Diseño de entornos de realidad virtual aplicables a sistemas de robótica asistencial: un análisis literario

Virtual Reality (VR) environments can be applied to assistive robotics to improve the effectiveness and the user experience perception in the rehabilitation process due to its innovative nature, getting to entertain patients while they recover their motor functions. This literature review pretends to analyze some design principles of VR environments developed for upper limb rehabilitation processes. The idea is to identify features related to peripheral and central nervous systems, types of information included as feedback to increase the user's levels of immersion having a positive impact on the user's performance and experience during the treatment. A total of 32 articles published in Scopus, IEEE, PubMed, and Web of Science in the last four years were reviewed. We present the article selection process, the division by concepts presented previously, and the guidelines that can be considered for the design of VR environments applicable to assistive robots for upper limbs rehabilitation processes.Los entornos de Realidad Virtual (RV) aplicables a sistemas de robótica asistencial pueden ser diseñados de manera que mejoren la efectividad y la experiencia de usuario de los procesos de rehabilitación debido a su naturaleza novedosa, logrando entretener a los pacientes mientras recuperan sus funciones motoras. Esta revisión literaria pretende analizar los criterios de diseño de entornos de RV utilizados en procesos de rehabilitación de miembro superior, identificando las características de entornos para rehabilitación de problemas asociados el sistema nervioso central y periféricos, los tipos de información que se realimenta al usuario para beneficiar los niveles de inmersión y su impacto en términos del desempeño y la experiencia del usuario en tratamiento. Un total de 32 artículos publicados en revistas indexadas de Scopus, IEEE, PubMed y Web of Science en los últimos cuatro años fueron revisados. Se presenta el proceso de selección de artículos, la división por las temáticas presentadas anteriormente y los lineamientos generales que pueden ser considerados para el diseño de entornos de RV aplicables a robots asistenciales en procesos de rehabilitación de miembro superior

Effect of virtual reality rehabilitation on motor function in patients with stroke : a narrative review

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2021Introdução: O acidente vascular cerebral é uma das principais causas de morte e incapacidade no mundo, sendo descrita como uma epidemia global. Défices motores causados por esta etiologia, afetam as tarefas diárias, bem como, a atividade profissional destas pessoas, resultando num dia-a-dia repleto de obstáculos. Desta forma, a reabilitação tem um papel fulcral, na melhoria destas queixas e consequentemente na qualidade de vida. A realidade virtual é uma ferramenta, que nos recentes anos tem vindo a ganhar um papel cada vez de maior importância para estes doentes. Nesta revisão narrativa, pretendemos comparar a reabilitação convencional com a reabilitação baseada na realidade virtual e perceber, desta forma, se existe benefício na combinação de ambas. Métodos: A nossa estratégia de pesquisa consistiu na pesquisa de ensaios clínicos randomizados em três diferentes plataformas (PubMed, sci-Elo e medRxiv), publicados nos últimos 10 anos cujo objetivo primário se focasse na função motora dos membros superiores. Usamos as seguintes palavras-chave como ponto de partida para a pesquisa de artigos: “Virtual Reality”, “rehabilitation”, “stroke”. Após ser aplicada a estratégia de pesquisa acima mencionada, obtivemos um total de 100 artigos. Após análise destes mesmos 100 artigos, somente 26 tinham os critérios necessários para a sua utilização na revisão, com uma amostra total de 1382 pacientes envolvidos nesta revisão de narrativa. Resultados: Como referido previamente, dos 100 artigos, somente 26 foram utilizados para a construção desta revisão narrativa. Os 74 artigos foram excluídos por não preencherem os critérios necessários para a sua inclusão. O facto do artigo não se focar na função motora do membro superior, foi a principal causa de exclusão de artigos. Outras razões como duplicados, não ter acesso livre, não focar o seu estudo na reabilitação do acidente vascular cerebral e não focar no estudo da realidade virtual também foram motivos para exclusão. Conclusão: Devido a inúmeras variáveis entre os diferentes ensaios, é impossível a conclusão de possíveis conexões entre a intervenção e os resultados obtidos. Sugere-se a realização de estudos em que certas variáveis como a intervenção realizada ao grupo de intervenção, o número de sessões, a duração das mesmas, sejam homogeneizados.Introduction: Stroke is one of the leading causes of death and disability and has been described as a worldwide epidemic. Motor function deficits due to stroke affect the patients' performance in daily tasks as well as in their jobs, which results in an increased difficulty in their everyday life. This way, rehabilitation in these patients plays an important role trying to improve their motor function and therefore their quality of life. Virtual reality, in recent years, has been increasingly more popular in this type of patients. In this narrative review, we aim to compare conventional therapy versus virtual reality-based therapy and find out if there is any kind of benefit in combining conventional therapy with virtual reality-based therapy. Methods: Our search strategy consisted in searching for randomized controlled trials published in the last 10 years with the primary outcome focusing on upper limb motor function, in three different platforms (PubMed, sci-Elo and medRxiv) using the following keywords: “virtual reality”, “rehabilitation”, “stroke”. After applied our search strategy we ended up with a total of 100 articles. After analyzing the 100 trials, only 26 of them met the necessary criteria to take part of this review, with a total sample of 1382 patients involved in the narrative review. Results: As previously mentioned, of the 100 articles, only 26 were used to build this narrative review. 74 articles excluded for not meeting the necessary criteria to make part of this review. The fact that the article did not focus on the motor function of the upper limb was the main reason for the exclusion of articles. Other reasons such as duplicates, not having open access, not focusing their study on stroke rehabilitation and not focusing on the study on virtual reality were also reasons for exclusion. Conclusion: Due to numerous variables between the different trials, it is impossible to conclude possible connections between the intervention and the results obtained. It is suggested that studies should be carried out with certain variables, such as the intervention carried out in the intervention group, the number of sessions, the duration of the sessions, homogenized

