Mixed reality (MR) has emerged as a promising tool for rehabilitation, offering immersive and interactive experiences that enhance patient engagement and increase motivation, without detaching them from their reality. This paper presents some preliminary usability and feasibility results about MiRR (Mixed Reality Rehabilitation), a prototype MR application developed for cognitive and motor rehabilitation using Microsoft HoloLens 2. The system integrates spatial computing, hand tracking, and real-time feedback to create engaging rehabilitation exercises that could be tailored to individual patient needs. MiRR was designed to stimulate patients by presenting tasks aimed at improving motor coordination, spatial awareness, and cognitive functions. The application provides guided exercises that require patients to interact with virtual objects with their hands or stepping onto virtual tiles placed on the floor. The MR device would also continuously collect measures during the exercises, allowing clinicians to track patient progress more objectively. This preliminary study was conducted with a small group of healthy subjects and rehabilitation specialists of Fondazione Don Carlo Gnocchi, to foster feasibility, usability, engagement, and potential therapeutic benefits. The qualitative feedback gathered suggests that MiRR may enhance motivation, improve adherence to rehabilitation protocols, and provide valuable data for clinicians to personalize therapy plans. Further and larger studies are needed to assess the efficacy of this MR-based treatment, and to thoroughly investigate the measurements and the derived indexes for an objective evaluation of the subject's performance. Despite the obvious limitations and the early stage of development, it seems that MiRR, leveraging the interesting features of MR technology, may contribute to developing novel, engaging, flexible, more personalized, forms of rehabilitation.

BackgroundIt has been widely demonstrated that siblings of children with autism spectrum disorder (ASD) have an increased risk of abnormal developmental trajectories. In response to this, early recognition protocols have been developed worldwide, aiming to promote early interventions that can positively impact the neurodevelopment of this population. This paper presents the protocol of a controlled trial: ERI-SIBS (Early Recognition and Intervention in SIBlingS at High Risk for Neurodevelopment Disorders) is an innovative and ecological early recognition and intervention program designed specifically for siblings of children with ASD.MethodsWe aim to recruit siblings at low risk and high risk of neurodevelopmental disorders. Based on clinical evaluation at T0, we will allocate the infants into three groups: Group 1, infants at low risk without any signs of neurodevelopmental disorders; Group 2, infants at high risk without any signs of neurodevelopmental disorders; Group 3: infants at low or high risk with signs suggestive of neurodevelopmental disorders. Children of Group 2 will undergo Active Monitoring (one 90 min session once a month for 6 months), while children of Group 3 will undergo Early Intervention (one 90 min session once a week for 6 months). In both cases, the ERI-SIBS contents are based on a multidimensional and naturalistic approach and always involve caregivers. All recruited children will be evaluated at three different time points (T0 within the 8 months of life of the child, T1 after 6 months and T2 after 12 months) using behavioural, technological, and biological techniques to assess infants’ neurodevelopmental functions, parent-infant interaction, and early ASD markers.DiscussionThe ERI-SIBS study will expand knowledge regarding the impact of early intervention on families of infants at risk of neurodevelopmental disorders for the presence of a child with a diagnosis of ASD. The study will have the potential to significantly contribute to future research and the scientific and clinical debate on the best way to implement early intervention in at-risk populations. Clinical Trial RegistrationClinicaltrials.gov identifier (NCT06512649).

