rehabilitation interventions., (© 2021 European Academy of Neurology.)

Background: It is often challenging to formulate a reliable prognosis for patients with acute ischemic stroke. The most accepted prognostic factors may not be sufficient to predict the recovery process. In this view, describing the evolution of motor deficits over time via sensors might be useful for strengthening the prognostic model. Our aim was to assess whether an actigraphic-based parameter (Asymmetry Rate Index for the 24 h period (AR2&#95;24 h)) obtained in the acute stroke phase could be a predictor of a 90 d prognosis., Methods: In this observational study, we recorded and analyzed the 24 h upper limb movement asymmetry of 20 consecutive patients with acute ischemic stroke during their stay in a stroke unit. We recorded the motor activity of both arms using two programmable actigraphic systems positioned on patients' wrists. We clinically evaluated the stroke patients by NIHSS in the acute phase and then assessed them across 90 days using the modified Rankin Scale (mRS)., Results: We found that the AR2&#95;24 h parameter positively correlates with the 90 d mRS (r = 0.69, p < 0.001). Moreover, we found that an AR2&#95;24 h > 32% predicts a poorer outcome (90 d mRS > 2), with sensitivity = 100% and specificity = 89%., Conclusions: Sensor-based parameters might provide useful information for predicting ischemic stroke prognosis in the acute phase.

Background: Functional recovery of the plegic upper limb in post-stroke patients may be enhanced by sequentially applying a myoelectrically controlled FES (MeCFES), which allows the patient to voluntarily control the muscle contraction during a functional movement, and robotic therapy which allows many repetitions of movements., Objective: Evaluate the efficacy of MeCFES followed by robotic therapy compared to standard care arm rehabilitation for post-stroke patients., Methods: Eighteen stroke subjects (onset ⩾ 3 months, age 60.1 ± 15.5) were recruited and randomized to receive an experimental combination of MeCFES during task-oriented reaching followed by robot therapy (MRG) or same intensity conventional rehabilitation care (CG) aimed at the recovery of the upper limb (20 sessions/45 minutes). Change was evaluated through Fugl-Meyer upper extremity (FMA-UE), Reaching Performance Scale and Box and Block Test., Results: The experimental treatment resulted in higher improvement on the FMA-UE compared with CG (P= 0.04), with a 10-point increase following intervention. Effect sizes were moderate in favor of the MRG group on FMA-UE, FMA-UE proximal and RPS (0.37-0.56)., Conclusions: Preliminary findings indicate that a combination of MeCFES and robotic treatment may be more effective than standard care for recovery of the plegic arm in persons > 3 months after stroke. The mix of motor learning techniques may be important for successful rehabilitation of arm function.

Myoelectrically Controlled Functional Electrical Stimulation (MeCFES) has proven to be a useful tool in the rehabilitation of the hemiplegic arm. This paper reports the steps involved in the development of a wearable MeCFES device (FITFES) through a user-centered design. We defined the minimal viable features and functionalities requirements for the device design from a questionnaire-based survey among physiotherapists with experience in functional electrical stimulation. The result was a necklace layout that poses minimal hindrance to task-oriented movement therapy, the context in which it is aimed to be used. FITFES is battery-powered and embeds a standard low power Bluetooth module, enabling wireless control by using PC/Mobile devices vendor specific built-in libraries. It is designed to deliver a biphasic, charge-balanced stimulation current pulses of up to 113 mA with a maximum differential voltage of 300 V. The power consumption for typical clinical usage is 320 mW at 20mA stimulation current and of less than [Formula: see text] in sleep mode, thus ensuring an estimated full day of FITFES therapy on a battery charge. We conclude that a multidisciplinary user-centered approach can be successfully applied to the design of a clinically and ergonomically viable prototype of a wearable myoelectrically controlled functional electrical stimulator to be used in rehabilitation.