Neuroplastic Changes Following Brain Ischemia and their Contribution to Stroke Recovery: Novel Approaches in Neurorehabilitation

Ischemic damage to the brain triggers substantial reorganization of spared areas and pathways, which is associated with limited, spontaneous restoration of function. A better understanding of this plastic remodeling is crucial to develop more effective strategies for stroke rehabilitation. In this review article, we discuss advances in the comprehension of post-stroke network reorganization in patients and animal models. We first focus on rodent studies that have shed light on the mechanisms underlying neuronal remodeling in the perilesional area and contralesional hemisphere after motor cortex infarcts. Analysis of electrophysiological data has demonstrated brain-wide alterations in functional connectivity in both hemispheres, well beyond the infarcted area. We then illustrate the potential use of non-invasive brain stimulation (NIBS) techniques to boost recovery. We finally discuss rehabilitative protocols based on robotic devices as a tool to promote endogenous plasticity and functional restoration

The role of sound in robot-assisted hand function training post-stroke

In Folge eines Schlaganfalls leiden 90% aller Patienten an einer Handparese, die sich in 30-40% als chronisch manifestiert. Derzeit wächst seitens der Neurologie und Technologie das Forschungsinteresse an der Effektivität robotergestützter Therapieansätze, welche für schwer betroffene Patienten als besonders vielversprechend eingestuft werden. Die hierfür verwendeten Therapieroboter setzen sich aus einem mechanischen Teil und einer softwaregestützten virtuellen Umgebung zusammen, welche neben dem graphischen Interface, audio-visuelles Feedback sowie Musik beinhaltet. Bisher wurden Effekte der klanglichen Anteile dieses Szenarios noch nicht hinsichtlich möglicher Einflüsse auf Motivation, Bewegungsdurchführung, motorisches Lernen und den gesamten Rehabilitationsprozess untersucht. Die vorliegende Arbeit untersucht die Rolle von Sound in robotergestütztem Handfunktionstraining. Die Hauptziele im Rahmen dessen sind es, 1) Potentiale von Sound/ Musik für den Kontext robotergestützten Handfunktionstrainings zu explorieren, 2) spezifizierte klangliche Umgebungen zu entwickeln, 3) zu untersuchen, ob Schlaganfallpatienten von diesen spezifizierten Soundanwendungen profitieren, 4) ein besseres Verständnis über Wirkmechanismen von Sound und Musik mit Potential für robotergestützte Therapie darzulegen, und 5) Folgetechnologien über eine effektive Applikation von Sound/ Musik in robotergestützter Therapie zu informieren.90% of all stroke survivors suffer from a hand paresis which remains chronic in 30-40% of all cases. Currently, there is an increasing research interest in neurology and technology on the effectiveness of robot-assisted therapies. Robotic training is considered as especially promising for patients suffering from severe limitations. Commonly, rehabilitation robots consist of a mechanical part and a virtual training environment with a graphical user interface, audio-visual feedback, sound, and music. So far, the effects of sound and music that are embedded within these scenarios have never been evaluated in particular while taking into account that it might influence motivation, motor execution, motor learning and the whole recovery process. This thesis investigates the role of sound in robot-assisted hand function training post-stroke. The main goals of this work are 1) to explore potentials of sound/ music for robotic hand function training post-stroke, 2) to develop specified sound-/ music-applications for this context, 3) to examine whether stroke patients benefit from these specified sound/ music-application, 4) to gain a better understanding of sound-/ music-induced mechanisms with therapeutic potentials for robotic therapy, and 5) to inform further arising treatment approaches about effective applications of sound or music in robotic post-stroke motor training

