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Li W, Zhu G, Lu Y, Wu J, Fu Z, Tang J, Zhang G, Xu D. The relationship between rehabilitation motivation and upper limb motor function in stroke patients. Front Neurol 2024; 15:1390811. [PMID: 38863513 PMCID: PMC11165190 DOI: 10.3389/fneur.2024.1390811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
Objective Insufficient motivation among post-stroke survivors may be an important factor affecting their motor function recovery. This study seeks to investigate the relationship between motivation and functional recovery in stroke patients undergoing rehabilitation training. Materials and methods 103 stroke patients with upper limb impairments were studied during their hospital stays. Assessments were done before and after rehabilitation training to measure motivation, emotional state, motor function, and independence in daily activities. Data analysis was conducted to examine the distribution of these factors among the participants. Pearson and Spearman correlation analyses were used to study the relationships between motivation, emotional state, and motor function. Patients were divided into high and low motivation groups based on the Rehabilitation Motivation Scale (RMS), and chi-square and rank-sum tests were used to compare functional differences before and after treatment among patients with varying levels of motivation. Results 66 participants were found to have low motivation in the initial assessment of the RMS (64.08%). Consistency in motivation levels was observed among patients with high motivation (r = 0.648, P<0.001). Apathy was identified as the main factor affecting motivation in patients with low motivation (p = 0.027), while depression and anxiety were not significantly correlated. Motivation was strongly linked to improvements in upper limb motor function, daily living activities, and self-exercise duration (p < 0.001) for stroke patients undergoing rehabilitation. Post-training, there was a notable increase in motivation, motor function, and independence in daily activities (p < 0.001). Increased rehabilitation motivation was linked to better upper limb motor function and daily independence in patients, particularly those with low motivation. This correlation was significant for both the FMA-UE and FIM scores. Discussion Old patients with poor upper limb motor function often have low motivation, which hinders their recovery. Using strategies to boost motivation in stroke patients with impaired upper limb function could greatly improve their rehabilitation and motor skills. It is crucial to prioritize these intervention strategies. Conclusion Enhancing rehabilitation motivation in stroke patients with low motivation and upper limb motor impairments can foster the restoration of their functional capabilities.
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Affiliation(s)
- Wenxi Li
- Department of Rehabilitation Medicine, Shanghai University of Traditional Chinese Medicine, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai, China
- Department of Rehabilitation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guangyue Zhu
- Department of Rehabilitation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yang Lu
- Department of Rehabilitation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jinglei Wu
- Department of Rehabilitation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhuoxin Fu
- Department of Rehabilitation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Junyi Tang
- Department of Rehabilitation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guohui Zhang
- Department of Rehabilitation Medicine, Shanghai University of Traditional Chinese Medicine, Yueyang Hospital of Integrated Traditional Chinese Medicine and Western Medicine, Shanghai, China
| | - Dongsheng Xu
- Department of Rehabilitation, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, China
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Horder J, Mrotek LA, Casadio M, Bassindale KD, McGuire J, Scheidt RA. Utility and usability of a wearable system and progressive-challenge cued exercise program for encouraging use of the more involved arm at-home after stroke-a feasibility study with case reports. J Neuroeng Rehabil 2024; 21:66. [PMID: 38685012 PMCID: PMC11059679 DOI: 10.1186/s12984-024-01359-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 04/16/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Understanding the role of adherence to home exercise programs for survivors of stroke is critical to ensure patients perform prescribed exercises and maximize effectiveness of recovery. METHODS Survivors of hemiparetic stroke with impaired motor function were recruited into a 7-day study designed to test the utility and usability of a low-cost wearable system and progressive-challenge cued exercise program for encouraging graded-challenge exercise at-home. The wearable system comprised two wrist-worn MetaMotionR+ activity monitors and a custom smartphone app. The progressive-challenge cued exercise program included high-intensity activities (one repetition every 30 s) dosed at 1.5 h per day, embedded within 8 h of passive activity monitoring per day. Utility was assessed using measures of system uptime and cue response rate. Usability and user experience were assessed using well-validated quantitative surveys of system usability and user experience. Self-efficacy was assessed at the end of each day on a visual analog scale that ranged from 0 to 100. RESULTS The system and exercise program had objective utility: system uptime was 92 ± 6.9% of intended hours and the rate of successful cue delivery was 99 ± 2.7%. The system and program also were effective in motivating cued exercise: activity was detected within 5-s of the cue 98 ± 3.1% of the time. As shown via two case studies, accelerometry data can accurately reflect graded-challenge exercise instructions and reveal differentiable activity levels across exercise stages. User experience surveys indicated positive overall usability in the home settings, strong levels of personal motivation to use the system, and high degrees of satisfaction with the devices and provided training. Self-efficacy assessments indicated a strong perception of proficiency across participants (95 ± 5.0). CONCLUSIONS This study demonstrates that a low-cost wearable system providing frequent haptic cues to encourage graded-challenge exercise after stroke can have utility and can provide an overall positive user experience in home settings. The study also demonstrates how combining a graded exercise program with all-day activity monitoring can provide insight into the potential for wearable systems to assess adherence to-and effectiveness of-home-based exercise programs on an individualized basis.