Inertial measurement units (IMU), including accelerometers and gyroscopes, can support the assessment of gait regularity, relevant for an effective walking. Gait regularity is typically quantified by an autocorrelation analysis of trunk/pelvis accelerations. A methodological upgrade fosters a multi-sensor approach including upper and lower limbs. Very few studies dealt with gait regularity using gyroscope data and no comparison between the two inertial sensors has been published. Therefore, this study compares gait regularity assessment by autocorrelation analyses performed on accelerometer and gyroscope data simultaneously acquired. Twenty-five adult healthy subjects walked steady-state on treadmill at three speeds (3.6, 5.0, 6.4 km/h), with rest between. Four IMUs were firmly attached on the trunk, pelvis, wrist and ankle. The autocorrelation method was applied to time-windows of the signal vector magnitude and resulted, on average for each trial, in its regularity index (RI) and periodicity index (PI), i.e. the stride time. Results showed that both sensors identified the same PI (Spearman correlation coefficient = 0.999), and evidenced that, for matched sensor locations and gait speeds, the accelerometer-based RI was larger/equal to the gyroscope-based RI on 86.3% of all conditions (overall median of gyroscope-to-accelerometer RI ratio was 91.1%). The two sensors gave always statistically different RI, with the exception of the ankle at the lowest speed and wrist at higher speeds. Such results help remove potential confounders from analyses performed with different sensors and support the use of accelerometers for gait regularity assessment, not excluding that gyroscopes may be more suitable for other human movements., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Persons with MS (PwMS) have markedly reduced push-off and toe-clearance during gait compared to healthy subjects (HS). These deficits may result from alterations in neuromotor control at the ankle. To optimize rehabilitation interventions for PwMS, a crucial step is to evaluate if and how altered neuromotor control, as represented by muscle synergies, improves with rehabilitation. In this study we investigated changes in ankle motor control and associated biomechanical parameters during gait in PwMS, occurring with increase in speed after gait rehabilitation. Methods: 3D motion and EMG data were collected while 11 PwMS (age 50.3 + 11.1; EDSS 5.2 + 1.2) walked overground at self-selected speed before (T0) and after 20 sessions (T1) of intensive treadmill training. Muscle synergies were extracted using non-negative matrix factorization. Gait parameters were computed according to the LAMB protocol. Pearson's correlation coefficient was used to evaluate the similarity of motor modules between PwMS and HS. To assess differences in distal module activations representing neuromotor control at the ankle [Forward Propulsion (FPM) and Ground Clearance modules (GCM)], each module's activation timing was integrated over 100% of the gait cycle and the activation percentage index (API) was computed in six phases. Ten age matched HS provided two separate speed-matched normative datasets for T0 and T1. For speed independent comparison for the PwMs Z scores were calculated for all their gait variables. Results: In PwMS velocity increased significantly from T0 to T1 (0.74-0.90 m/s, p < 0.05). The activation profiles (API) of FPM and GCM of PwMS improved in pre-swing ( p < 0.05): FPM (Mean [95% CI] [%]: T0: 12.5 [5.7-19.3] vs. T1: 9.0 [2.7-15.3]); GCM (T0: 26.7 [18.2-35.3] vs. T1: 24.5 [18.2-30.7]). This was associated with an increase in toe clearance (80.3 to 103.6 mm, p < 0.05) and a higher ankle power peak in pre-swing (1.53-1.93 W/kg, p < 0.05). Conclusion: Increased gait speed of PwMS after intensive gait training was consistent with improvements in spatio-temporal gait parameters. The most important finding of this study was the re-organization of distal leg modules related to neurophysiological changes induced by rehabilitation. This was associated with an improved ankle performance., (Copyright © 2020 Jonsdottir, Lencioni, Gervasoni, Crippa, Anastasi, Carpinella, Rovaris, Cattaneo and Ferrarin.)

Poor dynamic balance, such as poor walking stability, is a hallmark of multiple sclerosis. Instrumental measures of local dynamic stability (LDS, e.g. short-term Lyapunov's exponents, sLyEs) are genuine measures of walking stability and increasingly used as dynamic balance indicators. The current work aims to investigate if people with multiple sclerosis (PWMS) with no clinical evidence of gait impairment suffer poor LDS of gait. Eighty PWMS with minimal impairment (EDSS ≤2.5) and twenty controls completed the Six-Minute Walk Test (6MWT) at their maximum speed, wearing inertial sensors. sLyEs were calculated from trunk vertical, mediolateral and anteroposterior (sLyE AP ) acceleration. PWMS also completed a full clinical assessment including gait, balance and fatigue. Gait speed was lower in PWMS than controls (-15%), while sLyEs were larger in PWMS (+12%), even when adjusting for the different gait speed. High sLyE AP was associated with low gait speed, high impact of disease (including high fatigue) and poor balance, the three variables returned by a principal component analysis of the dataset of clinical measures. PWMS suffer poor LDS of gait, as indicated by large sLyEs. The association between high sLyE AP and poor balance supports the validity of sLyE AP as a dynamic balance measure. The inverse relationship between sLyE AP and gait speed is in line with the view that good balance is decisive for high gait speed. Finally, these findings are in line with the vicious circle linking poor balance and fatigue in PWMS, with fatigue worsening balance and poor balance leading to fatigue.

