Physical and Rehabilitation Medicine: say relational or functional, not holistic.

Modern medicine tends to privilege disciplines promising "objective" laws governing body parts (from molecules to organs). Studies on a person's illness and disability are (apparently) confined to "subjectivity." The Specialty of Physical and Rehabilitation Medicine is often regarded as a humanitarian approach, belonging at best to the family of "soft," "qualitative," or "quasi-experimental" sciences. This specialty often claims specificity by labelling itself as "functional" and "holistic." However, it is shown here that the former term is acceptable, yet redundant, and the second misleading. When human behaviors and perceptions are at stake, "function" indicates a person's relationship with the outer world (already tackled by the definitional term "physical" from the Greek "physis"). The word "holistic" emphasizes mind-body unity and person-environment interdependence but, in current usage, overshadows the complementary need for an analytic, experimental approach to any function. Medicine aims at fighting disease and disability in single persons. This endeavor requires knowing body parts and mechanisms and understanding how interventions on "parts" affect the "whole." This understanding rests on the experimental method. For instance, returning to a given societal role (participation) may require restoration of walking (activity), which may require reinforcement of weakened muscular groups (impairment). Working only on holistic bio-psycho-social "wholes" may miss the therapeutic mission of medicine.

Interpreting results from Rasch analysis 1. The "most likely" measures coming from the model.

Purpose: The present article summarises the characteristics of Rasch's theory, providing an original metrological model for persons' measurements. Properties describing the person "as a whole" are key outcome variables in Medicine. This is particularly true in Physical and Rehabilitation Medicine, targeting the person's interaction with the outer world. Such variables include independence, pain, fatigue, balance, and the like. These variables can only be observed through behaviours of various complexity, deemed representative of a given "latent" person's property. So how to infer its "quantity"? Usually, behaviours (items) are scored ordinally, and their "raw" scores are summed across item lists (questionnaires). The limits and flaws of scores (i.e., multidimensionality, non-linearity) are well known, yet they still dominate the measurement in Medicine.Conclusions: Through Rasch's theory and statistical analysis, scores are transformed and tested for their capacity to respect fundamental measurement axioms. Rasch analysis returns the linear measure of the person's property ("ability") and the item's calibrations ("difficulty"), concealed by the raw scores. The difference between a person's ability and item difficulty determines the probability that a "pass" response is observed. The discrepancy between observed scores and the ideal measures (i.e., the residual) invites diagnostic reasoning. In a companion article, advanced applications of Rasch modelling are illustrated. Implications for rehabilitationQuestionnaires' ordinal scores are poor approximations of measures. The Rasch analysis turns questionnaires' scores into interval measures, provided that its assumptions are respected.Thanks to the Rasch analysis, accurate measures of independence, pain, fatigue, cognitive capacities and other whole person's variables of paramount importance in rehabilitation are available.The current work is addressed to rehabilitation professionals looking for an introduction to interpreting published results based on Rasch analysis.The first of a series of two, the present article illustrates the most common graphic and numeric outputs found in published papers presenting the Rasch analysis of questionnaires.

Interpreting results from Rasch analysis 2. Advanced model applications and the data-model fit assessment.

Purpose: The present paper presents developments and advanced practical applications of Rasch's theory and statistical analysis to construct questionnaires for measuring a person's traits. The flaws of questionnaires providing raw scores are well known. Scores only approximate objective, linear measures. The Rasch Analysis allows you to turn raw scores into measures with an error estimate, satisfying fundamental measurement axioms (e.g., unidimensionality, linearity, generalizability). A previous companion article illustrated the most frequent graphic and numeric representations of results obtained through Rasch Analysis. A more advanced description of the method is presented here.Conclusions: Measures obtained through Rasch Analysis may foster the advancement of the scientific assessment of behaviours, perceptions, skills, attitudes, and knowledge so frequently faced in Physical and Rehabilitation Medicine, not less than in social and educational sciences. Furthermore, suggestions are given on interpreting and managing the inevitable discrepancies between observed scores and ideal measures (data-model "misfit"). Finally, twelve practical take-home messages for appraising published results are provided.Implications for rehabilitationThe current work is the second of two papers addressed to rehabilitation clinicians looking for an in-depth introduction to the Rasch analysis.The first paper illustrates the most common results reported in published papers presenting the Rasch analysis of questionnaires.The present article illustrates more advanced applications of the Rasch analysis, also frequently found in publications.Twelve take-home messages are given for a critical appraisal of the results.