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Affiliation(s)
- Jake Horder
- Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Leigh A Mrotek
- Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maura Casadio
- Biomedical Engineering, University of Genoa, Genoa, Italy
| | - Kimberly D Bassindale
- Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, USA
| | - John McGuire
- Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert A Scheidt
- Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, USA.
- Biomedical Engineering, Marquette University and the Medical College of Wisconsin, Engineering Hall, Rm 342, P.O. Box 1881, Milwaukee, WI, 53201-1881, USA.
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Terneusen A, Ponds R, Stapert S, Lannoo E, Schrijnemaekers AC, van Heugten C, Winkens I. Socratic guided feedback therapy after acquired brain injury: A multicenter randomized controlled trial to evaluate effects on self-awareness. Neuropsychol Rehabil 2024:1-29. [PMID: 38619859 DOI: 10.1080/09602011.2024.2337154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 03/19/2024] [Indexed: 04/16/2024]
Abstract
Impaired self-awareness after acquired brain injury (ABI) challenges neuropsychological rehabilitation. The current study aimed to compare the effects of Socratic Guided Feedback therapy to usual care in a multicenter randomized controlled trial with 64 participants with reduced self-awareness after ABI. The objectives were to study the effects on (1) self-awareness and (2) motivation for and participation in therapy, mood, quality of life, and social participation. Patients were recruited from rehabilitation centres in The Netherlands and Belgium. They were 50.8 (±16) years old and 2.7 months (±1.8) post-injury at baseline. Session duration ranged from 20-60 minutes and the number of sessions ranged from 1 to 162 sessions. Self-awareness increased over time in both groups. Between 9 and 12 months after baseline measurement, self-awareness (Patient Competency Rating Scale discrepancy score between patient and significant other) improved in the experimental group and deteriorated in care as usual. No significant differences were found on secondary outcome measures. In conclusion, Socratic Guided Feedback therapy is as effective as care as usual but provides a structure for therapists. We recommend further investigation of the added value of Socratic Guided Feedback therapy in later follow-up measurements, group therapy settings, and on other outcome domains such as caregiver burden.