INTRODUCTION:Autism Spectrum Disorder (ASD) is characterized by deficits in social interaction and communication, including joint attention (JA) impairment. This observational case-control study explores quantitative JA metrics in ASD preschool-aged children and typically-developing (TD) toddlers, interacting with both a human agent and a social robot. MATERIAL AND METHODS:Ten ASD and sixteen Typically Developing (TD) children, matched for developmental age, participated completing two JA tasks of the "Échelle par la Communication Sociale Precoce"(ECSP)-Gaze Following and Object Spectacle-administered by both a human (ECSP-H) and a social robot NAO (ECSP-R). A Kinect Azure Camera was used to track children's gaze and five performance indicators were defined to quantify JA-related behaviors: Number of Responses to JA, Time Latency to response and Fixation Time, both towards robot and human agent. RESULTS:Significant group differences emerged in responsiveness to social cues, particularly in the Gaze Following task. TD children responded more consistently to human prompts (p = 0.01) and showed greater visual interest in the human agent in both ECSP-H (p < 0.01) and ECSP-R (p = 0.02) conditions. In contrast, percentage of fixations on the robot was comparable across groups. DISCUSSION:This study introduces unobtrusive, gaze-based quantitative measures to assess joint attention in ASD. Significant differences between ASD and TD groups suggest that children with ASD exhibited greater attentional preference to the robot agent, giving potential for these metrics in distinguishing attentional patterns in these two populations. This feature may nonetheless be clinically relevant, as it may be leveraged to facilitate attention, promote participation, and support robot-assisted therapeutic interventions.

This document analyzes a survey conducted in three geographical areas in Spain, focusing on centers for individuals with cerebral palsy (CP). The study aims to determine the adherence rate to recommended physical activity guidelines, assess if there is a decline in interest in physical activity over time, identify the stage at which this decline occurs, and explore potential mechanisms, tools, or strategies to sustain long-term engagement in regular physical activity for this population. The 36-item questionnaire comprises multiple-choice, open-ended, and Likert scale-type questions. Data were collected on physical activity frequency and duration, daily living activities, and demographics. Statistical analysis identified patterns and relationships between variables. Findings reveal that only a 17.6% meets the World Health Organization (WHO) recommendations regarding regular physical activity (RPA), decreasing in frequency or number of days a week, (3.7 d/w to 2.9 d/w; p < 0.01) and duration (50.5 min/d to 45.2 min/d; p < 0.001) with age, especially for those with higher Gross Motor Function Classification System (GMFCS) mobility levels. Obesity slightly correlates with session duration (ρ = −0.207; p < 0.05), not mobility limitations. Gender has no significant impact on mobility, communication, or physical activity, while age affects variables such as body mass index (BMI) and engagement (p < 0.01). A substantial proportion follows regular physical activities based on health professionals’ advice, with interest decreasing with age. To improve adherence, focusing on sports-oriented goals, group sessions, and games is recommended. These findings emphasize the importance of personalized programs, particularly for older individuals and those with greater mobility limitations.

The growing number of children using mobile devices and Internet services, given the complexity and risks of the online world, is raising great concerns in parents, caregivers and teachers. Hence, many efforts have been developed to promote a safe, confident and aware use of these devices and services. Among these efforts, in 2017 Google introduced the "Be Internet Awesome" program, and the related serious game Interland. In this paper, we present Interland For All (I4A), anAR evolution of Interland, developed by Fondazione Don Carlo Gnocchi and Fondazione Mondo Digitale ETS, aiming to extend Interland's accessibility to children with some degree of impairment (such as hearing, visual or cognitive). I4A comprises both physical and virtual components running on a smartphone, including some aids specifically targeted to frail children, who could be more exposed to the online risks. The software has been tested by a lower secondary school class and their parents during the RomeCup 2023 event, receiving overall positive feedback but also highlighting some technical shortcomings. The prototype nature of this project requires further studies to investigate in a more structured way its effectiveness, its limitations and possible evolutions. In particular, the mixed use of physical and virtual components deserves to be further fostered, given its potential both in the educational field and in rehabilitation.