Background: In multiple sclerosis (MS) exercise improves upper limb functions, but it is unclear what training types are more effective., Objective: This study compares robot-assisted training based on haptic or sensorimotor exercise., Methods: 41clinically definite MS subjects with upper limb impairment were randomised into two groups: (i) Haptic and (ii) Sensorimotor. Subjects in the Haptic performed a robot-assisted training protocol designed to counteract incoordination and weakness. The task -interaction with a virtual mass-spring system against a resistive load- requires coordination skills. Task difficulty and magnitude of resistive load were automatically adjusted to the individual impairment. Subjects in the Sensorimotor performed reaching movements under visual control; the robot generated no forces. Both groups underwent eight training sessions (40 min/session, 2 sessions/week). Treatment outcome were 9HPT and ARAT scores., Results: The average 9HPT score decreased from 74±9 s to 61±8 s for the Haptic and from 49±6 s to 44±6 s. We found a significant Treatment (p=.0453) and Time differences (p=.005), but no significant Treatment×Time interactions although we found that the absolute change was only significant in the Haptic group (p=.011). We observed no significant changes in the ARAT score. Participants tolerated treatments well with a low drop-out rate. In the subjects evaluated at after 12 week (11 subject in sensory-motor and 17 in haptic group) no retention of the effect was found., Conclusions: Task oriented training may improve upper limb function in persons with MS especially in prevalent pyramidal impaired subjects without maintain the effects after three months., Clinical Trial Registration Number: NCT02711566 (clinicaltrial.gov)., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

People with tetraplegia are often lacking grip strength, causing impairment in activities of daily living. For them, improving hand function is a priority because it is important for autonomy and participation in daily life. A tendon transfer surgery may be an option to improve the tenodesis grip, but it is an invasive procedure. Alternatively a similar effect can be produced, using a non-invasive method. We have previously described how myoelectrically controlled functional electrical stimulation (MeCFES) can be efficient for enhancing grip strength, using a one channel research prototype with wired connections to surface electrodes. In this paper we focus on the usability for activities of daily living and how it can fulfill an actual need. We recruited 27 participants with a cervical spinal cord lesion (C5-C7) for this trial. They tested the device in 12 sessions of 2 h each, in which the participants performed self selected activities involving the tenodesis grip. User centered outcomes were validated questionnaires: the Individually Prioritized Problem Assessment (IPPA) and the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST). Furthermore, they were asked if they found the device useful for continued use in daily life. The device facilitated prioritized activities for all participants. The IPPA change score was 4.6 on average (STD:3.5, effect size:1.3), meaning that the system greatly facilitated problematic tasks and the large effect size evinces that this was a meaningful improvement of hand function. It compares to the impact that a mobility device like a wheelchair has on daily living. Fourteen subjects found the system useful, expressing the need for such a neuroprosthesis. Examples of acquiring new abilities while using the device, indicate that the method could have a therapeutic use as well. Furthermore, results from the IPPA questionnaire are indicating what issues people with tetraplegia may hope to solve with a neuroprosthesis for the hand. The satisfaction of the device (QUEST) indicates that further effort in development should address wearability, eliminate wires, and improve the fitting procedure., (Copyright © 2020 Thorsen, Dalla Costa, Beghi and Ferrarin.)

The maintenance of balance in dynamic conditions (e.g. during walking) is a necessary requirement that motor control must reach to avoid falls. However, this is a challenging situation, since to ensure the forward progression of the body, the center of mass must stay outside the base of support in the sagittal plane, and simultaneously remain inside the lateral borders in the frontal plane. Deviation from normative data of healthy subjects in dynamic balance could be used to quantify gait stability, fall risk and to provide hints for rehabilitation. However, normative data can be influenced by age, sex, anthropometry and spatio-temporal gait parameters, and such differences among subjects and leg side can hamper accurate assessment. The aims of this study were to investigate, in a group of healthy subjects: (1) possible asymmetry in dynamic balance maintenance strategies between leg sides, (2) the influence of age, sex and anthropometry on stability and (3) its dependence by spatio-temporal gait parameters. A total of 34 healthy subjects aged between 21 and 71 years, and ranging from 50.1 to 101.6 kg of body mass and from 155.0 to 188.9 cm of height were assessed on spatio-temporal and dynamic balance parameters (Foot Placement Estimator at heel strike and Margin of Stability at mid-stance) during self-selected gait. No parameter showed differences between legs. Dynamic balance parameters were influenced by sex, age, body mass and height mainly in the frontal plane. These measures were also correlated with gait speed and stride length both in the antero-posterior and medio-lateral directions. In addition also cadence and step width influenced the stability in the sagittal and frontal planes, respectively. The findings of this study confirm the symmetry in motor control of dynamic balance during self-selected gait in healthy subjects. Sex, anthropometry and spatio-temporal gait parameters have a significant effect on stability parameters, and this should be taken into account in dynamic balance studies.