Technology-supported training of arm-hand skills in stroke

Impaired arm-hand performance is a serious consequence of stroke that is associated with reduced self-efficacy and poor quality of life. Task-oriented arm training is a therapy approach that is known to improve skilled arm-hand performance, even in chronic stages after stroke. At the start of this project, little knowledge had been consolidated regarding taskoriented arm training characteristics, especially in the field of technology-supported rehabilitation. The feasibility and effects of technology-supported client-centred task-oriented training on skilled arm-hand performance had not been investigated but to a very limited degree. Reviewing literature on rehabilitation and motor learning in stroke led to the identification of therapy oriented criteria for rehabilitation technology aiming to influence skilled arm-hand performance (chapter 2). Most rehabilitation systems reported in literature to date are robotic systems that are aimed at providing an engaging exercise environment and feedback on motor performance. Both, feedback and engaging exercises are important for motivating patients to perform a high number of exercise repetitions and prolonged training, which are important factors for motor learning. The review also found that current rehabilitation technology is focussed mainly on providing treatment at a function level, thereby improving joint range of motion, muscle strength and parameters such as movement speed and smoothness of movement during analytical movements. However, related research has found no effects of robot-supported training at the activity level. The review concluded that a challenge exists for upper extremity rehabilitation technology in stroke patients to also provide more patienttailored task-oriented arm-hand training in natural environments to support the learning of skilled arm-hand performance. Besides mapping the strengths of different technological solutions, the use of outcome measures and training protocols needs to become more standardized across similar interventions, in order to help determine which training solutions are most suitable for specific patient categories. Chapter 4 contributes towards such a standardization of outcome measurement. A concept is introduced which may guide the clinician/researcher to choose outcome measures for evaluating specific and generalized training effects. As an initial operationalization of this concept, 28 test batteries that have been used in 16 task-oriented training interventions were rated as to whether measurement components were measured by the test. Future research is suggested that elaborates the concept with information on the relative weighing of components in each test, with more test batteries (which may lead to additional components) and by adding more test properties into the concept (e.g. psychometric properties of the tests, possible floor- or ceiling effects). Task-oriented training is one of the training approaches that has been shown to be beneficial for skilled arm-hand performance after stroke. Important mechanisms for motor learning that are identified are patient motivation for such training, and the learning of efficient goaloriented movement strategies and task-specific problem solving. In this thesis we operationalize task-oriented training in terms of 15 components (chapter 3). A systematic review that included 16 randomized controlled trials using task-oriented training in stroke patients, evaluated the effects of these training components on skilled arm-hand performance. The number of training components used in an intervention aimed at improving arm-hand performance after stroke was not associated with the post-treatment effect size. Distributed practice and feedback were associated with the largest post-intervention effect sizes. Random practice and use of clear functional training goals were associated with the largest follow-up effect sizes. It may be that training components that optimize the storage of learned motor performance in the long-term memory are associated with larger treatment effects. Unfortunately, feedback, random practice and distributed practice were reported in very few of the included randomized controlled trials (in only 6,3 and 1 out of the 17 studies respectively). Client-centred training, i.e. training on exercises that support goals that are selected by the patients themselves, improves patient motivation for training. Motivation in turn has proven to positively influence motor learning in stroke patients, as attention during training is heightened and storage of information in the long-term memory improves. Chapter 5 reports on an interview of 40 stroke