PURPOSE: Unilateral cerebral palsy (UCP) represents about 30–40% of overall cerebral palsy diagnoses. Upper limb impairment has a significant negative impact on activities of daily living (ADL), and recent studies have shown that the use of virtual reality (VR) can increase motivation and promote an improvement in ADL. This preliminary study was aimed at exploring the acceptability and usability of a VR rehabilitation treatment, using the VITAMIN Platform, for children with UCP. A secondary goal of the study was to compare the results of usual standardized clinical scales and questionnaires with kinematic results as well as with the quantitative measures acquired by the VITAMIN platform in each exercise of the rehabilitation sessions. METHODS: Six children with UCP (aged 7–15) were recruited for a preliminary investigation in using a non-immersive VR system. The treatment was composed of 10 weekly sessions of 45 minutes. Each child played five types of exergames, using the impaired upper limb to hit virtual objects projected on a wide screen. Standardized clinical scales, kinematic analysis, and questionnaires were used to extensively assess upper limb function before and at the end of treatment. Five typically-developing children provided a reference for the instrumented kinematic assessment. RESULTS: At the end of the treatment, Melbourne Assessment 2 (MA2) scores increased for all the participants (mean increase in range of movement (ROM) + 19.1%, accuracy + 4.6%, dexterity + 13.1%, fluency + 10.3%). Shoulder flexion-extension ROM also improved (mean increase + 10.5°), and according to the kinematic analysis, shoulder movements became more similar to reference profiles. These results were confirmed by a general improvement in performing ADL, assessed by the ABILHAND-Kids questionnaire. Finally, a general agreement among the different measures and indexes emerged from the acquired data. CONCLUSION: The results show that VR treatment with the VITAMIN platform could be engaging and functional for rehabilitation of children with UCP. The good agreement among the qualitative and quantitative measures and indexes confirms the potential of such novel treatment. However, due to the limited sample size and small number of sessions, further and larger investigations are required to evaluate the effectiveness and to generalize the results.

Background The application of Virtual Reality (VR) in the field of rehabilitation has been widely studied, because it has already proven to be an effective intervention for a variety of physical and cognitive conditions. Nevertheless, its application in pediatric rehabilitation is more recent. This pilot study aims to examine whether a VR-rehabilitation program may have positive effects on the Executive Functions (EFs) of children with Specific Learning Disorders (SLD). Materials and methods Twenty-four children with diagnosis of SLD participated to the study (range 7–11 years) and performed the VR-training across 6 weeks in the CARE Lab, that was designed with appropriate structural measures and ad hoc fittings, to hide the sophisticated technology necessary to allow the child to experience a rehabilitative setting with recreational and semi-immersive features. Children were evaluated across three main time-points: T0, assessment of cognitive level and EFs immediately before the start of the intervention; T1, assessment of EFs immediately after the end of VR intervention; T2, follow-up of EFs after 6 months from the end of the VR intervention. The rehabilitation programs were customized according to clinical needs and/or single patient’s characteristics, proposing different games with variable complexity levels. Results Results showed that scores for visual attention, inhibition, flexibility, and planning abilities were significantly higher than before the intervention, and the most part of these ameliorations were maintained after 6 months. Conclusion These findings provide important inputs for the development of new innovative rehabilitation interventions for children with SLD that must be founded in ecological and evidence-based approaches.

Rationale: Key pathophysiological traits or endotypes, that contribute to the development of obstructive sleep apnea (OSA) include an anatomically collapsible upper airway (UAC), a reduced dilator muscle responsiveness (MR), a reduced arousal threshold (AT) and an over-sensitive respiratory control system or loop gain (LG). Endotypes evaluation will permit to categorize OSA patient paving the way for a precision medicine. In Italy home respiratory polygraphy (HRP) are used for OSA routine evaluation. The aim of this research was to simply and indirectly evaluate OSA endotype from HRP reports. Methods: This was a retrospective analysis of HRP reports using an ad-hoc software to extrapolate OSA endotypes. We analyzed reports of routine HRP performed at two Institutes in Milano and in Monza-Brianza between 2014 and 2022 including only HRP with an apnea-hypopnea index (AHI)≥5/h. The software automatically categorized each HRP as having: a) high UAC if obstructive events>90%, if the AHI > 40/h and if the CPAP pressure > 8; b) high LG if central events > 20%, if there was periodic breathing and if there weren't REM-related events; c) low AT if AHI<30/h, desaturation nadir >82% and the ratio hypopneas\apneas > 58.3%. MR was not evaluated. Results: HRP's reports of 9068 patients were studied. 72% were males, the median [Q1-Q3] age was 60 [50-71] years and the BMI was 28 [25-32] kg\m2. Regarding endotypes: 9% presented a high UAC, 62% a low AT and 33% a high LG. Conclusions: OSA main endotype in our population was AT. We propose a simple method to automatically evaluate UAC, LG and AT from HRP's reports, that could be applied in the routine clinical practice of sleep specialists helping to a future personalized OSA therapy.