Background: Robot-based rehabilitation for persons post-stroke may improve arm function and daily-life activities as measured by clinical scales, but its effects on motor strategies during functional tasks are still poorly investigated. This study aimed at assessing the effects of robot-therapy versus arm-specific physiotherapy in persons post-stroke on motor strategies derived from upper body instrumented kinematic analysis, and on arm function measured by clinical scales., Methods: Forty persons in the sub-acute and chronic stage post-stroke were recruited. This sample included all those subjects, enrolled in a larger bi-center study, who underwent instrumented kinematic analysis and who were randomized in Center 2 into Robot (R&#95;Group) and Control Group (C&#95;Group). R&#95;Group received robot-assisted training. C&#95;Group received arm-specific treatment delivered by a physiotherapist. Pre- and post-training assessment included clinical scales and instrumented kinematic analysis of arm and trunk during a virtual untrained task simulating the transport of an object onto a shelf. Instrumented outcomes included shoulder/elbow coordination, elbow extension and trunk sagittal compensation. Clinical outcomes included Fugl-Meyer Motor Assessment of Upper Extremity (FM-UE), modified Ashworth Scale (MAS) and Functional Independence Measure (FIM)., Results: R&#95;Group showed larger post-training improvements of shoulder/elbow coordination (Cohen's d = - 0.81, p = 0.019), elbow extension (Cohen's d = - 0.71, p = 0.038), and trunk movement (Cohen's d = - 1.12, p = 0.002). Both groups showed comparable improvements in clinical scales, except proximal muscles MAS that decreased more in R&#95;Group (Cohen's d = - 0.83, p = 0.018). Ancillary analyses on chronic subjects confirmed these results and revealed larger improvements after robot-therapy in the proximal portion of FM-UE (Cohen's d = 1.16, p = 0.019)., Conclusions: Robot-assisted rehabilitation was as effective as arm-specific physiotherapy in reducing arm impairment (FM-UE) in persons post-stroke, but it was more effective in improving motor control strategies adopted during an untrained task involving vertical movements not practiced during training. Specifically, robot therapy induced larger improvements of shoulder/elbow coordination and greater reduction of abnormal trunk sagittal movements. The beneficial effects of robot therapy seemed more pronounced in chronic subjects. Future studies on a larger sample should be performed to corroborate present findings., Trial Registration: www.ClinicalTrials.gov NCT03530358. Registered 21 May 2018. Retrospectively registered.

Inertial measurement units (IMUs) allow accurate quantification of gait impairment of people with multiple sclerosis (pwMS). Nonetheless, it is not clear how IMU-based metrics might be influenced by pragmatic aspects associated with clinical translation of this approach, such as data collection settings and gait protocols. In this study, we hypothesised that these aspects do not significantly alter those characteristics of gait that are more related to quality and energetic efficiency and are quantifiable via acceleration related metrics, such as intensity, smoothness, stability, symmetry, and regularity. To test this hypothesis, we compared 33 IMU-based metrics extracted from data, retrospectively collected by two independent centres on two matched cohorts of pwMS. As a worst-case scenario, a walking test was performed in the two centres at a different speed along corridors of different lengths, using different IMU systems, which were also positioned differently. The results showed that the majority of the temporal metrics (9 out of 12) exhibited significant between-centre differences. Conversely, the between-centre differences in the gait quality metrics were small and comparable to those associated with a test-retest analysis under equivalent conditions. Therefore, the gait quality metrics are promising candidates for reliable multi-centric studies aiming at assessing rehabilitation interventions within a routine clinical context.

This paper reports the kinematic, kinetic and electromyographic (EMG) dataset of human locomotion during level walking at different velocities, toe- and heel-walking, stairs ascending and descending. A sample of 50 healthy subjects, with an age between 6 and 72 years, is included. For each task, both raw data and computed variables are reported including: the 3D coordinates of external markers, the joint angles of lower limb in the sagittal, transversal and horizontal anatomical planes, the ground reaction forces and torques, the center of pressure, the lower limb joint mechanical moments and power, the displacement of the whole body center of mass, and the surface EMG signals of the main lower limb muscles. The data reported in the present study, acquired from subjects with different ages, represents a valuable dataset useful for future studies on locomotor function in humans, particularly as normative reference to analyze pathological gait, to test the performance of simulation models of bipedal locomotion, and to develop control algorithms for bipedal robots or active lower limb exoskeletons for rehabilitation.