Reversed Mirror Therapy (REMIT) after Stroke-A Proof-of-Concept Study.

In mirror training (MIT), stroke patients strive to move their hands while looking at the reflected image of the unaffected one. The recruitment of the mirror neurons and visual-proprioceptive conflict are expected to facilitate the paretic voluntary movement. Here, a reversed MIT (REMIT) is presented, which requires moving hands while looking at the reflected image of the paretic one, giving the illusion of being unable to move the unimpaired hand. This study compares MIT and REMIT on post-stroke upper-limb recovery to gain clues on the mechanism of action of mirror therapies. Eight chronic stroke patients underwent two weeks of MIT and REMIT (five sessions each) in a crossover design. Upper-limb Fugl-Meyer, Box and Block and handgrip strength tests were administered at baseline and treatments end. The strength of the mirror illusion was evaluated after each session. MIT induced a larger illusory effect. The Fugl-Meyer score improved to the same extent after both treatments. No changes occurred in the Box and Block and the handgrip tests. REMIT and MIT were equally effective on upper-limb dexterity, challenging the exclusive role of mirror neurons. Contrasting learned nonuse through an intersensory conflict might provide the rationale for both forms of mirror-based rehabilitation after stroke.

Cervical Proprioception Assessed through Targeted Head Repositioning: Validation of a Clinical Test Based on Optoelectronic Measures.

Neck proprioception is commonly assessed with head repositioning tests. In such a test, an operator rotates the head of a blindfolded individual to a target position. After returning to the rest position, the participant actively repositions the head to the target. Joint Position Error (JPE) is the angular difference between the target angle (however oriented in a 3D space) and the actively reached positions (the smaller the difference, the better the proprioception). This study aimed to validate a head-to-target (HTT) repositioning test using an optoelectronic system for also measuring the components of the JPE in the horizontal, frontal, and sagittal planes. The head movements requested by the operator consisted of 30° left-right rotations and 25° flexion-extension. The operators or subjects could not obtain these movements without modest rotations in other planes. Two operators were involved. Twenty-six healthy participants (13 women) were recruited (mean (SD): 33.4 (6.3) years). The subjects' JPE in the requested (intended) plane of motion (JPEint-component) was a few degrees only and smaller for flexion-extensions than for left-right rotations (right rotation: 5.39° (5.29°); left rotation: 5.03° (4.51°), extension: 1.79° (3.94°); flexion: 0.54° (4.35°)). Participants' average error in unintended planes was around 1° or less. Inter-operator consistency and agreement were high. The smallest detectable change, at p < 0.05, for JPEint-component ranged between 4.5° and 6.98°. This method of optoelectronic measurement in HTT repositioning tests provides results with good metric properties, fostering application to clinical studies.

Validation of "Neurit.Space": Three Digital Tests for the Neuropsychological Evaluation of Unilateral Spatial Neglect.

Patients suffering from Unilateral Spatial Neglect (USN) fail to pay attention to, respond to, and report sensory events occurring in the contralesional side of space. The traditional neuropsychological assessment of USN is based on paper-and-pencil tests, whose data recording and scoring may be subjected to human error. The utilization of technological devices can be expected to improve the assessment of USN. Therefore, we built Neurit.Space, a modified digital version of three paper-and-pencil tests, widely used to detect signs of USN, namely: Bells Cancellation, Line Bisection and Five Elements Drawing Test. Administration and data processing is fully automatic. Twelve right brain-damaged patients (six with and six without USN) and 12 age- and education-balanced healthy participants were enrolled in the study. All participants were administered both the computerized and the paper-and-pencil versions of the tests. The results of this preliminary study showed good sensitivity, specificity, and usability of Neurit.Space, suggesting that these digital tests are a promising tool for the evaluation of USN, both in clinical and in research settings.

Determinants of age-related decline in walking speed in older women.