Background Air pollution and obstructive sleep apnea (OSA) are both linked with cardiovascular co-morbidities and share similar pathophysiological mechanisms. A causal association between the two has been postulated. However, the results of the studies on this topic are conflicting mainly because of the lack of adjustment for important confounders such as seasonality and temperature. We aimed to evaluate if such an association exists in a highly polluted area like Lombardy region (Italy) when accounting for all confounders. Methods Data of adult patients seen at the Sleep Disorder Centre in Milan from 2010 to 2020 were analysed and the main polygraphic data were retrieved. Air pollutant concentrations of the following pollutants NO 2 , O 3 , PM 2.5 , and PM 10 were collected through monitoring stations. Results A total of 3493 patients were included: males (2358, 67.5%) mean age 60.1 (SD = 14.3) years, BMI 29.2 (6.2) kg/m 2 , mean AHI 16.5 (18.1) events/h. After adjusting for all confounders, in the multivariable analysis, the only associations that remained significant were long-term exposure to O 3 with indexes of OSA severity (AHI and ODI) but only in spring. Furthermore, a positive association was seen between long-term exposure to PM 10 and ODI but in springtime only. Conclusion The findings of the current study does not support an association between fine particulate matter and OSA severity.

The combination of noradrenergic (reboxetine) plus antimuscarinic (oxybutynin) drugs (reb-oxy) reduced obstructive sleep apnea (OSA) severity but no data are available on its effects on cardiac autonomic modulation. We sought to evaluate the impact of 1-week reb-oxy treatment on cardiovascular autonomic control in OSA patients. OSA patients were randomized to a double-blind, crossover trial comparing 4 mg reboxetine plus 5 mg oxybutynin to a placebo for OSA treatment. Heart rate (HR) variability (HRV), ambulatory blood pressure (BP) monitoring (ABPM) over 24 h baseline and after treatment were performed. Baroreflex sensitivity was tested over beat-to-beat BP recordings. 16 subjects with (median [interquartile range]) age 57 [51–61] years and body mass index 30 [26–36]kg/m 2 completed the study. The median nocturnal HR was 65 [60–69] bpm at baseline and increased to 69 [64–77] bpm on reb-oxy vs 66 [59–70] bpm on placebo ( p = 0.02). The mean 24 h HR from ABPM was not different among treatment groups. Reb-oxy administration was not associated with any modification in HRV or BP. Reb-oxy increased the baroreflex sensitivity and did not induce orthostatic hypotension. In conclusion , administration of reb-oxy did not induce clinically relevant sympathetic overactivity over 1-week and, together with a reduction in OSA severity, it improved the baroreflex function.

The interest in photoplethysmography (PPG) for sleep monitoring is increasing because PPG may allow assessing heart rate variability (HRV), which is particularly important in breathing disorders. Thus, we aimed to evaluate how PPG wearable systems measure HRV during sleep at high altitudes, where hypobaric hypoxia induces respiratory disturbances. We considered PPG and electrocardiographic recordings in 21 volunteers sleeping at 4554 m a.s.l. (as a model of sleep breathing disorder), and five alpine guides sleeping at sea level, 6000 m and 6800 m a.s.l. Power spectra, multiscale entropy, and self-similarity were calculated for PPG tachograms and electrocardiography R–R intervals (RRI). Results demonstrated that wearable PPG devices provide HRV measures even at extremely high altitudes. However, the comparison between PPG tachograms and RRI showed discrepancies in the faster spectral components and at the shorter scales of self-similarity and entropy. Furthermore, the changes in sleep HRV from sea level to extremely high altitudes quantified by RRI and PPG tachograms in the five alpine guides tended to be different at the faster frequencies and shorter scales. Discrepancies may be explained by modulations of pulse wave velocity and should be considered to interpret correctly autonomic alterations during sleep from HRV analysis.