patients, investigating into training preferences. A list of 46 skills, ranked according to descending training preference scores, was provided that can be used for implementation of exercises in rehabilitation technology, in order for technologysupported training to be client-centred. Chapter 6 introduces T-TOAT, a technology supported task-oriented arm training method that was developed together with colleagues at Adelante (Hoensbroek, NL). T-TOAT enables the implementation of exercises that support task-oriented training in rehabilitation technology. The training method is applicable for different technological systems, e.g. robot and sensor systems, or in combination with functional electrical stimulation, etc. To enable the use of TTOAT for training with the Haptic Master Robot (MOOG-FCS, NL), special software named Haptic TOAT was developed in Adelante together with colleagues at the Centre of Technology in Care of Zuyd University (chapter 6). The software enables the recording of the patient’s movement trajectories, given task constraints and patient possibilities, using the Haptic Master as a recording device. A purpose-made gimbal was attached to the endeffector, leaving the hand free for the use and manipulating objects. The recorded movement can be replayed in a passive mode or in an active mode (active, active-assisted or activeresisted). Haptic feedback is provided when the patient deviates from the recorded movement trajectory, as the patient receives the sensation of bouncing into a wall, as well as feeling a spring that pulls him/her back to the recorded path. The diameter of the tunnel around the recorded trajectory (distance to the wall), and the spring force can be adjusted for each patient. An ongoing clinical trial in which chronic stroke patients train with Haptic-TOAT examines whether Haptic Master provides additional value compared to supporting the same exercises by video-instruction only. Together with Philips Research Europe (Eindhoven,Aachen), the T-TOAT method has been implemented in a sensor based prototype, called Philips Stroke Rehabilitation Exerciser. This system included movement tracking sensors and an exercise board interacting with real life objects. A very strong feature of the system is that feedback is provided to patients (real-time and after exercise performance), based on a comparison of the patient’s exercise performance to individual targets set by the therapist. Chapter 7 reports on a clinical trial investigating arm-hand treatment outcome and patient motivation for technology-supported task-oriented training in chronic stroke patients. It was found that 8 weeks of T-TOAT training improved arm-hand performance in chronic stroke patients significantly on Fugl-Meyer, Action Research Arm Test, and Motor Activity Log. An improvement was found in health-related quality of life. Training effects lasted at least 6 months post-training. Participants reported feeling intrinsically motivated and competent to use the system. The results of this study showed that T-TOAT is feasible. Despite the small number of stroke patients tested (n=9), significant and clinically relevant improvements in skilled arm-hand performance were found. In conclusion, this thesis has made several contributions. It motivated the need for clientcentred task-oriented training, which it has operationalized in terms of 15 components. Four of these 15 components were identified as most beneficial for the patient. A prioritized inventory of arm-hand training preferences of stroke patients was compiled by means of an interview study of 40 subacute and chronic stroke patients. T-TOAT, a method for technology-supported, client-centred, task-oriented training, was conceived and implemented in two target technologies (Haptic Master and Philips Stroke Rehabilitation Exerciser). Its feasibility was demonstrated in a clinical trial showing substantial and durable benefits for the stroke patients. Finally, the thesis contributes towards the standardization of outcome measures which is necessary for charting progress and guiding future developments of technology-supported stroke rehabilitation. Methodological considerations were discussed and several suggestions for future research were presented. The variety of treatment approaches and the various ways of support and challenge that are offered by existing rehabilitation technologies hold a large potential for offering a variety of extra training opportunities to stroke patients that may improve their arm-hand performance. Such solutions will be of increasing importance, to alleviate therapists and reduce economic pressure on the health care system, as the stroke incidence is increasing rapidly over the coming decades