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Affiliation(s)
- Anneke Terneusen
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Limburg Brain Injury Centre, Maastricht University, Maastricht, the Netherlands
| | - Rudolf Ponds
- Limburg Brain Injury Centre, Maastricht University, Maastricht, the Netherlands
- Department of Medical Psychology, Amsterdam University Medical Center, location VU, Amsterdam
- Department of Psychiatry and Neuropsychology, MHeNS School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Sven Stapert
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Engelien Lannoo
- Department of Physical Medicine and Rehabilitation, University Hospital, Ghent, Belgium
| | - Anne-Claire Schrijnemaekers
- Mondriaan Mental Health Institute, Heerlen, the Netherlands
- Department of Brain Injury, Adelante Rehabilitation Centre, Hoensbroek, the Netherlands
| | - Caroline van Heugten
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Limburg Brain Injury Centre, Maastricht University, Maastricht, the Netherlands
- Department of Psychiatry and Neuropsychology, MHeNS School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Ieke Winkens
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Limburg Brain Injury Centre, Maastricht University, Maastricht, the Netherlands
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Verrienti G, Raccagni C, Lombardozzi G, De Bartolo D, Iosa M. Motivation as a Measurable Outcome in Stroke Rehabilitation: A Systematic Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4187. [PMID: 36901206 PMCID: PMC10001639 DOI: 10.3390/ijerph20054187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
Motivated behaviours are thought to lead to enhanced performances. In the neurorehabilitation field, motivation has been demonstrated to be a link between cognition and motor performance, therefore playing an important role upon rehabilitation outcome determining factors. While motivation-enhancing interventions have been frequently investigated, a common and reliable motivation assessment strategy has not been established yet. This review aims to systematically explore and provide a comparison among the existing motivation assessment tools concerning stroke rehabilitation. For this purpose, a literature search (PubMed and Google Scholar) was performed, using the following Medical Subject Headings terms: "assessment" OR "scale" AND "motivation" AND "stroke" AND "rehabilitation". In all, 31 randomized clinical trials and 15 clinical trials were examined. The existing assessment tools can be grouped into two categories: the first mirroring the trade-off between patients and rehabilitation, the latter reflecting the link between patients and interventions. Furthermore, we presented assessment tools which reflect participation level or apathy, as an indirect index of motivation. In conclusion, we are left to put forth a possible common motivation assessment strategy, which might provide valuable incentive to investigate in future research.
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Affiliation(s)
- Giulio Verrienti
- Department of Neurorehabilitation, Casa di Cura Villa Verde, 73100 Lecce, Italy
| | - Cecilia Raccagni
- Department of Neurology, Provincial Hospital of Bolzano (SABES-ASDAA), Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, 39100 Bolzano, Italy
- Department of Neurology, Innsbruck Medical University, 6030 Innsbruck, Austria
| | | | | | - Marco Iosa
- Smart Lab, IRCCS Santa Lucia Foundation, 00179 Rome, Italy
- Department of Psychology, Sapienza University of Rome, 00185 Rome, Italy
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Karniel N, Raveh E, Schwartz I, Portnoy S. Functional electrical stimulation compared with ankle-foot orthosis in subacute post stroke patients with foot drop: A pilot study. Assist Technol 2021; 33:9-16. [PMID: 30945999 DOI: 10.1080/10400435.2019.1579269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background: The conventional treatment for foot drop includes an ankle-foot orthosis (AFO) or functional electrical stimulation (FES). Goal: To compare gait parameters in patients following a subacute post stroke with foot drop treated with AFO or FES. Method: Twenty one subacute patients with stroke with foot drop were fitted with FES (N = 10) or AFO (N = 11). Evaluations were performed at baseline, following 4 weeks and 12 weeks. Spatiotemporal gait parameters and symmetry, dynamic electromyography, 10-m walk test, 6-min walk test, timed up and go, functional ambulation classification, and perception of improvement in walking were measured. The gait analysis measures were collected without the assistive devices while the functional measures were collected with them. Results: Both groups showed improvement in all of the outcome measures, with no between-groups differences. The swing duration's and step length's symmetry indicated better gait symmetry in the FES group after 12 weeks (p = 0.037, effect size = -0.538 and p = 0.028 effect size = -0.568, respectively). The FES group perceived significant improvement in gait after 4 weeks, while subjects in the AFO group reported to perceive improvement only after 12 weeks. Conclusions: Our findings suggest that FES is at least as effective as traditional AFO and may be more so.