Background: Walking speed is reduced with aging. However, it is not certain whether the reduced walking speed is associated with physical and coordination fitness. This study explores the physical and coordination determinants of the walking speed decline in older women. Methods: One-hundred-eighty-seven active older women (72.2 ± 6.8 years) were asked to perform a 10-m walk test (self-selected and maximal walking speed) and a battery of the Senior fitness test: lower body strength, lower body flexibility, agility/dynamic balance, and aerobic endurance. Two parameters characterized the walking performance: closeness to the modeled speed minimizing the energetic cost per unit distance (locomotor rehabilitation index, LRI), and the ratio of step length to step cadence (walk ratio, WR). For dependent variables (self-selected and maximal walking speeds), a recursive partitioning algorithm (classification and regression tree) was adopted, highlighting interactions across all the independent variables. Results: Participants were aged from 60 to 88 years, and their self-selected and maximal speeds declined by 22% and 26% (p < 0.05), respectively. Similarly, all physical fitness variables worsened with aging (muscle strength: 33%; flexibility: 0 to -8 cm; balance: 22%; aerobic endurance: 12%; all p < 0.050). The predictors of maximal walking speed were only WR and balance. No meaningful predictions could be made using LRI and WR as dependent variables. Discussion: The results suggest that at self-selected speed, the decrease in speed itself is sufficient to compensate for the age-related decline in the motor functions tested; by contrast, lowering the WR is required at maximal speed, presumably to prevent imbalance. Therefore, any excessive lowering of LRI and WR indicates loss of homeostasis of walking mechanics and invites diagnostic investigation.

A multi-center international study on the spinal cord independence measure, version IV: Rasch psychometric validation.

CONTEXT: The Spinal Cord Independence Measure is a comprehensive functional rating scale for individuals with spinal cord lesion (SCL). OBJECTIVE: To validate the scores of the three subscales of SCIM IV, the fourth version of SCIM, using advanced statistical methods. STUDY DESIGN: Multi-center cohort study. SETTING: Nineteen SCL units in 11 countries. METHODS: SCIM developers created SCIM IV following comments by experts, included more accurate definitions of scoring criteria in the SCIM IV form, and adjusted it to assess specific conditions or situations that the third version, SCIM III, does not address. Professional staff members assessed 648 SCL inpatients, using SCIM IV and SCIM III, at admission to rehabilitation, and at discharge. The authors examined the validity and reliability of SCIM IV subscale scores using Rasch analysis. RESULTS: The study included inpatients aged 16-87 years old. SCIM IV subscale scores fit the Rasch model. All item infit and most item outfit mean-square indices were below 1.4; statistically distinct strata of abilities were 2.6-6; most categories were properly ordered; item hierarchy was stable across most clinical subgroups and countries. In a few items, however, we found misfit or category threshold disordering. We found SCIM III and SCIM IV Rasch properties to be comparable. CONCLUSIONS: Rasch analysis suggests that the scores of each SCIM IV subscale are reliable and valid. This reinforces the justification for using SCIM IV in clinical practice and research.

Why Questionnaire Scores Are Not Measures: A Question-Raising Article.

ABSTRACT: Any person is provided by characteristics that can be neither located in body parts nor directly observed (so-called latent variables): these may be behaviors, attitudes, perceptions, motor and cognitive skills, knowledge, emotions, and the like. Physical and rehabilitation medicine frequently faces variables of this kind, the target of many interventions. Latent variables can only be observed through representative behaviors (e.g., walking for independence, moaning for pain, social isolation for depression, etc.). To measure them, behaviors are often listed and summated as items in cumulative questionnaires ("scales"). Questionnaires ultimately provide observations ("raw scores") with the aspect of numbers. Unfortunately, they are only a rough and often misleading approximation to true measures for various reasons. Measures should satisfy the same measurement axioms of physical sciences. In the article, the flaws hidden in questionnaires' scores are summarized, and their consequences in outcome assessment are highlighted. The report should inspire a critical attitude in the readers and foster the interest in modern item response theory, with reference to Rasch analysis.

Balance impairment in myotonic dystrophy type 1: Dynamic posturography suggests the coexistence of a proprioceptive and vestibular deficit.

Falls are frequent in Myotonic Dystrophy type 1 (DM1), but the pathophysiology of the balance impairment needs further exploration in this disease. The current work aims to provide a richer understanding of DM1 imbalance. Standing balance in 16 patients and 40 controls was tested in two posturographic tests (EquiTest™). In the Sensory Organization Test (SOT), standstill balance was challenged by combining visual (eyes open vs. closed) and environmental conditions (fixed vs. sway-tuned platform and/or visual surround). In the "react" test, reflexes induced by sudden shifts in the support base were studied. Oscillations of the body centre of mass (COM) were measured. In the SOT, COM sway was larger in patients than controls in any condition, including firm support with eyes open (quiet standing). On sway-tuned support, COM oscillations when standing with closed eyes were larger in patients than controls even after taking into account the oscillations with eyes open. In the "react" paradigm, balance reflexes were delayed in patients. Results in both experimental paradigms (i.e., SOT and react test) are consistent with leg muscle weakness. This, however, is not a sufficient explanation. The SOT test highlighted that patients rely on vision more than controls to maintain static balance. Consistently enough, evidence is provided that an impairment of proprioceptive and vestibular systems contributes to falls in DM1. Rehabilitation programs targeted at reweighting sensory systems may be designed to improve safe mobility in DM1.