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design

<p>Abstract</p> <p>Background</p> <p>It is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning.</p> <p>Methods</p> <p>A literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997–2007).</p> <p>Results</p> <p>One hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems.</p> <p>Conclusion</p> <p>This review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.</p

Effectiveness of intensive physiotherapy for gait improvement in stroke: systematic review

Introduction: Stroke is one of the leading causes of functional disability worldwide. Approximately 80% of post-stroke subjects have motor changes. Improvement of gait pattern is one of the main objectives of physiotherapists intervention in these cases. The real challenge in the recovery of gait after stroke is to understand how the remaining neural networks can be modified, to be able to provide response strategies that compensate for the function of the affected structures. There is evidence that intensive training, including physiotherapy, positively influences neuroplasticity, improving mobility, pattern and gait velocity in post-stroke recovery. Objectives: Review and analyze in a systematic way the experimental studies (RCT) that evaluate the effects of Intensive Physiotherapy on gait improvement in poststroke subjects. Methodology: Were only included all RCT performed in humans, without any specific age, that had a clinical diagnosis of stroke at any stage of evolution, with sensorimotor deficits and functional gait changes. The databases used were: Pubmed, PEDro (Physiotherapy Evidence Database) and CENTRAL (Cochrane Center Register of Controlled Trials). Results: After the application of the criteria, there were 4 final studies that were included in the systematic review. 3 of the studies obtained a score of 8 on the PEDro scale and 1 obtained a score of 4. The fact that there is clinical and methodological heterogeneity in the studies evaluated, supports the realization of the current systematic narrative review, without meta-analysis. Discussion: Although the results obtained in the 4 studies are promising, it is important to note that the significant improvements that have been found, should be carefully considered since pilot studies with small samples, such as these, are not designed to test differences between groups, in terms of the effectiveness of the intervention applied. Conclusion: Intensive Physiotherapy seems to be safe and applicable in post-stroke subjects and there are indications that it is effective in improving gait, namely speed, travelled distance and spatiotemporal parameters. However, there is a need to develop more RCTs with larger samples and that evaluate the longterm resultsN/

Non-invasive brain stimulation techniques for the improvement of upper limb motor function and performance in activities of daily living after stroke: a systematic review and network meta-analysis

Objective: To compare the efficacy of non-invasive brain stimulation (NiBS) such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), theta-burst stimulation (TBS), and transcutaneous vagus nerve stimulation (taVNS) in upper limb stroke rehabilitation. Data sources: PubMed, Web of Science, and Cochrane databases were searched from January 2010 to June 2022. Data selection: Randomized controlled trials (RCT's) assessing the effects of "tDCS", "rTMS", "TBS", or "taVNS" on upper limb motor function and performance in activities of daily livings (ADLs) after stroke. Data extraction: Data were extracted by 2 independent reviewers. Risk of bias were was evaluated with the Cochrane Risk of Bias tool. Data synthesis: 87 RCTs with 3750 participants were included. Pairwise meta-analysis showed that all NiBS except continuous TBS (cTBS) and cathodal tDCS were significantly more efficacious than sham stimulation for motor function (Standard Meand Differerence (SMD) range 0.42 to 1.20) whereas taVNS, anodal tDCS, and both low and high frequency rTMS were significantly more efficacious than sham stimulation for ADLs (SMD range 0.54 to 0.99). NMA showed that taVNS was more effective than cTBS (SMD:1.00;95%CI(0.02 to 2.02), cathodal tDCS (SMD:1.07;95%CI(0.21 to 1.92) and Physical rehabilitation alone (SMD:1.46;95%CI(0.59 to 2.33)) for improving motor function. P-score found that taVNS is best ranked treatment in improving motor function (SMD: 1.20;95%CI(0.46 to 1.95) and ADLs (SMD:1.20;95%CI(0.45 to 1.94) after stroke. After taVNS, excitatory stimulation protocols (intermittent TBS, anodal tDCS and HF-rTMS) are most effective in improving motor function and ADLs after acute/sub-acute (SMD range 0.53 to 1.63) and chronic stroke (SMD range 0.39 to 1.16). Conclusions: Evidence suggests that excitatory stimulation protocols are the most promising intervention in improving upper limb motor function and performance in ADLs. taVNS appeared to be a promising intervention for stroke patients, but further large RCTs are required to confirm its relative superiority