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Affiliation(s)
- Naama Karniel
- Physical Medicine and Rehabilitation, Hadassah Mount Scopus University Hospital , Jerusalem, Israel
| | - Eitan Raveh
- Faculty of Medicine, Occupational therapy, School of Health Professions, Tel Aviv University Sackler , Tel Aviv, Israel
| | - Isabella Schwartz
- Physical Medicine and Rehabilitation, Hadassah Mount Scopus University Hospital , Jerusalem, Israel
| | - Sigal Portnoy
- Physical Medicine and Rehabilitation, Hadassah Mount Scopus University Hospital , Jerusalem, Israel.,Faculty of Medicine, Occupational therapy, School of Health Professions, Tel Aviv University Sackler , Tel Aviv, Israel
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Tijsen LM, Derksen EW, Achterberg WP, Buijck BI. Challenging rehabilitation environment for older patients. Clin Interv Aging 2019; 14:1451-1460. [PMID: 31496672 PMCID: PMC6697645 DOI: 10.2147/cia.s207863] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/07/2019] [Indexed: 01/19/2023] Open
Abstract
Introduction After hospitalization, 11% of the older patients are referred to rehabilitation facilities. Nowadays, there is a trend to formalize the rehabilitation process for these patients in a Challenging Rehabilitation Environment (CRE). This concept involves the comprehensive organization of care, support and the environment on a rehabilitation ward. However, since literature on the principles of CRE is scarce, this review aimed to explore and describe the principles of CRE. Methods A search was made in PubMed for relevant literature concerning CRE. Then, articles were hand searched for relevant keywords (ie, task-oriented training, therapy intensity, patient-led therapy, group training), references were identified, and topics categorized. Results After evaluating 51 articles, 7 main topics of CRE were identified: 1) Therapy time; ie, the level of (physical) activity; the intensity of therapy and activity is related to rehabilitation outcomes, 2) group training; used to increase practice time and can be used to achieve multiple goals (eg, activities of daily living, mobility), 3) patient-regulated exercise; increases the level of self-management and practice time, 4) family participation; may lead to increased practice time and have a positive effect on rehabilitation outcomes, 5) task-oriented training; in addition to therapy, nurses can stimulate rehabilitants to perform meaningful tasks that improve functional outcomes, 6) enriched environment; this challenges rehabilitants to be active in social and physical activities, and 7) team dynamics; shared goals during rehabilitation and good communication in a transdisciplinary team improve the quality of rehabilitation. Discussion This is the first description of CRE based on literature; however, the included studies discussed rehabilitation mainly after stroke and for few other diagnostic groups. Conclusion Seven main topics related to CRE were identified that may help patients to improve their rehabilitation outcomes. Further research on the concept and effectivity of CRE is necessary.
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Affiliation(s)
- Lian Mj Tijsen
- Department Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Oktober , Bladel, The Netherlands.,De Zorgboog , Bakel, The Netherlands
| | - Els Wc Derksen
- Department Primary and Community Care, Center for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wilco P Achterberg
- Department Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bianca I Buijck
- Oktober , Bladel, The Netherlands.,De Zorgboog , Bakel, The Netherlands
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Souesme G, Martinent G, Ferrand C. Perceived autonomy support, psychological needs satisfaction, depressive symptoms and apathy in French hospitalized older people. Arch Gerontol Geriatr 2016; 65:70-8. [PMID: 27002495 DOI: 10.1016/j.archger.2016.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/08/2016] [Accepted: 03/03/2016] [Indexed: 11/19/2022]
Abstract
Based on the self-determination theory, the aim of the present study was (1) to provide a better understanding of older people's psychological needs satisfaction in geriatric care units, then to link this information with depressive symptoms and apathy; (2) to examine whether the perceived autonomy support from health care professionals differs between needs satisfaction profiles; and (3) to investigate for all participants how each need satisfaction was related to depressive symptoms and apathy. Participants (N=100; Mage=83.33years, SD=7.78, 61% female) completed the measures of psychological needs satisfaction, perceived autonomy support, geriatric depression and apathy. Sociodemographic data were also collected. Cluster analyses showed three distinct profiles: one profile with low-moderate need satisfaction, one profile with high-moderate need satisfaction and one profile with high need satisfaction. These profiles are distinct, and did not differ in terms of participants' characteristics, except gender. Multivariate analysis of covariance (MANCOVA) revealed that participants with low-moderate need satisfaction profile have significantly higher level of depressive symptoms and apathy, and lower levels of perceived autonomy support than participants of the two other profiles. Moreover, for all participants, regression analyses revealed that both competence and relatedness needs satisfaction significantly and negatively explained 28% of the variance in depressive symptoms score and 44% of the variance in apathy score. Our results highlight the interest to examine more thoroughly the variables fostering autonomy-supportive environment in geriatric care units, and to deepen the relationship between competence and relatedness needs satisfaction and depressive symptoms and apathy.
