Mirko Filippetti

Background and Objectives: Gait impairment is a common and disabling manifestation of multiple sclerosis, affecting mobility, independence, and quality of life. However, gait differences between people with multiple sclerosis and healthy individuals have not been well characterized within corresponding age strata. Methods: This exploratory cross-sectional study included 23 participants with relapsing–remitting multiple sclerosis and 50 healthy individuals aged 20–69 years. Participants underwent instrumented gait analysis at self-selected walking speed using a Vicon motion-capture system synchronized with force plates. Spatiotemporal parameters, lower-limb and pelvic kinematics, and ground reaction forces were assessed. Between-group comparisons were performed within predefined age strata (20–39, 40–49, 50–59, and 60–69 years) using one-dimensional Statistical Parametric Mapping and non-parametric analyses. Results: Across age strata, participants with relapsing–remitting multiple sclerosis generally showed slower walking and shorter stride-related measures, together with phase-specific multi-joint kinematic and ground reaction force deviations. Estimated gait-speed and stride-length differences were largest in the youngest stratum, whereas mean stride width was 0.04 m greater in both the youngest and oldest strata; however, confidence intervals were wide, and no between-stratum contrast was tested. Exploratory threshold crossings were not interpreted as evidence that the underlying effects differed among strata. Conclusions: The age-stratified, participant-level analysis identified recurrent differences in forward progression, lower-limb and pelvic kinematics, and loading and propulsion. These findings provide a quantitative description that may support individualized gait assessment and hypothesis generation for adequately powered studies. They do not establish an independent effect of age or an age-by-disease interaction.

Post-stroke spasticity may interfere with function and rehabilitation and contribute to pain, contracture, care burden, and disability. Botulinum toxin type A is an established focal treatment for post-stroke spasticity, but it is often introduced in the chronic phase, when persistent involuntary muscle overactivity may coexist with secondary musculoskeletal complications. This opinion paper critically examines whether early treatment with botulinum toxin should be considered a myth or an emerging clinical reality. Current evidence from meta-analyses, randomized trials, observational cohorts, and pooled analyses was reviewed with particular attention to treatment timing, treatment triggers, functional outcomes, and prevention of secondary complications. The literature supports the clinical usefulness of earlier treatment in appropriately selected patients, particularly for reducing focal involuntary muscle overactivity and resistance to passive movement, delaying symptomatic progression, slowing contracture development, and reducing pain-related complications. However, a consistent additional effect on active motor recovery has not been demonstrated, and evidence for participation and long-term functional independence remains less definitive. Moreover, “early” is heterogeneously defined across studies, ranging from the first weeks to the first year after stroke. We therefore propose moving from a rigid time-based concept of “early” treatment toward timely, target- and goal-guided intervention, integrating botulinum toxin with rehabilitation when a clinically relevant and modifiable focal neural treatment target emerges. To operationalize this concept, we propose a pragmatic set of clinical variables including the neural treatment target, its clinical impact and trajectory, passive musculoskeletal status, pain and care burden, motor recovery context, rehabilitation goals, and patient priorities.

Background/Objectives. Spinal misalignment in childhood and adolescence may be associated with altered sensory integration and body representation. The subjective visual vertical reflects visual, vestibular, and somatosensory integration, but its relationship with pediatric spinal misalignment remains uncertain. This study investigated the subjective visual vertical using two complementary paradigms. Methods. This exploratory, single-center, cross-sectional study included participants aged 7–17 years with clinically identified spinal misalignment. Participants underwent standardized physiatric assessment and subjective visual vertical testing using a luminous-line test and the Bucket Test. Spearman’s rank correlations examined associations with clinical and radiographic variables, with false-discovery-rate control using the Benjamini–Hochberg procedure. Radiographic analyses were restricted to participants with available imaging. Results. Fifty-seven participants were included (mean age 12.8 years, SD 2.25), and all completed both tests. Mean subjective visual vertical was 0.053° (SD 0.953) with the luminous-line test and −0.561° (SD 1.165) with the Bucket Test. Radiographs were available for 21 participants. No association remained significant after false-discovery-rate correction. Two luminous-line associations were nominally significant before correction: primary lumbar curve presence (ρ = −0.278, p = 0.036) and secondary thoracolumbar curve presence (ρ = −0.324, p = 0.015); both had q = 0.721. The tests were moderately correlated (ρ = 0.493, p < 0.001). Radiographic sensitivity and subgroup analyses showed no significant findings. Conclusions. Subjective visual vertical was not robustly associated with spinal misalignment characteristics in this modest, clinically heterogeneous cohort. Larger controlled studies with standardized imaging and adequately powered severity groups are required.