Background: Stroke units provide patients with a multiparametric monitoring of vital functions, while no instruments are actually available for a continuous monitoring of patients motor performance. Our aim was to develop an actigraphic index able both to identify the paretic limb and continuously monitor the motor performance of stroke patients in the stroke unit environment., Methods: Twenty consecutive acute stroke patients (mean age 69.2 years SD 10.1, 8 males and 12 females) and 17 bed-restrained patients (mean age 70.5 years SD 7.3, 7 males and 10 females) hospitalized for orthopedic diseases of the lower limbs, but not experiencing neurological symptoms, were enrolled. This last group represented our control group. The motor activity of arms was recorded for 24 h using two programmable actigraphic systems showing off as wrist-worn watches. The firmware segmented the acquisition in epochs of 1 minute and for each epoch calculates two motor activity indices: MA e1 (Epoch-related Motor Activity index) and MA e2 (Epoch-related Motor Activity index 2). MA e1 is defined as the standard deviation of the acceleration module and MA e2 as the module of the standard deviation of acceleration components. To describe the 24 h motor performance of each limb, we calculated the mean value of MA e1 and MA e2 (respectively MA 1&#95;24h and MA 2&#95;24h ). Then we obtained two Asymmetry Rate Indices: AR 1&#95;24h and AR 2&#95;24h to show the motor activity prevalence. AR 1&#95;24h refers to the asymmetry index between the values of MA e1 of both arms and AR 2&#95;24h to MA e2 values. The stroke patients were clinically evaluated by NIHSS at the beginning (NIHSS T0 ) and at the end (NIHSS T1 ) of the 24 h actigraphic recordings., Results: Both MA 1&#95;24h and MA 2&#95;24h indices were smaller in the paretic than in the unaffected arm (respectively p = 0.004 and p = 0.004). AR 2&#95;24h showed a better capability (95% of paretic arms correctly identified, Phi Coefficient: 0.903) to discriminate the laterality of the clinical deficit than AR 1&#95;24h (85% of paretic arms correctly identified, Phi Coefficient: 0,698). We also found that AR 1&#95;24h did not differ between the two groups of patients while AR 2&#95;24h was greater in stroke patients than in controls and positively correlated with NIHSS total scores (r: 0.714, p < 0.001 for NIHSS, IC95%: 0.42-0.90) and with the sub-score relative to the paretic upper limb (r: 0.812, p < 0.001, IC95%: 0.62-0.96)., Conclusions: Our data show that actigraphic monitoring of upper limbs can detect the laterality of the motor deficit and measure the clinical severity. These findings suggest that the above described actigraphic system could implement the existing multiparametric monitoring in stroke units.

Background: Gait instability is common in adults with neurologic disorders and the modified Dynamic Gait Index (mDGI) was recently introduced to assess dynamic balance. However, instrumental assessment is needed to provide quantitative measures., Objective: To develop and validate an instrumented version of the mDGI., Design: Cross-sectional study., Setting: Clinical setting., Participants: Thirty adults with neurologic disorders (10 with multiple sclerosis, 10 with Parkinson disease, and 10 with stroke) and 20 healthy volunteers., Methods: Participants were assessed with the Timed Up and Go test (TUG) and with the mDGI. During the assessment of mDGI, data were collected by a single Inertial Measurement Unit (IMU) positioned on the sternum. Principal component analysis (PCA) was performed on the instrumented data extracting eight PC scores (ImPC) describing dynamic balance. The instrumented overall score (ImDGI) was then calculated as the sum of the mPCs. PCA revealed two components associated with stride features and regularity (ImDGI&#95;Gait&#95;Pattern) and trunk movements (ImDGI&#95;Trunk&#95;Sway). Spearman coefficients were calculated between mDGI and ImDGI, whereas Mann-Whitney (U) and Kruskal-Wallis (H) tests assessed differences between groups and neurologic conditions., Main Outcome Measurements: ImDGI., Results: ImDGI did not show ceiling effects, and good correlations were found between ImDGI and mDGI (r = .84), and TUG (r = .84) for people with neurologic disorders (P < .001). Significant differences among pathologies (H test (2) =12.5, P = .002) and between healthy participants and adults with neurologic disorders (U test = 47.0, P = .001) were found. ImDGI&#95;Trunk&#95;Sway discriminated between people using or not using walking aids and among the three pathologies (H (2) = 10.0, P = .007)., Conclusions: The ImDGI test seems to provide valid measures to objectively assess dynamic balance in neurologic conditions and possibly quantify balance deficits also in adults with neurologic disorders., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Previous evidence has shown that tool-use can reshape one's own body schema, extending peripersonal space and modulating the representation of related body parts. Here, we investigated the role of tool action in shaping the body metric representation, by contrasting two different views. According to a first view, the shaping would rely on the mere execution of tool action, while the second view suggests that the shaping induced by tool action on body representation would primarily depend on the representation of the action goals to be accomplished. To this aim, we contrasted a condition in which participants voluntarily accomplish the movement by representing the program and goal of a tool action (i.e., active tool-use training) with a condition in which the tool-use training was produced without any prior goal representation (i.e., passive tool-use training by means of robotic assistance). If the body metric representation primarily depends on the coexistence between goal representation and bodily movements, we would expect an increase of the perceived forearm length in the post- with respect to the pre-training phase after the active training phase only. Healthy participants were asked to estimate the midpoint of their right forearm before and after 20 min of tool-use training. In the active condition, subjects performed "enfold-and-push" movements using a rake to prolong their arm. In the passive condition, subjects were asked to be completely relaxed while the movements were performed with robotic assistance. Results showed a significant increase in the perceived arm length in the post- with respect to the pre-training phase only in the active task. Interestingly, only in the post-training phase, a significant difference was found between active and passive conditions, with a higher perceived arm length in the former than in the latter. From a theoretical perspective, these findings suggest that tool-use may shape body metric representation only when action programs are motorically represented and not merely produced. From a clinical perspective, these results support the use of robots for the rehabilitation of brain-damaged hemiplegic patients, provided that robot assistance during the exercises is present only "as-needed" and that patients' motor representation is actively involved., (Copyright © 2019 Bruno, Carpinella, Rabuffetti, De Giuli, Sinigaglia, Garbarini and Ferrarin.)