Telephone-based Frontal Assessment Battery (t-FAB): standardization for the Italian population and clinical usability in neurological diseases.

BACKGROUND: Despite the relevance of telephone-based cognitive screening tests in clinical practice and research, no specific test assessing executive functioning is available. The present study aimed at standardizing and providing evidence of clinical usability for the Italian telephone-based Frontal Assessment Battery (t-FAB). METHODS: The t-FAB (ranging 0-12), comprising two subtests, has two versions: one requiring motor responses (t-FAB-M) and the other verbal responses (t-FAB-V). Three hundred and forty-six Italian healthy adults (HPs; 143 males; age range = 18-96 years; education range = 4-23 years) and 40 participants with neurological diseases were recruited. To HPs, the t-FAB was administered along with a set of telephone-based tests: MMSE, verbal fluency (VF), backward digit span (BDS). The in-person version of the FAB was administered to both HPs and clinical groups. Factorial structure, construct validity, inter-rater and test-retest reliability, t-FAB-M vs. t-FAB-V equivalence and diagnostic accuracy were assessed. Norms were derived via Equivalent Scores. RESULTS: In HPs, t-FAB measures yielded high inter-rater/test-retest reliability (ICC = .78-.94), were internally related (p ≤ .005) and underpinned by a single component, converging with the telephone-based MMSE, VF, BDS (p ≤ .0013). The two t-FAB versions were statistically equivalent in clinical groups (ps of both equivalence bounds < .001). Education predicted all t-FAB scores (p < .001), whereas age only the t-FAB-M score (p ≤ .004). t-FAB scores converge with the in-person FAB in HPs and clinical groups (rs = .43-.78). Both t-FAB versions were accurate in discriminating HPs from the clinical cohort (AUC = .73-.76). DISCUSSION: The t-FAB is a normed, valid, reliable and clinically usable telephone-based cognitive screening test to adopt in both clinical and research practice.

Balance Impairment in Fahr's Disease: Mixed Signs of Parkinsonism and Cerebellar Disorder. A Case Study.

Fahr's disease is a rare idiopathic degenerative disease characterized by calcifications in the brain, and has also been associated with balance impairment. However, a detailed analysis of balance in these patients has not been performed. A 69-year-old woman with Fahr's disease presented with a long-lasting subjective imbalance. Balance was analyzed using both clinical (EquiScale, Timed Up and Go test, and Dizziness Handicap Inventory-short form) and instrumented tests (the sway of the body center of mass during quiet, perturbed, and self-perturbed stance, and the peak curvature of the center of mass during single stance while walking on a force-treadmill). The patient's balance was normal during clinical tests and walking. However, during standing, a striking impairment in vestibular control of balance emerged. The balance behavior displayed mixed parkinsonian (e.g., slowness and reduced amplitude of movement) and cerebellar (e.g., increased sway during standing in all conditions and decomposition of movement) features, with a discrepancy between the high severity of the static and the low severity of the dynamic balance impairment. The balance impairment characteristics outlined in this study could help neurologists and physiatrists detect, stage, and treat this rare condition.

Standard Psychometric Criteria for Measurements in Physical and Rehabilitation Medicine.

ABSTRACT: Measurements of person's variable, such as behavior, perceptions, or attitudes, are essential to physical and rehabilitation medicine in both clinical practice and research. These measurements are commonly based on cumulative questionnaires and follow special statistical rules, belonging to the domain of psychometrics. Selecting the most appropriate measurement is critical. This article provides an overview of the standard psychometric criteria to consider in measurement selection. The article focuses on the criteria related to the contemporary psychometric approach as it considers the construct, the target population, and the purpose for which measurements are used. Common strategies related to psychometric testing are discussed and applied to critically appraise, as a representative example, one of the most commonly used pain measurements: Brief Pain Inventory. The measurement construct, conceptual framework, target population, purpose, and psychometric properties are highlighted. Observed limitations for its implementation in different settings also are discussed.