Cerebral palsy is a leading cause of childhood motor disability, and ambulatory children with spastic hemiplegia commonly present with dynamic equinus, calf muscle overactivity, and gait impairment. Evidence on focal vibration after botulinum toxin type A injection remains limited. This exploratory proof-of-concept pilot study assessed short-term changes following a four-week multimodal rehabilitation program incorporating focal vibration. In this uncontrolled single-group pre–post study, nine ambulatory children (mean age, 12.1 years), all classified as level II on the Gross Motor Function Classification System, received onabotulinumtoxinA injections into the affected gastrocnemius muscles, followed by twelve outpatient sessions combining focal vibration, conventional physiotherapy, and robotic gait training. Passive ankle dorsiflexion increased, calf muscle spasticity decreased, and selected gait parameters improved. Walking speed increased from 0.79 to 0.90 m per second, an absolute change of 0.11 m per second, comparable in magnitude to published estimates of clinically important change in ambulatory children with cerebral palsy. After Bonferroni correction, only walking speed and affected-limb stride length remained significant. No adverse events occurred. These findings describe outcomes associated with the combined program but do not establish the efficacy or independent contribution of focal vibration.

Objective: Although telerehabilitation has emerged as a promising and accessible alternative to traditional in-person therapy, robust evidence supporting its clinical effectiveness across multiple functional domains remains limited. We tested the non-inferiority of synchronous multi-domain telerehabilitation for motor, cognitive, language, and disability outcomes in stroke survivors. Design: Bicentric, single-blind (assessor-blinded), randomized controlled non-inferiority trial. Methods: Fifty-six participants were randomized to home-based telerehabilitation or conventional outpatient therapy. Both groups completed twenty real-time supervised sessions over four weeks. The primary outcome was change in Fugl–Meyer Assessment upper-extremity motor score (0–66); secondary outcomes included Fugl–Meyer Assessment lower-extremity motor (0–34), Aachen Aphasia Test (Italian version) naming/written language/comprehension, Oxford Cognitive Screen orientation and memory subtests, and Barthel Index. Non-inferiority was evaluated using a prespecified margin (Δ=−5.2) and confidence-interval–based linear mixed-effects models (per-protocol primary, intention-to-treat sensitivity); non-inferiority was concluded if the lower bound of the 95% CI for the adjusted between-group contrast at T1 (telerehabilitation minus conventional) was > −Δ. Results: The adjusted between-group difference in change for the primary outcome was compatible with non-inferiority at post-treatment, with consistent results in sensitivity analyses. No significant between-group differences were observed in language, cognitive, or functional independence outcomes, and findings were similar at one-month follow-up. Conclusions: Synchronous multi-domain telerehabilitation appears feasible and yields short-term motor recovery comparable to standard outpatient rehabilitation within a prespecified non-inferiority framework. Interpretation is limited by the short follow-up and restricted cognitive outcome coverage.

Objective: To investigate the effects of a two-week robot-assisted gait training (RAGT) program on walking performance and brain activation in children with spastic hemiplegic cerebral palsy (CP). Design: Single-group, pre–post pilot study. Methods: Eight children with CP were enrolled; six completed the protocol and provided usable gait and functional MRI (fMRI) data. Participants received 10 RAGT sessions over two weeks. Walking performance (6-min walk test [6MWT], 10-meter walk test [10MWT], GAITRite gait speed and cadence) was assessed at baseline, immediately after the intervention, and at one-month follow-up. Pre- and post-intervention fMRI during a lower-limb motor task quantified activated voxels in motor and cerebellar regions. Results: 6MWT distance, 10MWT speed, and GAITRite gait speed and cadence improved significantly (all p ≤ 0.009) at post-intervention and follow-up versus baseline. In children with isolated subcortical lesions (n = 4), activated voxels during the lower-limb task increased in the lesioned motor cortex (from 363 to 1,075; p = 0.02), with similar increases in ipsilesional cerebellar hemispheres (p = 0.02), whereas no significant changes were seen in children with additional hydrocephalus (n = 2). Change in cadence correlated positively with change in lesioned motor cortex activation (Spearman's ρ = 0.83, p = 0.03). Conclusions: In this small cohort, a two-week RAGT program was associated with short-term improvements in walking performance and increased fMRI activation in motor-related regions, particularly in children with subcortical lesions. These preliminary, lesion-type–specific findings suggest neuroplastic responses to RAGT that warrant confirmation in larger controlled studies.