Gait and balance disorders are among the main predisposing factors of falls in elderly. Clinical scales are widely employed to assess the risk of falling, but they require trained personnel. We investigate the use of objective measures obtained from a wearable accelerometer to evaluate the fall risk, determined by the Tinetti clinical scale. Seventy-nine patients and eleven volunteers were enrolled in two rehabilitation centers and underwent a full Tinetti test, while wearing a triaxial accelerometer at the chest. Tinetti scores were assessed by expert physicians and those subjects with a score ≤18 were considered at high risk. First, we analyzed 21 accelerometer features by means of statistical tests and correlation analysis. Second, one regression and one classification problem were designed and solved using a linear model (LM) and an artificial neural network (ANN) to predict the Tinetti outcome. Pearson's correlation between the Tinetti score and a subset of 9 features (mainly related with standing and walking) was 0.71. The misclassification error of high risk patient was 0.21 and 0.11, for LM and ANN, respectively. The work might foster the development of a new generation of applications meant to monitor the time evolution of the fall risk using low cost devices at home., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Gait analysis has demonstrated to efficaciously support clinical investigations. The patterns of the outcome variables (joint angles, moments and powers) are characterized by an intrinsic and extrinsic variability. Particularly, extrinsic variability is induced by operator-dependent differences in markers' placement, with errors propagating non-linearly to alter outcome variable patterns. The aims of this study are (1) to consider a specific gait analysis protocol named LAMB and provide a description of its procedures, (2) to experimentally assess the between-operator and within-operator variability induced by operator-dependent marking of required anatomical landmarks and (3) to evidence how such inaccuracies propagates to the gait analysis kinematic and kinetic outcome variables. Six expert gait analysis operators performed LAMB anatomical landmarks marking on three healthy adult participants; moreover, one operator repeated three times the marking on one participant. The participants then performed a set of locomotor tasks including stair negotiation and heel- and toe-walking. An anatomical calibration approach let to register each marking and to compute, starting from one single raw data set, a set of outcome variables for each marking/operator. The between-operator variability of gait analysis outcome was assessed in terms of mean absolute variability to quantify offsets and minimal correlation coefficient to quantify patterns' similarity. The results evidence average minimal correlation coefficient ranging from 0.857 for moments to 0.907 for angles and average mean absolute variability accounted for few degrees in angular variables (worst between-operator mean absolute variability is 7.3°), while dynamic variables mean absolute variability, relative to the variable range, was below 5% for moment and below 10% for powers. The variability indexes are comparable to those related to previously published protocols and are independent from the considered task, thus suggesting that the LAMB is a reliable protocol suitable for the analysis of different locomotor tasks.