Reliability Validity and Responsiveness of the Spinal Cord Independence Measure 4th Version in a Multicultural Setup.

OBJECTIVE: To examine the fourth version of the Spinal Cord Independence Measure for reliability and validity. DESIGN: Partly blinded comparison with the criterion standard Spinal Cord Independence Measure III, and between examiners and examinations. SETTING: A multicultural cohort from 19 spinal cord injury units in 11 countries. PARTICIPANTS: A total of 648 patients with spinal cord injury. INTERVENTION: Assessment with Spinal Cord Independence Measure (SCIM IV) and Spinal Cord Independence Measure (SCIM III) on admission to inpatient rehabilitation and before discharge. MAIN OUTCOME MEASURES: SCIM IV interrater reliability, internal consistency, correlation with and difference from SCIM III, and responsiveness. RESULTS: Total agreement between examiners was above 80% on most SCIM IV tasks. All Kappa coefficients were above 0.70 and statistically significant (P<.001). Pearson's coefficients of the correlation between the examiners were above 0.90, and intraclass correlation coefficients were above 0.90. Cronbach's alpha was above 0.96 for the entire SCIM IV, above 0.66 for the subscales, and usually decreased when an item was eliminated. Reliability values were lower for the subscale of respiration and sphincter management, and on admission than at discharge. SCIM IV and SCIM III mean values were very close, and the coefficients of Pearson correlation between them were 0.91-0.96 (P<.001). The responsiveness of SCIM IV was not significantly different from that of SCIM III in most of the comparisons. CONCLUSIONS: The validity, reliability, and responsiveness of SCIM IV, which was adjusted to assess specific patient conditions or situations that SCIM III does not address, and which includes more accurate definitions of certain scoring criteria, are very good and quite similar to those of SCIM III. SCIM IV can be used for clinical and research trials, including international multi-center studies, and its group scores can be compared with those of SCIM III.

Efficacy of Repetitive Transcranial Magnetic Stimulation for Acute Central Post-stroke Pain: A Case Study.

Although rare, central post-stroke pain remains one of the most refractory forms of neuropathic pain. Repetitive transcranial magnetic stimulation (rTMS) has been reported to be effective in chronic cases. However, there are no data on the effects in the acute and subacute phases after stroke. In this study, we present a case of a patient with thalamic stroke with acute onset of pain and paresthesia who was responsive to rTMS. After a right thalamic stroke, a 32-year-old woman presented with drug-resistant pain and paresthesia on the left side of the body. There were no motor or sensory deficits, except for blunted thermal sensation and allodynia on light touch. Ten daily sessions were performed, where 10 Hz rTMS was applied to the hand area of the right primary motor cortex, 40 days after stroke. Before rTMS treatment (T0), immediately after treatment conclusion (T1), and 1 month after treatment (T2), three pain questionnaires were administered, and cortical responses to single and paired-pulse TMS were assessed. Eight healthy participants served as controls. At T0, when the patient was experiencing the worst pain, the excitability of the ipsilesional motor cortex was reduced. At T1 and T2, the pain scores and paresthesia' spread decreased. The clinical improvement was paralleled by the recovery in motor cortex excitability of the affected hemisphere, in terms of both intra- and inter-hemispheric connections. In this subacute central post-stroke pain case, rTMS treatment was associated with decreased pain and motor cortex excitability changes.

Kinematic patterns during walking in children: Application of principal component analysis.

The relative displacements of body segments during walking can be reduced to a small number of multi-joint kinematic patterns, pmk, through Principal Component Analysis (PCA). These patterns were extracted from two groups of children (n = 8, aged 6-9 years, 4 males, and n = 8, aged 10-13 years, 4 males) and 7 adults (21-29 years, 1 male), walking on a treadmill at various velocities, normalized to body stature (adimensional Froude number, Fr). The three-dimensional coordinates of body markers were captured by an optoelectronic system. Five components (pm1 to pm5) explained 99.1% of the original dataset variance. The relationship between the variance explained ("size") of each pmk and the Fr velocity varied across movement components and age groups. Only pm1 and pm2, which described kinematic patterns in the sagittal plane, showed significant differences (at p < 0.05) across pairs of age groups. The time course of the size of all the five components matched various mechanical events of the step cycle at the level of both body system and lower limb joints. Such movement components appeared clinically interpretable and lend themselves as potential markers of neural development of walking.