BACKGROUND: The recent discovery that a combination of noradrenergic and antimuscarinic drugs improved upper airway muscle function during sleep and reduced OSA severity has revitalized interest in pharmacologic therapies for OSA. RESEARCH QUESTION: Would 1 week of reboxetine plus oxybutynin (Reb-Oxy) be effective on OSA severity? STUDY DESIGN AND METHODS: A randomized, placebo-controlled, double-blind, crossover trial was performed comparing 4 mg reboxetine plus 5 mg oxybutynin (Reb-Oxy) vs placebo in patients with OSA. After a baseline in-laboratory polysomnogram (PSG), patients underwent PSGs after 7 nights of Reb-Oxy and 7 nights of placebo to compare apnea-hypopnea index (AHI), which was the primary outcome. Response rate was based on the percentage of subjects with a >= 50% reduction in AHI from baseline. Secondary outcomes included Epworth Sleepiness Scale (ESS) score and psychomotor vigilance test (PVT) values. Home oximetry evaluated overnight oxygen desaturation index (ODI) throughout treatment. RESULTS: Sixteen subjects aged 57 [51-61] years (median [interquartile range]) with a BMI of 30 [26-36] kg/m(2) completed the study. Reb-Oxy lowered AHI from 49 [35-57] events per hour at baseline to 18 [13-21] events per hour (59% median reduction) compared with 39 [29-48] events per hour (6% median reduction) with placebo (P < .001). Response rate for Reb-Oxy was 81% vs 13% for placebo (P < .001). Although ESS scores were not significantly lowered, PVT median reaction time decreased from 250 [239-312] ms at baseline to 223 [172-244] ms on Reb-Oxy vs 264 [217-284] ms on placebo (P < .001). Home oximetry illustrated acute and sustained improvement in the oxygen desaturation index on Reb-Oxy vs placebo. INTERPRETATION: The administration of Reb-Oxy greatly decreased OSA severity and increased vigilance. These results highlight potential possibilities for pharmacologic treatment of OSA.

The progressive miniaturization of electronic devices and their exponential increase in processing, storage and transmission capabilities, represent key factors of the current digital transformation, also sustaining the great development of Ambient Assisted Living (AAL) and the Internet of Things. Although most of the investigations in the recent years focused on remote monitoring and diagnostics, rehabilitation too could be positively affected by the widespread integrated use of these devices. Smart Objects in particular may be among the enablers to new quantitative approaches. In this paper, we present a proof-of-concept and some preliminary results of an innovative pediatric rehabilitation protocol based on Smart Objects and biofeedback, which we administered to a sample of children with unilateral cerebral palsy. The novelty of the approach mainly consists in placing the sensing device into a common toy (a ball in our protocol) and using the information measured by the device to administer multimedia-enriched type of exercises, more engaging if compared to the usual rehabilitation activities used in clinical settings. We also introduce a couple of performance indexes, which could be helpful for a quantitative continuous evaluation of movements during the exercises. Even if the number of children involved and sessions performed are not suitable to assess any change in the subjects’ abilities, nor to derive solid statistical inferences, the novel approach resulted very engaging and enjoyable by all the children participating in the study. Moreover, given the almost non-existent literature on the use of Smart Objects in pediatric rehabilitation, the few qualitative/quantitative results here reported may promote the scientific and clinical discussion regarding AAL solutions in a “Computer Assisted Rehabilitation” perspective, towards what can be defined “Pediatric Rehabilitation 2.0”.