The regularity of pseudo-periodic human movements, including locomotion, can be assessed by autocorrelation analysis of measurements using inertial sensors. Though sensors are generally placed on the trunk or pelvis, movement regularity can be assessed at any body location. Pathological factors are expected to reduce regularity either globally or on specific anatomical subparts. However, other non-pathological factors, including gait strategy (walking and running) and speed, modulate locomotion regularity, thus potentially confounding the identification of the pathological factor. The present study's objectives were (1) to define a multi-sensor method based on the autocorrelation analysis of the acceleration module (norm of the acceleration vector) to quantify regularity; (2) to conduct an experimental study on healthy adult subjects to quantify the effect on movement regularity of gait strategy (walking and running at the same velocity), gait speed (four speeds, lower three for walking, upper two for running), and sensor location (on four different body parts). Twenty-five healthy adults participated and four triaxial accelerometers were located on the seventh cervical vertebra (C7), pelvis, wrist, and ankle. The results showed that increasing velocity was associated with increasing regularity only for walking, while no difference in regularity was observed between walking and running. Regularity was generally highest at C7 and ankle, and lowest at the wrist. These data confirm and complement previous literature on regularity assessed on the trunk, and will support future analyses on individuals or groups with specific pathologies affecting locomotor functions.

Background: Postural stabilization is the function which allows an individual, after a transitional movement, to recover balance in a quiet erect posture. An experimental method has been proposed (Rabuffetti, 2011) and proved valid for the assessment of balance disorders in individuals with neurological diseases. It would seem that the two original indices were not fully independent since their concurrent distribution was confined by a hyperbolic boundary., Research Question: A methodological advancement involving non-linear transformation techniques is required to overcome the limitations of the original approach., Methods: A hyperbolic transformation is applied to the original indices related to the mechanics of the stabilization (instability at beginning of stabilization and time rate of stabilization), thus defining two novel indices (Instability and Promptness). These novel indices may be related to different functional domains concerning, respectively, peripheral force capacity and central nervous motor control. The validity of these novel indices is quantified by their correlation with clinical scales in an already validated group of patients with Charcot-Marie-Tooth disease (N = 47) or Multiple Sclerosis (N = 20)., Results: The novel indices generally improved validity compared to the original indices (+66% of indices show a statistically significant concurrent validity on a clinical scale). Moreover, Instability was more related to the Charcot-Marie-Tooth group (9 out of 12 valid correlations), and Promptness to the Multiple Sclerosis group (4 out of 5, when also considering statistical trends), in accordance to the, respectively, more peripheral and more central nature of the two neurological diseases., Significance: The novel postural stabilization indices support a clinical application for two reasons: 1) they have shown improved validity, compared to the original indices, in two groups of patients affected by neurological pathologies of different nature, 2) they are more closely related, compared to the original indices, to different functional domains., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Parkinson's disease impacts health-related quality of life (HRQoL), however no studies inquired on predictors of HRQoL changes after rehabilitation. This study assessed the relationship between mobility domain of HRQoL measured by Parkinson's Disease Questionnaires-39 (PDQ-39) and clinical-demographic characteristics and developed a model predicting changes after rehabilitation., Methods: Subjects with Parkinson's disease underwent rehabilitation treatment and completed the following predictors: 10-m walking test (10MWT), Timed Up and Go (TUG), Berg Balance scale (BBS), Activities-specific Balance Confidence scales (ABC), Freezing of Gait (FOGQ) and PDQ-39. Two general linear models were calculated to predict the relationship between HRQoL at baseline and to predict HRQoL changes after rehabilitation., Results: Forty-two subjects (age 74.9 ± 7.3 years, Hoehn&Yahr 2.8 ± 0.6) completed the baseline evaluation. The first model (multiple R 2  = 0.59, F = 5.86, P  < 0.001) showed that ABC (B = - 0.51, CI = - 0.86 to 0.15, R 2  = 0.41, P  = 0.005) and FOGQ (B = 2.38, CI = 1.03 to 3.73, R 2  = 0.07, P  = 0.001) were statistically significant predictors of mobility aspect of HRQoL at baseline. Thirty seven subjects completed the rehabilitation sessions, data were entered in the second model (multiple R 2  = 0.40, F = 4.24, P  < 0.004) showing that gender (B = - 5.12, CI = - 9.86 to - 0.39, R 2  = 0.23, P  = 0.034), Hoehn&Yahr (B = 10.93, CI = + 3.27 to + 18.61, R 2  = 0.22, P  = 0.006) and PDQ-39 mobility at baseline (B = - 0.38, CI = - 0.63 to - 0.14, R 2  = 0.55, P  = 0.002) were statistically significant predictors of changes of the mobility aspect of HRQoL., Conclusions: Balance confidence and Freezing of Gait are associated with the mobility aspect of HRQoL. Changes in mobility domain of HRQoL (as assessed by PDQ-39) are likely to be greater in males, in people at higher stages of the disease and in people with more severe limitation in mobility domain of HRQoL (as assessed by PDQ-39) before rehabilitation. Results might be different when considering different outcomes or different measures for the same outcome (performance mobility test instead of self-report questionnaires). Further investigations are needed to better understand other components of HRQoL in addition to mobility., Trial Registration: NCT02713971 registered March 8, 2016., Competing Interests: The study was approved by the Ethical Committee of Don Gnocchi Foundation.Subjects signed an informed consent form before the beginning of the study.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Stair ascent is a challenging daily-life activity highly related to independence. This task is usually assessed with clinical scales suffering from partial subjectivity and limited detail in evaluating different task aspects. In this paper, we instrumented the assessment of stair ascent in people with multiple sclerosis (MS), stroke (ST), and Parkinson's disease (PD) to analyze the validity of the proposed quantitative indexes and characterize subjects' performances. Participants climbed 10 steps wearing a magneto-inertial sensor [magneto-inertial measurement unit (MIMU)] at sternum level. Gait pattern features (step frequency, symmetry, regularity, and harmonic ratios), and upper trunk sway were computed from MIMU signals. Clinical modified dynamic gait index (mDGI) and mDGI-Item 8 "Up stairs" were administered. Significant correlations with clinical scores were found for gait pattern features ( ) and trunk pitch sway ( ) demonstrating their validity. Instrumental indexes showed alterations in the three pathological groups compared to healthy subjects and significant differences, not clinically detected, among MS, ST, and PD. MS showed the worst performance, with alterations of all gait pattern aspects and larger trunk pitch sway. ST showed worsening in gait pattern features but not in trunk motion. PD showed fewer alterations consisting in reduced step frequency and trunk yaw sway. These results suggest that the use of an MIMU provided valid objective indexes revealing between-group differences in stair ascent not detected by clinical scales. Importantly, the indexes include upper trunk measures, usually not present in clinical tests, and provide relevant hints for tailored rehabilitation.