Velocity of the Body Center of Mass During Walking on Split-Belt Treadmill.

ABSTRACT: Walking on split-belt treadmills (each belt rotating at a different velocity) has inspired a growing number of researchers to study gait adaptation and rehabilitation. An overlooked peculiarity of this artificial form of gait is that the mean velocity adopted by the participant, considered as a whole system represented by the body Center of Mass, can be different from the mean velocity of the two belts. Twelve healthy adults (21-34 yrs) were requested to walk for 15 mins on a treadmill with belts rotating at 0.4 and 1.2 m sec-1, respectively (mean = 0.8 m sec-1). Each belt was supported by four 3-dimensional force sensors. For each participant, six strides were analyzed during the 1st and the 15th minute of the trial. The mean Center of Mass velocity was computed as the sum of the velocities of each belt weighted by the percentage of time during which the resulting forces, underlying the accelerations of the Center of Mass, originated from each belt. Across early and late observations, the median Center of Mass velocities were 0.72 and 0.67 m sec-1, respectively (P < 0.05). Therefore, the real velocity of the Center of Mass and its time course should be individually assessed when studying walking on split-belt treadmills.

The curvature peaks of the trajectory of the body centre of mass during walking: A new index of dynamic balance.

During walking, falling is most likely to occur towards the side of the supporting lower limb during the single stance. Timely lateral redirection of the centre of mass (CoM) preceding the no-return position is necessary for balance. We analysed the curvature peaks (the inverse of the radius of curvature) of the three-dimensional path of the CoM during the entire stride. Twelve healthy adults walked on a force-sensorized treadmill at constant velocities from 0.4 to 1.2 m s-1, in 0.2 m s-1 increments. The three-dimensional displacements of the CoM, the muscular power sustaining the CoM motion with respect to the ground, and the efficiency of the pendulum-like transfer of the CoM were computed via the double integration of the ground reaction forces. The curvatures of the CoM trajectory were measured (Frenet-Serret formula). During the single stance, the curvature showed a bell-shaped increment, lasting a few tenths of a millisecond, and peaking at 365-683 m-1 (radius of 2.7-1.4 mm, respectively), the higher the walking velocity. The CoM was redirected towards the swinging lower limb. The curvature increment was sustained by muscle-driven braking of the CoM. Smoother increments of curvature (peaking at approximately 37-150 m-1), further orienting the CoM towards the leading lower limb, were observed during the double stance. The peaks of the curvatures were symmetric between the two sides. The high curvature peaks during the single stance may represent an index of dynamic balance during walking. This index might be useful for both rehabilitation and sports training purposes.

A theoretical framework to improve the construct for chronic pain disorders using fibromyalgia as an example.

Fibromyalgia (FM) is a frequent, complex condition of chronic musculoskeletal pain with no evidence for biological correlates. For this reason, despite many efforts from the medical community, its construct still appears ill defined. Promising candidate biomarkers are critically reviewed. A research agenda is proposed for developing a clearer construct of FM. The ideal theoretical framework is one of overcoming the illness-disease dichotomy and considering reciprocal interactions between biology and behaviour. This approach may foster research in other fields of pain medicine and of medicine in general.

Multisensory stimulation for the rehabilitation of unilateral spatial neglect.

Unilateral spatial neglect (USN) is a neuropsychological syndrome, typically caused by lesions of the right hemisphere, whose features are the defective report of events occurring in the left (contralesional) side of space and the inability to orient and set up actions leftwards. Multisensory integration mechanisms, largely spared in USN patients, may temporally modulate spatial orienting. In this pilot study, the effects of an intensive audio-visual Multisensory Stimulation (MS) on USN were assessed, and compared with those of a treatment that ameliorates USN, Prismatic Adaptation (PA). Twenty USN stroke patients received a 2-week treatment (20 sessions, twice per day) of MS or PA. The effects of MS and PA were assessed by a set of neuropsychological clinical tests (target cancellation, line bisection, sentence reading, personal neglect, complex drawing) and the Catherine Bergego Scale for functional disability. Results showed that MS brought about an amelioration of USN deficits overall comparable to that induced by PA; personal neglect was improved only by MS, not by PA. The clinical gains of the MS treatment were not influenced by duration of disease and lesion volume, and they persisted up to one month post-treatment. In conclusion, MS represents a novel and promising rehabilitation procedure for USN.