Coronavirus disease (COVID-19) has severely affected healthcare systems all over the world. Although age, hypertension, cardiovascular diseases, lung diseases, and diabetes mellitus seem to represent the main risk factors for worse outcomes in COVID-19 (1), a possible role has also been ascribed to sleep-disordered breathing (SDB) (2–4). A recent preliminary study collecting questionnaire data in a case series of COVID-19 pneumonia showed that 25% of patients presented a history of SDB (5). It has been hypothesized that SDB might predispose patients to COVID-19 severe pneumonia and that the coexistence of these two respiratory conditions might worsen patients’ prognosis (2, 4). In the days of pandemic outbreak, we sought to correlate the presence and severity of SDB with COVID-19 outcomes during hospitalization. Despite the dramatic situation we were experiencing, which prevented us from optimizing the standardization of examinations, such as the sleep apnea test (SAT), wemanaged to include patients with spontaneous breathing for SDB evaluation. Consecutive patients who were hospitalized at our institution in Milan because of COVID-19 over a 1-month period, from April 8 to May 8, 2020, underwent an SAT. The test was performed either at entry or at any time during the course of hospitalization, provided that the patients were breathing spontaneously. Those who had previously required ventilatory support because of COVID-19 respiratory failure underwent an SAT only after weaning from either noninvasive ventilation (NIV) or invasive mechanical ventilation after improvement of their clinical conditions within the recruitment period. Outcomes were evaluated at the time of patients’ discharge and defined according to the two types of treatments needed during hospitalization: 1) none or oxygen support or 2) NIV, including continuous or bilevel positive airways pressure, or mechanical ventilation in the ICU. Owing to the severity of COVID-19, many patients who were hospitalized required NIV or mechanical support at the time of admission and for a long time, or they eventually died, so they could not be included in our study. The SATs were scored after the recruitment period by a sleep clinician who was blinded to hospitalization outcomes. The patients were treated according to their clinical conditions and following the local guidelines for COVID-19. Based on the international criteria and the apnea–hypopnea index (AHI) calculation, we defined the disease as 1) “none” if AHI, 5/h, 2) “mild” if 5/h 30/h. The 95% confidence interval (CI) of the SDB presence was calculated through the exact Clopper-Pearson method. A Poisson regression model with robust error variance was implemented to estimate the prevalence ratio and its 95% CI to receive mechanical or nonmechanical ventilation. The model included as covariates sex, age, and body mass index (BMI) as continuous variables and those variables that presented P< 0.15 in the univariate analysis. Our study received ethical clearance from the appropriate authority, and all patients provided informed consent to the collection of their clinical data and to the execution of sleep tests for research purposes. Our screened sample included 93 subjects. Among them, 39 did not perform the SAT, as they were using 24-hour NIV because of COVID-19–related respiratory failure. Out of the total 44 patients who underwent the SAT, 13 were on oxygen treatment. Two subjects were treated with nocturnal continuous positive airway pressure owing to their previous history of obstructive sleep apnea (OSA) and were included in the study. The proportion of SDB presence in our sample was 75% (95% CI, 60–87%). Table 1 describes the main characteristics of the 44 subjects stratified for SDB severity; 33 patients (75%) had SDB, of which 15 (34%) presented mild SDB, 6 (14%) presented moderate SDB, and 12 (27%) presented severe disease. Moreover, 15 (34%) patients showed signs of OSA and 18 (41%) showed signs of central sleep apnea. Of the eight patients who had Cheyne-Stokes respiration with central sleep apnea breathing, one had a history of stroke, one of renal failure, three of chronic ischemic cardiopathy, and three were in atrial fibrillation. Concerning outcomes, 24 patients (52%) necessitated only oxygen support, whereas 22 (48%) needed NIV or invasive ventilation in the ICU. Ventilated patients were characterized by higher BMI, predominant OSA, and greater obstructive AHI, as shown in Table 2. Arterial oxygen saturation as measured by pulse oximetry parameters did not differ between the groups, feasibly because of the required oxygen support in the COVID-19 unit. Multivariate analysis revealed that higher BMI (prevalence ratio, 1.20; 95% CI, 1.10–1.31; P, 0.001) and higher obstructive AHI (prevalence ratio, 1.03; 95% CI, 1.01–1.05; P= 0.015) were the variables significantly associated with the need of ventilation. To our knowledge, this is the first evaluation of SAT in patients hospitalized for COVID-19. Almost two-thirds of our sample had SDB, and OSA severity predicted respiratory outcome. Several mechanisms may contribute to the increased risk of severe COVID-19 in patients with OSA (6). Even though obesity confirms an established relation with OSA (4), our findings highlight that higher obstructive AHI is also associated with the need of NIV or invasive ventilation, even after controlling for age and BMI. Our interpretation is supported by the results of a recent study by Feuth and colleagues (7), who found that 29% of their cohort of patients hospitalized for COVID-19 presented a previous diagnosis of OSA, although not confirmed using SAT. Previous evidence on patients hospitalized for different kinds of respiratory This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/). For commercial usage and reprints, please contact Diane Gern (dgern@thoracic.org).