This study aimed to explore the potential role of artificial intelligence in optimizing botulinum toxin type A treatment for spasticity and to evaluate its alignment with expert clinical decisions. A comparative analysis was conducted using thirty hypothetical clinical cases involving individuals with spasticity resulting from various neurological conditions. Five rehabilitation physicians, each with more than five years of experience, participated in the study. An artificial intelligence model trained on scientific literature and clinical guidelines generated treatment recommendations, including target muscles and dosages, which were compared with those proposed independently by the physicians. The primary outcome was the level of agreement in muscle selection and dosage. The model demonstrated consistency and adherence to guidelines but showed limited adaptability in complex presentations, such as an adducted thigh and equinovarus foot. It generally recommended lower dosages and differed significantly from physicians in both muscle selection and treatment strategies. Artificial intelligence shows promise as a clinical support tool in spasticity management, offering standardized and reproducible recommendations. However, its limited capacity to interpret clinical subtleties currently restricts its practical application. Future models should integrate multimodal clinical data and real-time clinician feedback to better emulate expert decision-making processes.

(1) Background: Post-stroke spasticity limits motor recovery and independence. Combining botulinum toxin type-A (BoNT-A) injection with intensive, task-specific robot-assisted therapy (RAT) might enhance neuroplasticity and functional gains, but its additive effect and optimal timing are uncertain. (2) Methods: We systematically searched major medical databases and trial registries up to April 2025 for randomized controlled trials in adults with post-stroke spasticity comparing botulinum toxin type-A injection plus RAT with toxin injection plus conventional therapy, or RAT alone with RAT combined with toxin injection. Risk of bias was assessed using the RoB 2 tool, and findings were synthesized narratively. (3) Results: Seven trials (n = 229) were included. Across all studies, toxin treatment reduced spasticity within groups, whereas additional spasticity reduction with RAT versus conventional rehabilitation was inconsistent. In contrast, several lower-limb trials reported greater improvements in walking capacity and balance when RAT was added, while upper-limb trials showed comparable motor recovery across treatment arms with occasional advantages in strength and movement quality. A pilot four-arm study suggested that starting RAT around four weeks after injection may maximize upper-limb motor gains. (4) Conclusions: The combination of BoNT-A with RAT appears safe and is particularly promising for gait rehabilitation, but further research is needed to define optimal timing and protocols.

Spasticity after stroke impairs motor control, delays recovery, and reduces quality of life. Botulinum toxin type A is the first-line treatment, but it is often administered in the chronic phase, potentially limiting its impact on rehabilitation. Emerging evidence suggests that earlier treatment may enhance recovery, though functional benefits remain uncertain. We conducted a secondary analysis of a multicenter, open-label, longitudinal cohort study to investigate whether the timing of the first botulinum toxin type A injection influences outcomes in post-stroke patients naïve to this treatment. All participants received botulinum toxin injections combined with conventional rehabilitation. Assessments were performed at baseline and at 4, 12, and 24 weeks post-injection. The primary outcome was muscle tone; secondary outcomes included motor strength, sensorimotor recovery, and global disability. Statistical analyses used mixed-effects models and trend tests. Patients treated within 90 days of stroke onset showed greater reductions in spasticity at 4 and 12 weeks compared with later treatment. Despite having more severe baseline impairments, early treated patients demonstrated faster and more pronounced improvements in upper-limb strength, sensorimotor recovery, and global disability. Early toxin administration is associated with enhanced reduction in spasticity and improved motor recovery, particularly in patients with severe initial deficits.

Background: Given the prevalence of scoliosis, it is essential for residents in Physical and Rehabilitation Medicine to develop proficiency in evaluating spinal radiographs, particularly in measuring the Cobb angle. This education and training study aimed to define the minimum educational requirements for residents to achieve competency in Cobb angle measurement with acceptable inter- and intra-operator variability, as reported in the literature. Methods: In this ethics-approved study, Physical and Rehabilitation Medicine residents measured Cobb angles and the Risser index using specialized software on 30 different spinal X-rays, with oversight to ensure consistency and eliminate bias. Results: The data revealed that 44.4% of residents achieved the target accuracy for primary Cobb angles (<3.6°), but only 11.1% did so for secondary curves. For intra-operator error, 88.9% of residents met the target for primary curves, but only 11.1% achieved the target for secondary curves. The Risser index showed minimal deviation across all participants. Conclusions: These findings highlight that mastering Cobb angle measurement is challenging and generally requires more than 20 different measurements for inter-operator reliability and over 30 repetitions for intra-operator reliability, particularly when secondary curves are included.