Abnormalities of body-weight transfer occur during several motor tasks in people with Parkinson's disease (PwPD). In this study, a novel robotic paradigm for assessment and training of dynamic balance was developed and applied to twelve healthy subjects (HS) and ten PwPD to verify its feasibility and to assess the capability of PwPD to counteract postural perturbations through body-weight shifts. At variance with other robotic paradigms, subjects had to react as fast as possible to the perturbation, bringing the platform back to the horizontal and keeping it until the end of the task. Four randomized perturbations, obtained varying the platform equilibrium angle from 0° to ±6° in sagittal (backward, forward) and frontal (right, left) planes, were repeated 3 times. Compared to HS, PwPD showed, in all perturbation directions, increased delay in counteraction phase onset (p<=0.01), prolonged time to stabilize the platform (p<=0.02), and higher deviation of the final plate inclination from the horizontal (p<=0.04), the deviation being larger during sagittal perturbations. PwPD showed also larger (p=0.01) postural sway around the stabilization angle following frontal perturbations. Results are in keeping with known hypo- and bradykinesia as well as proprioceptive and kinesthetic impairments in PD. We suggest that the proposed approach is feasible and might be included in balance evaluation and training in PD.

Several robotic devices have been developed for the rehabilitation of treadmill walking in patients with movement disorders due to injuries or diseases of the central nervous system. These robots induce coordinated multi-joint movements aimed at reproducing the physiological walking or stepping patterns. Control strategies developed for robotic locomotor training need a set of predefined lower limb joint angular trajectories as reference input for the control algorithm. Such trajectories are typically taken from normative database of overground unassisted walking. However, it has been demonstrated that gait speed and the amount of body weight support significantly influence joint trajectories during walking. Moreover, both the speed and the level of body weight support must be individually adjusted according to the rehabilitation phase and the residual locomotor abilities of the patient. In this work, 10 healthy participants (age range: 23-48 years) were asked to walk in movement analysis laboratory on a treadmill at five different speeds and four different levels of body weight support; besides, a trial with full body weight support, that is, with the subject suspended on air, was performed at two different cadences. The results confirm that lower limb kinematics during walking is affected by gait speed and by the amount of body weight support, and that on-air stepping is radically different from treadmill walking. Importantly, the results provide normative data in a numerical form to be used as reference trajectories for controlling robot-assisted body weight support walking training. An electronic addendum is provided to easily access to such reference data for different combinations of gait speeds and body weight support levels.