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Affiliation(s)
- Guillaume Souesme
- Research Team of Psychology of Ages of Life (EA 2114), University François Rabelais, Tours, France.
| | - Guillaume Martinent
- Laboratoire sur les Vulnérabilités et l'Innovation dans le Sport (L-Vis), University Claude Bernard Lyon 1, Villeurbanne, France.
| | - Claude Ferrand
- Research Team of Psychology of Ages of Life (EA 2114), University François Rabelais, Tours, France.
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Corbetta D, Sirtori V, Castellini G, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev 2015; 2015:CD004433. [PMID: 26446577 PMCID: PMC6465192 DOI: 10.1002/14651858.cd004433.pub3] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND In people who have had a stroke, upper limb paresis affects many activities of daily life. Reducing disability is therefore a major aim of rehabilitative interventions. Despite preserving or recovering movement ability after stroke, sometimes people do not fully realise this ability in their everyday activities. Constraint-induced movement therapy (CIMT) is an approach to stroke rehabilitation that involves the forced use and massed practice of the affected arm by restraining the unaffected arm. This has been proposed as a useful tool for recovering abilities in everyday activities. OBJECTIVES To assess the efficacy of CIMT, modified CIMT (mCIMT), or forced use (FU) for arm management in people with hemiparesis after stroke. SEARCH METHODS We searched the Cochrane Stroke Group trials register (last searched June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 1, 2015), MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (1982 to January 2015), and the Physiotherapy Evidence Database (PEDro; January 2015). SELECTION CRITERIA Randomised control trials (RCTs) and quasi-RCTs comparing CIMT, mCIMT or FU with other rehabilitative techniques, or none. DATA COLLECTION AND ANALYSIS One author identified trials from the results of the electronic searches according to the inclusion and exclusion criteria, three review authors independently assessed methodological quality and risk of bias, and extracted data. The primary outcome was disability. MAIN RESULTS We included 42 studies involving 1453 participants. The trials included participants who had some residual motor power of the paretic arm, the potential for further motor recovery and with limited pain or spasticity, but tended to use the limb little, if at all. The majority of studies were underpowered (median number of included participants was 29) and we cannot rule out small-trial bias. Eleven trials (344 participants) assessed disability immediately after the intervention, indicating a non-significant standard mean difference (SMD) 0.24 (95% confidence interval (CI) -0.05 to 0.52) favouring CIMT compared with conventional treatment. For the most frequently reported outcome, arm motor function (28 studies involving 858 participants), the SMD was 0.34 (95% CI 0.12 to 0.55) showing a significant effect (P value 0.004) in favour of CIMT. Three studies involving 125 participants explored disability after a few months of follow-up and found no significant difference, SMD -0.20 (95% CI -0.57 to 0.16) in favour of conventional treatment. AUTHORS' CONCLUSIONS CIMT is a multi-faceted intervention where restriction of the less affected limb is accompanied by increased exercise tailored to the person's capacity. We found that CIMT was associated with limited improvements in motor impairment and motor function, but that these benefits did not convincingly reduce disability. This differs from the result of our previous meta-analysis where there was a suggestion that CIMT might be superior to traditional rehabilitation. Information about the long-term effects of CIMT is scarce. Further trials studying the relationship between participant characteristics and improved outcomes are required.
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Affiliation(s)
- Davide Corbetta
- San Raffaele HospitalUnit of Functional RecoveryVia Olgettina, 48MilanItaly20132
| | - Valeria Sirtori
- San Raffaele HospitalUnit of Functional RecoveryVia Olgettina, 48MilanItaly20132
| | - Greta Castellini
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
| | - Lorenzo Moja
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanItaly20133
| | - Roberto Gatti
- University Vita‐Salute San RaffaeleSchool of PhysiotherapyVia Olgettina, 58MilanItaly20132
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