The progressive miniaturization of electronic devices and their exponential increase in processing, storage and transmission capabilities, is opening new scenarios in pervasive computing, like the Ambient Assisted Living (AAL) and Internet Of Things (IoT). Although most of the investigations in the recent years focused on remote monitoring and diagnostic efforts, rehabilitation too could be positively affected by the use of these solutions, since these small Smart Objects may enable novel quantitative approaches. In this paper, we present the preliminary efforts in designing a pediatric rehabilitation protocol based on Smart Objects and biofeedback, which we administered to a small sample of hemiplegic children. Despite the few treatments (not suitable to assess any change in the subjects’ abilities), children enjoyed participating in the study, and the initial qualitative/quantitative results highlight that such approach could represent an interesting starting point to fuel the scientific and clinical discussion towards a Pediatric Rehabilitation 2.0.

The progressive miniaturization of electronic devices and their exponential increase in processing, storage and transmission capabilities, is leading to unprecedented scenarios as the Internet of Things (IoT). Although most of the recent biomedical research applications of pervasive technology focused on remote monitoring and diagnostics, Smart Objects may enable novel quantitative approaches in rehabilitation too. In this paper, we present some preliminary results regarding a pediatric rehabilitation protocol based on Smart Objects and biofeedback, administered to a small group of hemiplegic children. Despite the very limited number of treatments, all children enjoyed participating in the study, and the preliminary results represent an interesting starting point to fuel the scientific and clinical discussion towards what could be defined “Pediatric Rehabilitation 2.0”.

BACKGROUND AND OBJECTIVE:The presence of executive deficits in patients with Amyotrophic Lateral Sclerosis is well established, even if standardized measures are difficult to obtain due to progressive physical disability of the patients. We present clinical data concerning a newly developed measure of cognitive flexibility, administered by means of Eye-Tracking (ET) technology in order to bypass verbal-motor limitations.METHODS:21 ALS patients and 21 age-and education-matched healthy subjects participated in an ET-based cognitive assessment, including a newly developed test of cognitive flexibility (Arrows and Colors Cognitive Test-ACCT) and other oculomotor-driven measures of cognitive functions. A standard screening of frontal and working memory abilities and global cognitive efficiency was administered to all subjects, in addition to a psychological self-rated assessment. For ALS patients, a clinical examination was also performed.RESULTS:ACCT successfully discriminated between patients and healthy controls, mainly concerning execution times obtained at different subtests. A qualitative analysis performed on error distributions in patients highlighted a lower prevalence of perseverative errors, with respect to other type of errors. Correlations between ACCT and other ET-based frontal-executive measures were significant and involved different frontal sub-domains. Limited correlations were observed between ACCT and standard 'paper and pencil' cognitive tests.CONCLUSIONS:The newly developed ET-based measure of cognitive flexibility could be a useful tool to detect slight frontal impairments in non-demented ALS patients by bypassing verbal-motor limitations through the oculomotor-driven administration. The findings reported in the present study represent the first contribution towards the development of a full verbal-motor free executive test for ALS patients.

Pediatric Rehabilitation therapists have always worked using a variety of off-the-shelf or custom-made objects and devices, more recently including computer based systems. These Information and Communication Technology (ICT) solutions vary widely in complexity, from easy-to-use interactive videogame consoles originally intended for entertainment purposes to sophisticated systems specifically developed for rehabilitation. This paper describes the principles underlying an innovative “Pediatric Rehabilitation 2.0” approach, based on the combination of suitable ICT solutions and traditional rehabilitation, which has been progressively refined while building up and using a computer-assisted rehabilitation laboratory. These principles are thus summarized in the acronym EPIQ, to account for the terms Ecological, Personalized, Interactive and Quantitative. The paper also presents the laboratory, which has been designed to meet the children’s rehabilitation needs and to empower therapists in their work. The laboratory is equipped with commercial hardware and specially developed software called VITAMIN: a virtual reality platform for motor and cognitive rehabilitation.