Use of Electroencephalography Brain-Computer Interface Systems as a Rehabilitative Approach for Upper Limb Function After a Stroke: A Systematic Review

Background: Brain-computer interface (BCI) systems have been suggested as a promising tool for neurorehabilitation. However, to date, there is a lack of homogeneous findings. Furthermore, no systematic reviews have analyzed the degree of validation of these interventions for upper limb (UL) motor rehabilitation poststroke. Objectives: The study aims were to compile all available studies that assess an UL intervention based on an electroencephalography (EEG) BCI system in stroke; to analyze the methodological quality of the studies retrieved; and to determine the effects of these interventions on the improvement of motor abilities. Type: This was a systematic review. Literature Survey: Searches were conducted in PubMed, PEDro, Embase, Cumulative Index to Nursing and Allied Health, Web of Science, and Cochrane Central Register of Controlled Trial from inception to September 30, 2015. Methodology: This systematic review compiles all available studies that assess UL intervention based on an EEG-BCI system in patients with stroke, analyzing their methodological quality using the Critical Review Form for Quantitative Studies, and determining the grade of recommendation of these interventions for improving motor abilities as established by the Oxford Centre for Evidence-based Medicine. The articles were selected according to the following criteria: studies evaluating an EEG-based BCI intervention; studies including patients with a stroke and hemiplegia, regardless of lesion origin or temporal evolution; interventions using an EEG-based BCI to restore functional abilities of the affected UL, regardless of the interface used or its combination with other therapies; and studies using validated tools to evaluate motor function. Synthesis: After the literature search, 13 articles were included in this review: 4 studies were randomized controlled trials; 1 study was a controlled study; 4 studies were case series studies; and 4 studies were case reports. The methodological quality of the included papers ranged from 6 to 15, and the level of evidence varied from 1b to 5. The articles included in this review involved a total of 141 stroke patients. Conclusions: This systematic review suggests that BCI interventions may be a promising rehabilitation approach in subjects with stroke. Level of Evidence: I

Nuovi approcci per la riabilitazione dell&#8217;arto superiore paretico dopo ictus cerebri

Il deficit funzionale dell\u2019arto superiore \ue8 una tra le pi\uf9 invalidanti sequele dello stroke. Esso gioca, infatti, un ruolo fondamentale nelle attivit\ue0 della vita quotidiana (ADL) e nella vita sociale e lavorativa. Per fronteggiare questa problematica, negli ultimi anni sono state introdotte nuove metodiche riabilitative. Questa revisione si propone di fornire una sintesi dei nuovi approcci riabilitativi, sulla base di un\u2019analisi della letteratura, con riferimento alle evidenze e alle prove di efficacia, distinguendo i risultati nelle diverse fasi del percorso riabilitativo (acuta, subacuta, cronica). \uc8 stata condotta una ricerca bibliografica, estesa al periodo gennaio 2013-luglio 2018. Sono stati selezionati 124 studi relativi a Trial Clinici, che avessero come oggetto pazienti adulti (&gt; 18 anni) affetti da ictus cerebri, riabilitati con le seguenti metodiche: Action Observation Training (AOT), Bilateral Transfer (BT), Bio-feedback (BF), Constraint Induced Motor Therapy (CIMT), Mirror Therapy (MT), Realt\ue0 Virtuale (VR), Robot Assistance (RA), Stimolazione Elettrica Funzionale e Neuromuscolare (FES e NMES) e Stimolazione Transcranica con Correnti Dirette (tDCS). La revisione ha evidenziato che la letteratura non \ue8 esaustiva, n\ue9 omogenea circa le metodiche analizzate. I dati pi\uf9 rilevanti sono quelli relativi alla CIMT in fase cronica e alla MT in fase subacuta. Altri dati interessanti sono stati evidenziati per la MT in fase cronica e per la FES e NMES in fase cronica. I risultati meno significativi invece sono stati riscontrati con l\u2019utilizzo della VR in fase subacuta, della RA in fase cronica e della tDCS in fase subacuta